STENOSIS AFTER BARIATRIC SURGERY
Riccardo BRACHET CONTUL
MD, Adjunct Professor at Turin University Master of Laparoscopic Surgery,
Unit of Bariatric Surgery
P. MILLO, MD, Unit of Bariatric Surgery - Chief
M. FABOZZI, MD
Unit of Bariatric Surgery
DEPARTMENT OF LAPAROSCOPIC, BARIATRIC E COLORECTAL
SURGERY – CHIEF DR. R. ALLIETA
AOSTA “U. PARINI” REGIONAL HOSPITAL - ITALY
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
STENOSIS: DEFINITION
An abnormal narrowing or constriction of the diameter of a
bodily passage or orifice (as from inflammation, cancer, or the
formation of scar tissue).
STENOSIS: SYMPTOMS
•
Dysphagia (first with solids and progressing to intolerance even with
liquids)
•
Vomiting (sometimes with nausea)
•
Symptoms of obstruction when moving from fluids to solid food
•
Sticking to fluid comsumption, not progressing to solids
•
Saliva or food regurgitation
•
Impaction of food (especially meat or bread)
•
De novo gastroesophageal reflux disease symptoms
•
At times pain in the epigastric to retrosternal area.
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STENOSIS: DIAGNOSIS
•
Symptoms
•
UGI-radiograms
•
Endoscopy (narrowing of the anastomosis
or suture or outlet that did not allow
passage or afforded significant resistance to
passage of the 9-mm endoscope in the
symptomatic patients)
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STENOSIS AND TYPE OF OPERATION
•
SAGB
•
LAPAROSCOPIC VERTICAL BANDED
GASTROPLASTY
•
LAPAROSCOPIC GASTRIC GREAT CURVATURE
PLICATION
•
LAPAROSCOPIC SLEEVE GASTRECTOMY
•
LAPAROSCOPIC GASTRIC BYPASS
•
LAPAROSCOPIC BILIO-PANCREATIC DIVERSION
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STENOSIS AND TYPE OF OPERATION
SAGB
FUNCTIONAL STENOSIS RELATED TO
COMPLICATIONS (GASTRIC POUCH DILATATION,
SLIPPAGE, GASTRIC WALL EROSION/BAND
MIGRATION, TOO MUCH INFLATION OF THE
BAND,…)
THERAPY
TREATMENT OF THESE COMPLICATION
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STENOSIS AND TYPE OF OPERATION
LAPAROSCOPIC VBG
(actually abandoned technique)
STENOSIS RELATED TO NARROW OUTLET,
EROSION, GASTRIC POUCH DILATION…
THERAPY
TREATMENT OF THESE COMPLICATION
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STENOSIS AFTER LSG
Due to the long staple line and altered
intragastric pressures.
STENOSIS is reported in 0.26-4% of operations
This rate is underestimated:
-Because
early published series of LSG tended to use larger
bougies with the intention of two-stage weight loss.
- Additionally,
little literature exists regarding patient
characteristics, operative techniques, and other variables that
may contribute to the development of a sleeve stenosis
Few reports have described the subsequent management of
these patients
-
STENOSIS AFTER LSG - CAUSES
ACUTE
•
Gastric mucosal edema
Kinking (specially when a very narrow sleeve makes an acute turn in the
middle, usually in relation to incisura angularis
•
•
Narrowing owing to oversewing of the staple line
•
Irregular staple line
CRONIC
Ischemia of the pouch
Retraction due to scarring
Fistula
Inclusion of the gastroesophageal junction in the staple line
Conversion of Gastric Banding in Sleeve (or LRYGBP)
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LSG
FUNCTIONAL
STENOSIS
AFTER LSG
Twisting of the
sleeve
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STENOSIS AFTER LSG – HOW TO AVOID
1.
Keep a safe distance between the incisura angularis and
edge where staples are applied (with boogie in place while
stapling) - to avoid stricture and kinking
2.
When cutting the adesions between stomach and posterior
peritoneum over the pancreas, preserve the branches of the
left gastric artery - to avoid ischemic lesions
3.
Keeping the staple line straight, by resecting simmetrically
anterior and posterior gastric walls (trick: pull the
gastroepiploic margin of section) - to avoid kinking and
twisting of the tube.
4.
Also the reinforcement oversewing has to respect point 3.
Zundel N, et al. SURG LAPAROENDOSC PERCUTAN TECH 2010, 20(3): 154-8
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STENOSIS AFTER LSG - TREATMENT
1.
EDEMA: NIL PER OS, HIDRATION, PPI + Escina ev,
CLINICAL OBSERVATION
2.
OTHER STENOSIS
-
ENDOSCOPY with pneumatic balloon dilation (1- several
sessions) or X-ray guided dilation
-
STENTS (covered or partially covered): usually remain in
place only a week (have to be removed for migration or
pain)
-
SURGERY (laparoscopy with cutting of a narrowing stitch,
seromyotomy, stricturoplasty, conversion to RYGBP, total
gastrectomy)
Zundel N, et al. SURG LAPAROENDOSC PERCUTAN TECH 2010, 20(3): 154-8
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STENOSIS AFTER LSG - TREATMENT
230 LSG
•Caution should be taken in
performing LSG to avoid the creation
of sleeve stenosis.
•Clinically significant short-segment
stenoses may be treated successfully
with endoscopic balloon dilation.
•Long-segment stenoses are less
likely to respond to endoscopic
techniques and may ultimately require
conversion to Roux-en-Y gastric
bypass.
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STENOSIS AFTER LGCP
1.
2.
Frequent but transitory (1-2 weeks) nausea and
vomiting and/or sialorrea due to edema and
congestion – about 30%
Only sometimes persisting symptoms (range 2-5%)
linked to stricture due to stomach kinking or
invaginated gastric fold or gastro-gastric hernia or
serous fluid collection within the cavity formed by
gastric plication  ENDOSCOPIC AND/OR
RADIOLOGIC DIAGNOSIS  SURGICAL
TREATMENT (reversal of plication, revision to
sleeve gastrectomy, for ex.)
Abdelbaki TN, et al. GASTRIC PLICATION FOR MORBID OBESITY: A SYSTEMATIC REVIEW; OB SURG 2012, 22:1633-9
Friede M, et al. LGCP FOR TREATMENT OF MORBID OBESITY – 244 PAT.S; OB SURG 2012, 22:1298-307
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STENOSIS AFTER LRYGBP
One of the most common complications.
The presentation is readily recognizable with symptoms of :
•
Dysphagia (first with solids and progressing to intolerance even with
liquids)
•
Emesis
•
At times pain in the epigastric to retrosternal area.
Diagnosis with:
•
UGI
•
Endoscopy (narrowing of the anastomosis or suture that did not allow
passage or afforded significant resistance to passage of the 9-mm
endoscope in the symptomatic patients)
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STENOSIS AFTER LRYGBP - CAUSES
Historically, rates of GJ strictures have varied considerably in the
literature with some studies citing stricture rates of greater than 20 %.
This discrepancy may be due to factors such as
different surgical techniques for creating the GJ anastomosis (end-toend, end-to-side, and side-to-side)
•
•
size of the gastric pouch
•
tension
•
path of the Roux limb
•
medications
•
smoking
•
how the strictures are defined and diagnosed.
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STENOSIS AFTER LRYGBP – ??
1. There is considerable variability in stricture rates between
different techniques utilizing different size staplers.
2. Within one stapler category, however, there is still significant
variability in GJ stricture rates.
3. This variation in rates may be partly explained by the
difference in how some clinicians defined a stricture and how
patients with clinical symptoms are worked up.
4. For ex. the variation in determining when a patient is
appropriate for endoscopic evaluation is also accompanied
with a variation of the overall date of presentation of
strictures.
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STENOSIS AFTER LRYGBP
Pathogenesis
Csendes A et al, Ob Surg 2008
Early stenosis
Presence of fibrin
Presence of inflammatory material
< 4 p.o. weeks
Presence of submucosal hematoma
Fibrin + soft inflammatory tissue
Late stenosis
Fibrotic tissue
MORE DIFFICULT TO BE DILATED BY ENDOSCOPE
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STENOSIS AFTER LRYGBP
Results
Csendes A et al, Ob Surg 2008
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This is the largest series (835 pat.s) which report
stratification and analysis of LRYGBP according to GJA
technique.
No significant differences in the rates of anastomotic
stricture were found between the techniques, and rates
are comparable to those previously reported in the
literature.
This report suggests that the type of GJA technique
does not affect the incidence of early anastomotic
complications.
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(mean 5.5%)
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BARIATRIC SURGERY – U. PARINI HOSPITAL
AOSTA
STENOSIS
•
LSG
3/101 (3%)
•
LRYGBP
18/503 (3.6%)
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STENOSIS AFTER Robotic RYGBP
1093 LRYGBP
vs
593 RRYGBP
INCIDENCE AFTER Robotic RYGBP: 0-4.4%
Markar SR et al; ROBOTIC VS LAP RYGBP IN MORBIDLY OBESE PATIENTS; INT J ROB COM ASS SURG 2011, 7:393-400
Matthew M, et al. ROBOTIC BARIATRIC SURGERY: A SYSTEMATIC REVIEW; SURG OB REL DIS 2012, 8:483-8
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STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
105/1330 PAT.S (7.8%) TREATED
PREDICTORS for need of repeated dilations
•Age
•Gender
•Basal BMI
• Time interval between surgery and synmptoms
• Previous anastomotic leak
• Diameter of the stenosis
• Presence of ulcerations in the anastomosis
• Diameter achieved in the first dilation
STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
Relation found between time elapsed from surgery and
recurrence of the stricture:
•The earlier the stricture develops, the more difficult is its treatment, and
more sessions are needed to obtain a sustained response
•Perhaps because the fibrous scarring of the anastomosis is not complete
until the second to third month of the procedure, and it keeps its tendency
towards the stricture formation after the dilation.
•Only 24% of cases with a stricture diagnosed after the fourth month
needed a second dilation; meanwhile, 75% of those that presented
symptoms in the first month after surgery needed two or more dilations.
STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
Relation between achieving a 15-mm diameter ballon dilation
in the first procedure and the need of repeated dilations:
•The group of pat.s dilated ONCE had been dilated wider than the
group of TWO to FOUR dilation.
• The desidered diameter of the GJA is at least TWO AND HALF
TIMES the initial diameter
• Dilate careful (it is not safe to dilate until the final desidered diameter
with only one procedure specially in cases with very narrow initial
diameter).
STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
DA COSTA M, et al OBES SURG (2011) 21:36-41
105/1330 (7.8%) 3±1.8 months Hand-sewn sutures 1 (57%), 2 (27.6%), 3 (12.3%)
1.6 (1-4) (1.8%)
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STENOSIS AFTER LRYGBP
Suggested Prevention
1. Intraoperative EGD
2. Modified GJ anastomosis
3. Drugs administrations (ex. Stheroids during endoscopic
dilation? High dose IPP? other?)
4. High-quality f.u. care ensures that the few pat.s that do
develop aa stricutres are expeditiously and effectively
diagnosed and treated when the complication does occurr
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STENOSIS AFTER LBPD±DS
1.
INCIDENCE 9-20% (GI or DI anastomosis with stapler, higher
during Laparoscopy and with Circular Stapler anastomosis)
2.
INCIDENCE 0-4% (handsewn GI anastomosis in standard
BPD)
3.
Associated sometimes with gastroparesis in standard LBPD
4.
DIAGNOSIS with UGI radiograms, Endoscopy
5.
TREATMENT
- Endoscopic dilation
- GJ anastomosis revision (if failed endoscopic treatment)
- Partial/total gastrectomy ± conversion to RYGBP or full restoration of
bowel anatomy (if failed conservative treatments)
Samin KA, et al Ob Surg 2006; Scopinaro N et al, Ob Surg 2002; Silecchia G et al, Surg End 2009 ; Serra C et al, Ob Surg 2006
COMPLICATIONS AFTER GASTRO-JEJUNAL BYPASS
CONCLUSION
Usually Endoscopic dilation is the treatment of
choice of sleeve or anastomotic stenosis.

After several sessions (with persisting
symptoms and/or narrow gastric lumen), stent
positioning may be a good alternative.

Surgical treatment is the last resource (and
should not be spared in case of need)

Baia Chia (CA)
GRAZIE!!