STENOSIS AFTER BARIATRIC SURGERY

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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
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XXI CONGRESSO NAZIONALE SICOB Attualità e nuove
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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

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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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XXI CONGRESSO NAZIONALE SICOB Attualità e nuove
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STENOSIS AFTER LSG - TREATMENT

• EDEMA NIL PER OS, HIDRATION, PPI Escina ev,
  CLINICAL OBSERVATION
• 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. Frequent but transitory (1-2 weeks) nausea and
   vomiting and/or sialorrea due to edema and
   congestion about 30
2. 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,
221633-9 Friede M, et al. LGCP FOR TREATMENT OF
MORBID OBESITY 244 PAT.S OB SURG 2012,
221298-307
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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-to-end, 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

Presence of fibrin Presence of inflammatory
material Presence of submucosal hematoma
Early stenosis lt 4 p.o. weeks
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 HOSPITALAOSTA
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove
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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,
7393-400 Matthew M, et al. ROBOTIC BARIATRIC
SURGERY A SYSTEMATIC REVIEW SURG OB REL DIS
2012, 8483-8
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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

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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.

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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).

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STENOSIS AFTER LRYGBP ENDOSCOPIC TREATMENT
DA COSTA M, et al OBES SURG (2011)
2136-41 105/1330 (7.8) 31.8 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 LBPDDS

• INCIDENCE 9-20 (GI or DI anastomosis with
  stapler, higher during Laparoscopy and with
  Circular Stapler anastomosis)
• INCIDENCE 0-4 (handsewn GI anastomosis in
  standard BPD)
• Associated sometimes with gastroparesis in
  standard LBPD
• DIAGNOSIS with UGI radiograms, Endoscopy
• 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
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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)

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Baia Chia (CA)
GRAZIE!!