OBES SURG DOI 10.1007/s11695-015-1883-4
ORIGINAL CONTRIBUTIONS
Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management Lionel Rebibo 1 & Sami Hakim 2 & Abdennaceur Dhahri 1 & Thierry Yzet 3 & Richard Delcenserie 2 & Jean-Marc Regimbeau 1,4,5
# Springer Science+Business Media New York 2015
Abstract Purpose The use of laparoscopic sleeve gastrectomy (LSG) is increasing worldwide. Although post-LSG gastric stenosis (GS) is less frequent, it has not been well defined and lacks standardized management procedures. The objective of the present study was to describe a series of patients with GS symptoms after LSG and to develop a standardized management procedure for this complication. Methods We performed a retrospective analysis of a prospective database of patients presenting with GS after LSG procedures performed between January 2008 and March 2014. The primary efficacy criterion was the frequency of post-LSG GS. GS was classified as functional (i.e. a gastric twist) or organic. The secondary efficacy criteria included the time interval between LSG and diagnosis of GS, the type of stenosis, the type of management, and the follow-up data. Results During the study period, 1210 patients underwent primary or secondary LSG. Seventeen patients had post-
* Jean-Marc Regimbeau
[email protected] 1
2
Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, F-80054 Amiens Cedex 01, France Department of Gastroentrology, Amiens University Medical Center, Avenue René Laennec, F-80054 Amiens Cedex 01, France
3
Department of Radiology, Amiens University Medical Center, Avenue René Laennec, F-80054 Amiens Cedex 01, France
4
Jules Verne University of Picardie, EA4294, F-80054 Amiens Cedex 01, France
5
Clinical Research Center, Amiens University Medical Center, Avenue René Laennec, F-80054 Amiens Cedex 01, France
operative symptoms of GS (1.4 %); one patient had achalasia that had not been diagnosed preoperatively and thus was excluded from our analysis. The median time interval between LSG and diagnosis of GS was 47.2 days (1–114). Eleven patients had organic GS and six had functional GS. Seven patients required nutritional support. Endoscopic treatment was successful in 15 patients (88.2 %) after balloon dilatation (n=13) or insertion of a covered stent (n=2). Two of the 15 patients required conversion to Roux-en-Y gastric bypass (11.8 %). Conclusion GS after LSG is a rare complication but requires standardized management. Most cases can be treated successfully with endoscopic balloon dilatation. Keywords Laparoscopic sleeve gastrectomy . Stenosis . Gastric twist . Endoscopic dilatation . Stent
Abbreviations BMI body mass index GF gastric fistula GS gastric stenosis LSG laparoscopic sleeve gastrectomy OSA obstructive sleep apnea syndrome
Introduction Bariatric surgery is the only obesity treatment with long-term efficacy. Of the various surgical techniques available, laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular because of its good weight loss results [1, 2], its ability to correct comorbidities associated with obesity [3], and its low post-operative complication rate. The early-onset complications of LSG (i.e., those that appear in the first three post-
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operative months) include gastric fistula (in 2.5 % of cases, according to a recent meta-analysis [4]) and hemorrhage (in fewer than 5 % of cases [5]). Stenosis is a less frequently described early-onset complication of LSG, with an incidence of 0.69 to 3.5 % [6–8]. Few series have offered a standardized management approach: primary endoscopy, primary surgery, and surgery after the failure of endoscopic treatment have all been suggested. The objectives of the present study were to (1) describe a series of patients with symptoms of gastric stenosis (GS) after LSG, (2) describe the mechanism of stenosis and its treatment, and (3) suggest a standardized approach to management of post-LSG GS on this basis.
Material and Methods Population We performed a retrospective analysis of our prospective database of patients having undergone LSG between January 2008 and March 2014. In all cases, the indication for bariatric surgery had been validated in a multidisciplinary staff meeting and was in accordance with the French national guidelines [7, 8]. All patients attended a surgical consultation and a nutrition/dietetics consultation. They also underwent respiratory, endocrine, and psychological assessments. Screening for achalasia, hiatus hernia, gastritis, and Helicobacter pylori infection was performed endoscopically. H. pylori infections were always eradicated prior to LSG. Overnight, polysomnography was used to screen for obstructive sleep apnea syndrome (OSAS).
of the surgical procedure. To check for the absence of complications and thus to enable oral refeeding, all patients underwent an upper gastrointestinal swallow study with oral contrast agent (Gastrografin®, Bayer HealthCare, Puteaux, France) on post-operative day 1.
Definition of Stenosis Dysphagia, epigastric pain, and poor tolerance of oral feeding in the immediate or later post-operative period were suggestive of GS. We differentiated between these symptoms and gastroesophageal reflux disease (which features heartburn after eating but in the absence of dysphagia). GS was classified as being organic or functional, on the basis of an upper gastrointestinal swallow study and/or an endoscopy procedure. Organic GS was apparent in an upper gastrointestinal swallow study, either directly (segmental narrowing of the stomach, with a thin line of oral contrast) or indirectly (stagnation of the oral contrast product above the stenosis, possibly associated with dilatation of the esophagus (Fig. 1)). The oral contrast study thus enabled to define the site and length of the GS. The study protocol mandates an upper endoscopy followed by a water-soluble contrast agent under radiological guidance. Functional GS was diagnosed using an upper gastrointestinal endoscopy procedure (i.e., the presence of a gastric twist) but not in the swallow study test.
Surgical Procedure Our surgical procedures for primary and secondary LSGs [9, 10] have been described elsewhere. A 34-gauge French bougie was used when stapling the greater gastric curvature. The LSG transection began 6 cm proximal to the pylorus. For LSGs performed between January 2004 and December 2009, stapling was performed using Endo GIA Universal XL 60 with two green reloads and then four or five blue reloads (COVIDIEN France SAS, Elancourt, France). For LSGs performed between January 2010 and December 2014, purple staplers (Tri-Staple™, COVIDIEN France SAS) were used. In our institution, we do not reinforce the staple line for first-line LSGs. For secondary LSGs, cases of previous gastric banding or cases of gastric banding removal and LSG in the same procedure, we used black Tri-Staple™ reloads (COVIDIEN France SAS) with GORE® SEAMGUARD® bioabsorbable staple line reinforcement (WL GORE and Associés, Paris, France) for the last two staples. A methylene blue test was always performed at the end
Fig. 1 Upper gastrointestinal swallow study with oral contrast agent showing narrowing of the sleeve (white arrow) and dilatation of the esophagus (black arrow)
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Management of GS All cases of post-LSG GS were discussed in a multidisciplinary staff meeting that included bariatric surgeons, radiologists, and endoscopists. This enabled to develop a protocol for the standardized management of post-LSG GS, depending on the type of GS (Fig. 2). Endoscopic Procedures Endoscopic procedures were performed under general anesthesia. During endoscopy, a 0.035-in. guidewire straight tip (Jagwire®, Boston Scientific, Natick, MA, USA) was implemented through the scope below the GS (Fig. 3a, b). After removing the endoscope, an achalasia balloon (Rigiflex™ II Single-Use Achalasia Balloon Dilators, Boston Scientific, Natick, MA, USA) was inserted over the wire until a previous hallmark under fluoroscopy. Achalasia balloon dilators were used starting with a balloon diameter of 30 mm and progressing to 35 and 40 mm if unsuccessful. The achalasia balloons were dilated to achieve 20 psi pneumatic pressure, and the pressure was maintained for 1 min (Fig. 3c, d). Inflation for 1 min was often enough to remove the stenosis. To check the effectiveness of this procedure, an assessment of the upper gastrointestinal tract using water-soluble contrast agent was performed during the same endoscopy session.
For patients with early-onset GS (i.e., occurrence before post-operative day (POD) 7), a covered stent was inserted in the stenosed gastric segment. After the presence of GS had been confirmed by an upper gastrointestinal swallow study, the guidewire was positioned below the stenosed gastric segment. After removal of the endoscope, a metal covered stent (diameter 24 mm, length 23 cm) (HANAROSTENT®, Life Partners Europe, Bagnolet, France) was inserted over the wire under radiological guidance. Inclusion Criteria The main inclusion criterion was primary or secondary LSG, followed by the symptoms of GS. Patients having undergone other bariatric surgical procedures (gastric banding, Roux-enY gastric bypass, or duodenal switch), those with achalasia, and those free of stenosis after LSG were excluded from the study. Study Criteria The study’s primary end point was the frequency of GS after LSG. The secondary end points were the time to diagnosis of GS, the type of stenosis (organic or functional), the type of management (endoscopic, surgical, or both), endoscopic data, surgical data, and follow-up data. Hence, the following data were recorded:
Fig. 2 Algorithm for the management for post-LSG GS discovered later than POD 7
OBES SURG Fig. 3 Endoscopic procedure for GS. a Endoscopic procedure showing GS. b Implementation of guidewire through the scope below the GS. c Dilatation of GS with under control of fluoroscopy using 30-mm-diameter achalasia balloon with 20 psi pneumatic pressure. d Endoscopy findings during dilatation of GS
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Pre-operative data: age, gender, body mass index (BMI), comorbidities (diabetes mellitus, hypertension, dyslipidemia, and OSAS). Operating data: operating time, type of procedure performed, and type of pre-operative complications. Stenosis-related data: time to diagnosis of stenosis, type of stenosis (organic or functional), the GS site, the length of the stenosed segment, and nutritional management. Treatment-related and endoscopic data: the type of endoscopic management, the number of endoscopic procedures, the success rate associated with endoscopy, revisional surgery data, and follow-up data.
Statistics The statistical analysis was performed with SAS software (version 4.3, SAS Institute Inc., Cary, NC, USA). Data are quoted as the median (range) or as the number (percentage).
developed post-operative symptoms of GS (1.4 %). One of these patients was excluded because of achalasia that had not been diagnosed before surgery. The study population (n=17) thus consisted of 16 women (94.1 %) and one male with a mean age of 45 years (28–63) and a mean pre-operative BMI of 42.2 kg/m2 (35.6–60.1). One patient (5.8 %) had a BMI of ≥50 kg/m2. The main comorbidities were diabetes mellitus (47 %; n = 8), hypertension (47 %; n = 8), dyslipidemia (17.6 %; n=3), and OSAS (29.4 %; n=5). Operating Data Sixteen first-line LSG procedures and one second-line LSG procedure (gastric banding removal and LSG in the same surgical procedure) were performed. The mean operating time was 89.4 min (50–130). During LSG, bleeding at the gastric staple line required suturing in ten cases (58.8 %), with a single (absorbable) suture in four cases, and continuous suture (absorbable V-Loc running suture) in six cases. None of the LSG procedures were associated with leakage (according to an intra-operative methylene blue test).
Results Diagnosis of Stenosis The Study Population During the study period, 1210 patients underwent primary or secondary LSG in our institution and 18 of the latter
The median time interval between LSG and diagnosis of GS was 47.2 days (1–114). The stenosis was diagnosed as organic GS (following an upper gastrointestinal swallow study) in 11
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cases (58.8 %); the stenosis was located within the middle third of the sleeve in nine of these cases and at the angular incisure in two cases. The median length of the GS was 2.5 cm (1–4). Following upper gastrointestinal endoscopy, a gastric twist (i.e., functional GS) was diagnosed in the six remaining cases (Fig. 3). All of the stenoses were located within the middle third of the sleeve. In two patients, GS had been diagnosed on the basis of an upper gastrointestinal swallow study on POD 1. In one of these cases, the final diagnosis (on POD 7) was gastric fistula (GF) requiring revisional surgery for drainage and the implementation of feeding jejunostomy. Management All the patients with GS (except the patient with GF) (n=16) underwent first-line endoscopic treatment (100 %). For the patient in whom GS was diagnosed over on POD 1, a covered stent was inserted on POD 3. The stent was removed 27 days later; there were no signs of GS in an upper gastrointestinal swallow study or in an endoscopic assessment. In the remaining 15 patients, GS was initially treated with endoscopic balloon dilatation. The success rate for balloon dilatation was 86.6 % (n=13). The median number of balloon dilatation procedures per patient was 2 (1–3). Patients in whom three endoscopic balloon dilatations had failed (n=2) underwent Roux-en-Y gastric bypass (RYGBP). Revisional surgery revealed organic GS in one case and an old hematoma (between a kinked gastric remnant and the left liver lobe) in the other. The patient with GF as a result of GS underwent endoscopy after reoperation and was treated with a covered stent and two double-pigtail stents. The stents were removed 28 days after implementation; there were no signs of GS, and the GF had closed. The success rate for endoscopic management was 88.2 % (n=15). Seven of the 18 patients required nutritional support (a nasojejunal tube in six cases and feeding jejunostomy in the patient with GF). During the treatment of GS, one patient s t a r t e d t o s h o w s i g n s o f We r n i c k e ’s s y n d r o m e (ophthalmoplegia) as a result of thiamine deficiency. After correction of this vitamin deficiency, the patient’s condition improved and there were no sequelae. There were no morbidities related to the endoscopic procedure (whether balloon dilatation or stenting). Over a median follow-up time of 12.5 months (5–34), there were no signs of GS recurrence in the endoscopically treated patients.
frequency of post-operative complications (the most prominent of which is GF). Thanks to improvements in the surgical technique and perioperative management [12], the incidence of GF has fallen steadily over recent years and further reinforced the value of this surgical procedure. However, as one of the other early-onset complications of LSG, GS has been less well described and is probably underestimated (with an incidence of between 0 and 4 %, depending on the series) [13]. In the literature, post-LSG GS has been classified as either organic or functional. A number of risk factors for organic post-LSG GS have been described in the literature, including the suture reinforcement of the gastric staple line in general and use of a running suture in particular. For example, the staple line had been sutured in two of the five patients with post-LSG GS in the report by Burgos et al. [6]. Furthermore, the use of reinforced staplers appears to be associated with a higher rate of GS; Parikh et al. [7, 8] reported an incidence of 3.5 % in a series of 230 patients. Our present results are in line with the literature data on the origin of GS. The gastric staple line had been partially or fully sutured in all the cases of organic GS in our series (except for one in which a hematoma was discovered during revisional surgery). When suturing is indicated (by bleeding on the staple line, for example), placing a bougie in the gastric lumen during this phase may help to avoid subsequent GS. Functional GS after LSG is rarely described. This complication is probably due to twisting of the gastric wall during LSG transection—probably as a result of insufficient release of the posterior gastric wall. Recently, Iannelli et al. [14] described two cases of gastric twist following RYGBP. One case was diagnosed with upper gastrointestinal endoscopy and the other was diagnosed with oral 99mTechnetium scintigraphy. Contival et al. [15] also described a case of gastric twist, with conversion to Roux-en-Y gastric bypass in the absence of prior endoscopic treatment. In the present series, an atypical gastrointestinal endoscopic procedure was used to diagnose
Discussion LSG is an increasingly popular surgical technique; indeed, it has been the most frequently performed bariatric procedure in France since 2011 [11]. The procedure is associated with a low
Fig. 4 Upper gastrointestinal endoscopy, showing a gastric twist as a kink in the gastric lumen (white arrow)
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GS. Such diagnosis can be done during a particular upper gastrointestinal endoscopy in particular with a slow decline of the endoscope showing a brutal bascule of the gastric lumen. Initially, this gastric twist was discovered fortuitously after a negative upper gastrointestinal swallow study and three Bconventional^ upper gastrointestinal endoscopic procedures (Fig. 4). In contrast to the report by Iannelli et al. [14], all but one of the cases of gastric twist in our series were treated successfully via balloon dilatation. The remaining patient required an additional revisional surgical procedure (RYGBP). Furthermore, in a 15-patient study, Gero et al. [16] have suggested that gastric twist can be prevented by fixing the distal corner of the gastric tube to the greater omentum. This technique requires evaluation over a larger period and in a larger number of patients, since the cause of the gastric twist is subject to debate. One particular feature of the present series was the concomitant presence of GS and GF in two patients; we suppose the GF appears as a result of GS. In such as case, balloon dilatation cannot be used to treat the GS because it may worsen the GF. Hence, we used a covered stent alone in one case and a combined covered stent and two double-pigtail stents in the other case [17]. Both patients had good outcomes; the stents were removed 27 and 28 days later, with no recurrence of GS or GF. In our experience, use of a covered stent to treat GS is only required for early-onset stenosis (i.e., in the week following surgery). After POD 7, we prefer to perform balloon dilatation because it is better tolerated than a covered stent (Fig. 2). One major aspect of our management of patients with postLSG GS is to systematically refeed patients during all management for GS as long as an oral feeding cannot be achieved without vomiting. Furthermore, we now perform vitamin supplementation systematically—notably to avoid thiamine deficiency and Wernicke’s disease, as observed in one case in our series, some other case reports in the literature, and in the context of post-operative vomiting after LSG [18]. Achalasia is very rare in obese patients undergoing bariatric surgery, with a prevalence of 1 % [19]. In the present study, the case of achalasia was not detected by an upper gastrointestinal swallow study. This observation is slightly worrying, since LSG in this context is usually contraindicated—even though some cases have been described in the literature [20]. If achalasia is detected prior to surgery, we tend to perform RYGBP with Heller’s cardiomyotomy [21].
necessary. Nutritional support and vitamin supplementation are necessary in cases of poor oral feeding with recurrent vomiting. Conflict of Interest None of the authors have any conflicts of interest to declare. Ethical Approval For this type of study, formal consent is not required. Informed Consent Informed consent for this study does not apply.
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Conclusion
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Gastric stenosis is a rare but potentially life-threatening complication of LSG. Endoscopic treatment (balloon dilatation in particular) is effective, safe, and avoids the need for revisional surgery. If three attempts at dilatation fail, surgery is
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