- Email: [email protected]
Gastric Outlet Obstruction caused by Benign Anastomotic Stricture: Treatment by Fluoroscopically Guided Balloon Dilation
Gastric Outlet Obstruction caused by Benign Anastomotic Stricture: Treatment by Fluoroscopically Guided Balloon Dilation Jin Hyoung Kim, MD, Ji Hoon Shin, MD, Jae-Ik Bae, MD, Zhen-Hai Di, MD, Jin-Oh Lim, BS, Tae-Hyung Kim, MS, Gi Young Ko, MD, Hyun-Ki Yoon, MD, Kyu-Bo Sung, MD, and Ho-Young Song, MD
PURPOSE: To evaluate the clinical efficacy and safety of fluoroscopically guided balloon dilation of gastric outlet obstruction caused by benign anastomotic stricture. MATERIALS AND METHODS: Fluoroscopically guided balloon dilation was performed on 17 patients with gastric outlet obstruction caused by benign anastomotic stricture. Fourteen patients underwent surgery for malignant disease and three patients for complication of benign gastric ulcer. The sites of anastomotic stricture were gastrojejunal (n ⴝ 12) or gastroduodenal (n ⴝ 5). An upper gastrointestinal (UGI) series was performed just following and 1 month after balloon dilation to evaluate both the clinical success of the procedure and any complications. A dietary intake was evaluated by using the score for patients with malignant dysphagia and the pre- and postballoon dilation scores were analyzed with the Wilcoxon signed rank test. RESULTS: In all patients, fluoroscopically guided balloon dilation was performed in one (n ⴝ 15) or two (n ⴝ 2) sessions and was technically and clinically successful (100%). The diameters of the balloon catheters used were 15 mm (n ⴝ 4), 20 mm (n ⴝ 14), and 25 mm (n ⴝ 1 mm; mean, 19.5 mm) in a total of 19 sessions. All patients had significant improvement of their levels of dietary intake (P < .001). Two of the 17 patients required the second procedure due to recurrent symptom nine and 15 months, respectively, after initial balloon dilation. Overall, 16 patients (94%) showed good results and no recurrence during a mean follow-up period of 13.5 months (range, 5–39 months). There were no major complications associated with balloon dilation. CONCLUSION: Fluoroscopically guided balloon dilation seems to be effective and safe for patients with gastric outlet obstruction caused by benign anastomotic stricture. Achieving a luminal diameter of 20 mm seems to be necessary to prevent recurrence of symptoms. J Vasc Interv Radiol 2005; 16:699 –704 Abbreviations: PTFE ⫽ polytetrafluoroethylene, UGI ⫽ upper gastrointestinal
IT is well known that anastomotic stricture after gastric surgery is a common complication that requires treatment if
From the Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388 –1, Pungnap-2dong, Songpa-gu, Seoul 138 –736, Korea. Presented at the 2005 SIR Annual Meeting. Received October 11, 2004; revision requested November 20; revision received and accepted December 9. Address correspondence to J.H.S.; E-mail: jhshin@amc. seoul.kr This investigation has disclosed a potential conflict of interest. None of the other authors have identified a potential conflict of interest. © SIR, 2005 DOI: 10.1097/01.RVI.0000153923.38343.72
significant obstruction occurs (1). As nonsurgical treatment for benign postoperative stricture or stricture of the gastric outlet, endoscopically or fluoroscopically guided balloon dilation has been a safe and effective modality and alternative to surgery according to numerous literature reports (1–12). It is a quick procedure with relatively low cost and involving less time than surgery. Fluoroscopically guided balloon dilation was introduced more recently than endoscopically balloon dilation and has advantages over the endoscopically guided method (6). In brief, fluoroscopy allows not only identification of the proximal and distal ends of a stricture
but also fluoroscopic control of the entire balloon catheter during its placement and inflation. As endoscopy cannot visualize the distal end of a stricture, endoscopically guided balloon dilation can potentially cause severe laceration or perforation. There are a few reports focusing on fluoroscopically guided balloon dilation for gastric outlet obstruction due to benign anastomotic strictures (1,6); moreover, their most indication for balloon dilation was gastric outlet obstruction after surgery for morbid obesity. The purpose of our study was to evaluate the clinical efficacy and safety of fluoroscopically guided balloon di-
699
700
•
Balloon Dilation for Benign Gastric Outlet Anastomotic Obstruction
lation in the treatment of patients with gastric outlet obstruction caused by benign anastomotic stricture.
MATERIALS AND METHODS Patients From March 2001 to December 2003, 17 patients with benign anastomotic stricture after gastric surgery were referred to our department (Table; available online at www.jvir.org). Fourteen patients underwent surgery for malignant disease and three patients for complication of benign gastric ulcer. Our institution does not require institutional review board approval for retrospective review of patient records or images. Diagnosis was established in all patients by means of endoscopic biopsy and was proved to be benign anastomotic stricture without any other cause such as marginal ulcer or malignancy. There were 11 male and six female patients in our study, with an average age of 61.9 years (range, 47–76 years). The sites of anastomotic stricture were gastrojejunal (n ⫽ 12) or gastroduodenal (n ⫽ 5). Their major symptoms were vomiting or dysphagia. Upper gastrointestinal (UGI) series and endoscopy were performed within 2 weeks prior to the balloon dilation to confirm the degree and location of the stricture. Balloon Dilation Technique Informed consent was obtained from all study patients at the time of the procedure. Balloon dilation was performed by one of two interventional radiologists with more than 2 years of experience with this technique. Strictures were initially treated with balloon dilation 2 weeks to 7.6 years (mean, 9.4 months) after surgery. Topical anesthesia of the pharynx was routinely achieved prior to the procedure with an aerosol spray of lidocaine hydrochloride (Dai Han, Seoul, Korea). Neither sedatives nor general anesthesia was used. A nasogastric tube was placed in all patients 24 hours before the procedure to empty the stomach. With fluoroscopic guidance, a 0.035inch exchange guide wire (Terumo, Tokyo, Japan) was inserted through the patient’s mouth and down the esopha-
gus into the remnant stomach. When intubation of the stricture was difficult with fluoroscopic guidance alone, we performed it with the aid of endoscopy or a gastric sheath to provide the stability for cannulation of the stricture. The gastric sheath was made with a polytetrafluoroethylene (PTFE) tube (6 mm in diameter, 70 cm long) with a bent tip (3 cm long, 60° angle). It was designed to effectively guide the guide wire, balloon catheter or stent introducer toward the stricture site of the gastric outlet or duodenum. A multifunctional coil catheter (S & G biotec, Seoul, Korea) was then passed over the guide wire into the distal part of the stricture. Through the multifunctional coil catheter, we injected contrast medium to opacify the area of interest while a guide wire was in place and measured the diameter and length of the strictures as described previously (13,14). The coil catheter was then removed with the guide wire left in place. Then an angioplasty balloon catheter (Cordis, Roden, The Netherlands) was passed over the guide wire to a position over the stricture. The balloon was slowly inflated with fluoroscopic guidance with hand pressure with diluted water-soluble contrast medium for 1 to 3 minutes until the “hourglass deformity” created by the stricture disappeared from the balloon contour or the patient could not tolerate further inflation. A pressure gauge was not used. The ultimate diameter of the balloon was chosen on the basis of our projection of the desirable anastomotic diameter (usually 20 mm) to be achieved. Usually, a 10- or 15-mm balloon was initially used. If dilation with a 10- or 15-mm balloon was easily accomplished and the patient did not experience severe pain during the dilation, we progressed to a 20-mm balloon. However, in three patients (patients 3, 6, 7), the maximum balloon diameter used was 15 mm because of tightness of the stricture and our concern that 20-mm balloon dilation might increase the risk of perforation. In one patient (patient 15) with suspected functional gastric outlet obstruction, the maximum balloon diameter used was 25 mm because the stricture in this patient was mild and the balloon showed no waist during the 20-mm-diameter balloon dilation. Immediately after balloon dilation, a UGI series was performed with water-soluble contrast medium to con-
May 2005
JVIR
firm whether there was a perforation. If there was no evidence of perforation using water-soluble contrast medium, a UGI series with barium was performed to evaluate the degree of contrast passage. Follow-up All patients underwent a UGI series with barium 1 month after balloon dilation to verify the status of the stricture and the presence of passage disturbance. A further follow-up UGI series was only performed in patients with recurrent symptoms. When study patients did not visit our hospital during the follow-up period, the patients or their families were contacted by telephone for information concerning vomiting or dysphagia. Analysis of Results According to the Society of Interventional Radiology (SIR) reporting standards (15), we defined major complications as those that required further treatment or more hospitalization and minor complications as those that resolved spontaneously or with conservative treatment. Patient ability to swallow was expressed as a dysphagia score similar to that used in patients with malignant dysphagia (16,17) (online Table). The pre- and postballoon dilation scores were analyzed with the Wilcoxon signed rank test; P ⬍ .05 was considered statistically significant. The improvement of dysphagia was defined as a decrease of more than one grade in the dysphagia score 1 month after balloon dilation. Technical success was defined as successful dilation without any major complications. Clinical success was defined as improvement of dysphagia and good gastric emptying as demonstrated on a UGI series performed one month after balloon dilation. Recurrence was defined as the return of symptoms.
RESULTS The results are summarized in the online Table. In all patients, fluoroscopically guided balloon dilation was performed in one (n ⫽ 15) or two (n ⫽ 2) sessions and was technically successful in all patients (100%) (Figure). The diameter of the balloon catheter
Volume 16
Number 5
Kim et al
•
701
Figure. Fluoroscopically guided balloon dilation (patient 2) for anastomotic stricture at gastroduodenostomy. (a) UGI series before balloon dilation showed severe anastomotic stricture (arrow) at gastroduodenostomy. (b) Intubation of the guide wire with adjuvant endoscopy with fluoroscopic guidance failed in this patient. After use of the gastric sheath (arrowheads), the guide wire and coil catheter were successfully inserted through the stricture (arrows). (c, d) A 20-mm-diameter balloon was placed and inflated until the waist formed by the stricture disappeared. In addition to its assistance for intubation of the guide wire or catheter, the gastric sheath also gives extra stability during the balloon inflation. (e) UGI series with water-soluble nonionic contrast medium immediately after balloon dilation showed improvement of the luminal diameter (arrow).
used was 15 mm (n ⫽ 4), 20 mm (n ⫽ 14), and 25 mm (n ⫽ 1) (mean: 19.5 mm) in a total of 19 sessions. In five sessions, insertion of the guide wire was difficult with fluoroscopic guidance because of the severe stricture and dilated stomach. The guide wire was successfully inserted in one session with the help of endoscopy. In the remaining four sessions in which ad-
juvant endoscopy failed, the gastric sheath was effective for successful insertion of the guide wire. One month after balloon dilation, all patients showed improvement of their presenting symptoms and good contrast passage on UGI series. Therefore, clinical success was achieved in all patients (100%) and they all experienced improvement of more than
one grade in their level of dietary intake (online Table). The median dysphagia score improved from 3 to 0. When pre- and post- procedure scores were compared, a statistically significant improvement in overall scores was seen (Wilcoxon signed rank test, P ⬍ .001). Fifteen patients (88%) required only one session of dilation for sustained
702
•
Balloon Dilation for Benign Gastric Outlet Anastomotic Obstruction
relief of their clinical symptoms during the follow-up period (5ⵑ39 months). In three of these 15 patients (patient 1, 4, 15), the waist of the balloon formed by the stricture was not visible and showed easier distensibility on 20-mm or 25-mm-diameter balloon inflation. A presumptive diagnosis of functional gastric outlet obstruction was made in these three patients. Two patients (patients 3 and 7) required second balloon dilations caused by their recurrent symptoms nine and 15 months after the initial balloon dilation, respectively. During the second attempted procedure in patient 7, the lumen of the stricture site had been dilated to 15 mm without resistance; we then used a 20-mm-diameter balloon in this patient and dilated until the mild waist formation disappeared. This patient obtained sustained symptom relief during the follow-up period until the end of this study (24 months) after the second balloon dilation. In patient 3, the stricture seemed resistant to the initial balloon dilation because the stricture site of the gastrojejunostomy was tortuous and twisted. This patient also showed resistance to the second balloon dilation. In contrast to the initial balloon dilation, this patient showed little symptom improvement after the second procedure and eventually underwent surgical revision. Overall, 16 patients (94%) experienced good results and no recurrence during a mean follow-up period of 13.5 months (range, 5–39 months). There were no major complications associated with balloon dilation. As for minor complications, a small amount of mucosal bleeding occurred in two patients (13%) immediately after balloon dilation. The balloons were tinged with blood in these patients. However, this bleeding resolved spontaneously within one hour without significant clinical sequelae.
DISCUSSION It is well known that stricture of the gastric outlet is a common complication after gastric surgery and occurs in 3% to 13% of cases (18 –20). In most cases, the stricture occurs soon after surgery, usually within the first 2 months (1). The causes of stricture after surgery include postoperative
anastomotic ischemia, anastomotic edema, and fibrosis. Since its initial use in the esophagus, fluoroscopically guided balloon dilation has been a safe and effective treatment for a variety of strictures in the upper gastrointestinal tract, including lysis of anastomotic strictures (21). Balloon dilation is a simple and quick procedure and is linked to low morbidity and no mortality. Alternative therapeutic modalities, such as bougienage or surgical revision, involve considerably more time and risk. An anastomotic stricture is usually a short lesion resulting from a single, discrete event, and it would thus appear that these lesions are most ideally suited to balloon therapy (22). Over the past decade, endoscopically or fluoroscopically guided balloon dilation has been effective for treating gastric outlet obstruction caused by benign anastomotic strictures. In one series, endoscopic balloon dilation was performed for gastric outlet obstruction in 40 patients who had undergone either vertical banded gastroplasty or gastric bypass surgery for morbid obesity (23). Endoscopic balloon dilation was effective in 27 patients (68%), and surgical revision was necessary in the other 13 patients (32%) during their follow-up of 4 months to 4 years. In another series, 18 of 24 patients (75%) with anastomotic strictures or pyloric narrowing after gastric surgery were successfully treated by fluoroscopically guided balloon dilation; the other six patients (25%) required surgery during the follow-up period ranging from 1 to 36 months (1). The reported results of endoscopically or fluoroscopically guided balloon dilation were both effective. However, fluoroscopically guided balloon dilation has advantages over endoscopically guided dilation. Although endoscopy can directly visualize the proximal end of the stricture and can confirm the diagnosis by means of biopsy, endoscopy cannot visualize the distal end of the stricture; therefore, the interventional devices are passed distally without visual control and perforation by the tip of the dilator may occur (2,21). In contrast, fluoroscopy allows not only identification of the proximal and distal ends of the stricture but also visual control of the entire balloon catheter during its
May 2005
JVIR
placement and inflation. Complete visual control is more important when treating anastomotic strictures which occur at an acute angled site such as a gastroenterostomy. When we reviewed the literature regarding balloon therapy for benign gastric outlet obstruction, serious complications, such as arterial bleeding or immediate perforation requiring surgery, occurred in patients who underwent endoscopically guided balloon dilation (2,4,7,11,12), while no serious complications occurred in patients who underwent fluoroscopically guided balloon dilation (1,6,22,24). Stricture occurring at gastroenterostomies should be dilated enough to prevent symptoms of obstruction but not so much as to allow excessively rapid dumping of luminal contents into the anastomosed distal bowel (24). It is therefore important to find the optimal diameter. McLean et al (22,24) have targeted a luminal diameter of 12 mm or 15 mm for 22 patients with anastomotic strictures at the gastrojejunostomy (ie, 12 mm for patients who have undergone gastrojejunostomy for morbid obesity and a diameter of 15 mm for those who have undergone gastrojejunostomy for other reasons). Among their 22 patients, six patients (27%) did not show symptom improvement, and they did not provide the long-term results and any data of the remaining 16 patients (22,24). Kozarek et al (2) used a mean 15 mm diameter of balloon for 23 patients with benign gastric outlet obstruction including seven benign anastomotic strictures. Only three (43%) of the seven patients with anastomotic strictures obtained sustained symptom relief during their long-term follow-up. In our study, we used a larger balloon (mainly 20 mm in diameter) and achieved better results in patients with benign anastomotic strictures causing gastric outlet obstruction than those results in the previous reports (1,2,22–24) without notable complications. Among all our study patients except one who showed resistance to balloon dilation, 13 patients who underwent 20-mm-diameter balloon dilation showed sustained symptom relief and no recurrence. One of the three patients who underwent 15-mm balloon dilation showed symptom recurrence 15 months after first balloon dilation although the full 15-mm lumi-
Volume 16
Number 5
nal diameter had been achieved. After achieving 20-mm luminal diameter at the stricture in this patient, her symptoms improved and symptom recurrence did not occur during the follow-up up to 24 months after the second attempt. In addition, in cases of functional gastric outlet obstruction suspected because the stricture was mild compared with their symptoms and showed easier distensibility on balloon inflation, treatment with lager balloon (20 –25 mm) catheters was effective in this study as it was in other reports (5,12). Therefore, our study shows that a luminal diameter of at least 20 mm should be achieved to prevent symptoms of obstruction in benign anastomotic strictures at gastroenterostomy. Intubation of the guide wire seems to be difficult in severe strictures on gastroenterostomies because of its angulation and the little side support of the capacious stomach. In this situation, adjuvant endoscopy may be helpful because it gives extra-stability for the guide wire or balloon catheter passing through the stricture. In addition, the gastric sheath may be effective for inserting the guide wire when intubation of the guide wire fails despite the use of adjuvant endoscopy, as shown in this study. Fluoroscopically guided balloon dilation failed to obtain the sustained symptom relief in one of our 17 study patients (6%). In this patient, the stricture at the gastrojejunostomy was resistant to both the initial and second balloon dilations because of its tortuousness and twisting and surgery was finally required. We agree that patients who do not respond well to an initial dilation procedure may be unlikely to respond more favorably to subsequent dilations and may require early surgery (1,7). As an alternative to surgery, temporary placement of a retrievable expandable metallic stent can be effective for those patients who show resistance to balloon therapy. Bae et al (25) attempted temporary placement of a polytetrafluoroethylene (PTFE)-covered retrievable expandable nitinol stent for 2 months to treat a benign anastomotic duodenojejunal stricture which was refractory to repeated balloon dilations; they achieved a favorable outcome without any complications up to 6 months after the stent removal.
Kim et al
The principal limitation of this study is the nonrandomized and retrospective fashion, which may decrease the statistical strength. Nevertheless, this study may provide an attractive hypothesis that supports future prospective randomized studies with proper methodologic designs. In conclusion, fluoroscopically guided balloon dilation seems to be effective and safe for patients with benign anastomotic stricture causing gastric outlet obstruction. In addition, a luminal diameter of 20 mm seems to be optimal to be achieved in benign anastomotic strictures at gastroenterostomies to prevent recurrent symptoms with the fewest complications. Acknowledgments: The authors thank Bonnie Hami, MA, of the Department of Radiology, University Hospitals Health System, Cleveland, OH, for her editorial assistance in the preparation of this manuscript.
References 1. Holt PD, de Lange EE, Shaffer HA. Strictures after gastric surgery: treatment with fluoroscopically guided balloon dilatation. AJR Am J Roentgenol 1995; 164:895– 899. 2. Kozarek RA, Botoman VA, Patterson DJ. Long-term follow-up in patients who have undergone balloon dilation for gastric outlet obstruction. Gastrointest Endosc 1990; 36:558 –561. 3. Kuwada KS, Alexander GL. Longterm outcome of endoscopic dilation of nonmalignant pyloric stenosis. Gastrointest Endosc 1995; 41:15–17. 4. Lau JYW, Chung SCS, Sung JJY, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc 1996; 43:98 –101. 5. Glaser D, Mason A, Le Port P. Balloon dilation in functional gastric outlet obstruction. J Clin Gastroenterol 1995; 20:178. 6. Vance PL, de Lange EE, Shaffer HA, Schirmer B. Gastric outlet obstruction following surgery for morbid obesity: efficacy of fluoroscopically guided balloon dilation. Radiology 2002; 222:70 –72. 7. Perng CL, Lin HJ, Lo WC, Lai CR, Guo WS, Lee SD. Characteristics of patients with benign gastric outlet obstruction requiring surgery after endoscopic balloon dilation. Am J Gastroenterol 1996; 91:987–990. 8. Hogan RB, Hamilton JK, Polter DE. Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction. Gastrointest Endosc 1986; 32:71–74.
•
703
9. Misra SP, Dwivedi M. Long-term follow-up of patients undergoing balloon dilation for benign pyloric stenoses. Endoscopy 1996; 28:552–554. 10. Hewitt PM, Krige JEJ, Funnell IC, Wilson C, Bornman PC. Endoscopic balloon dilatation of peptic pyloroduodenal strictures. J Clin Gastroenterol 1999; 28:33–35. 11. DiSario JA, Fennerty MB, Tietze CC, Hutson WR, Burt RW. Endoscopic balloon dilation for ulcer-induced gastric outlet obstruction. Am J Gastroenterol 1994; 89:868 – 871. 12. Solt J, Bajor J, Szabó M, Horváth ÖP. Long-term results of balloon catheter dilation for benign gastric outlet stenosis. Endoscopy 2003; 35:490 – 495. 13. Song HY, Shin JH, Lim JO, Kim TH, Lee GH, Lee SK. Use of a newly designed multifunctional coil catheter for stent placement in the upper gastrointestinal tract. J Vasc Interv Radiol 2004; 15:369 –373. 14. Shin JH, He X, Lee JH, et al. Newly designed multifunctional coil catheter for gastrointestinal intervention: feasibility determined by experimental study in dogs. Invest Radiol 2003; 38: 796 – 801. 15. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of interventional radiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14:S199 –S202. 16. Jung GS, Song HY, Seo TS, et al. Malignant gastric outlet obstructions: treatment by means of coaxial placement of uncovered and covered expandable nitinol stents. J Vasc Interv Radiol 2002; 13:275–283. 17. Song HY, Shin JH, Yoon CJ, et al. A dual expandable nitinol stent: experience in 102 patients with malignant gastroduodenal strictures. J Vasc Interv Radiol 2004; 15:1443–1449. 18. Kretzschmar CS, Hamilton JW, Wissler DW, Yale CE, Morrissey JF. Balloon dilatation for the treatment of stomal stenosis complicating gastric surgery for morbid obesity. Surgery 1987; 102: 443– 446. 19. Buckwalter JA, Herbst CA. Perioperative complications of gastric restrictive operations. Am J Surg 1983; 146: 613– 618. 20. Wolper JC, Messmer JM, Turner MA, Sugerman HJ. Endoscopic dilation of late stomal stenosis. Arch Surg 1984; 119:836 – 837. 21. de Lange EE, Shaffer HA. Anastomotic strictures of the upper gastrointestinal tract: results of balloon dilation. Radiology 1988; 167:45–50. 22. McLean GK, Cooper GS, Hartz WH, Burke DR, Meranze SG. Radiologically guided balloon dilation of gastrointestinal strictures. II. Results of long-
704
•
Balloon Dilation for Benign Gastric Outlet Anastomotic Obstruction
term follow-up Radiology 1987; 165:41– 43. 23. Sataloff DM, Lieker CP, Seinige UL. Strictures following gastric stapling for morbid obesity: results of endoscopic dilatation. Am Surg 1990; 56:167–174.
24. McLean GK, Cooper GS, Hartz WH, Burke DR, Meranze SG. Radiologically guided balloon dilation of gastrointestinal strictures. I. Technique and factors influencing procedural success. Radiology 1987; 165:35– 40.
May 2005
JVIR
25. Bae JI, Shin JH, Song HY, Lee GH. Treatment a benign anastomotic duodenojejunal stricture with a polytetrafluoroethylene-covered retrievable expandable nitinol stent. J Vasc Interv Radiol 2004; 15:769 –772.
PURPOSE: To evaluate the clinical efficacy and safety of fluoroscopically guided balloon dilation of gastric outlet obstruction caused by benign anastomotic stricture. MATERIALS AND METHODS: Fluoroscopically guided balloon dilation was performed on 17 patients with gastric outlet obstruction caused by benign anastomotic stricture. Fourteen patients underwent surgery for malignant disease and three patients for complication of benign gastric ulcer. The sites of anastomotic stricture were gastrojejunal (n ⴝ 12) or gastroduodenal (n ⴝ 5). An upper gastrointestinal (UGI) series was performed just following and 1 month after balloon dilation to evaluate both the clinical success of the procedure and any complications. A dietary intake was evaluated by using the score for patients with malignant dysphagia and the pre- and postballoon dilation scores were analyzed with the Wilcoxon signed rank test. RESULTS: In all patients, fluoroscopically guided balloon dilation was performed in one (n ⴝ 15) or two (n ⴝ 2) sessions and was technically and clinically successful (100%). The diameters of the balloon catheters used were 15 mm (n ⴝ 4), 20 mm (n ⴝ 14), and 25 mm (n ⴝ 1 mm; mean, 19.5 mm) in a total of 19 sessions. All patients had significant improvement of their levels of dietary intake (P < .001). Two of the 17 patients required the second procedure due to recurrent symptom nine and 15 months, respectively, after initial balloon dilation. Overall, 16 patients (94%) showed good results and no recurrence during a mean follow-up period of 13.5 months (range, 5–39 months). There were no major complications associated with balloon dilation. CONCLUSION: Fluoroscopically guided balloon dilation seems to be effective and safe for patients with gastric outlet obstruction caused by benign anastomotic stricture. Achieving a luminal diameter of 20 mm seems to be necessary to prevent recurrence of symptoms. J Vasc Interv Radiol 2005; 16:699 –704 Abbreviations: PTFE ⫽ polytetrafluoroethylene, UGI ⫽ upper gastrointestinal
IT is well known that anastomotic stricture after gastric surgery is a common complication that requires treatment if
From the Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388 –1, Pungnap-2dong, Songpa-gu, Seoul 138 –736, Korea. Presented at the 2005 SIR Annual Meeting. Received October 11, 2004; revision requested November 20; revision received and accepted December 9. Address correspondence to J.H.S.; E-mail: jhshin@amc. seoul.kr This investigation has disclosed a potential conflict of interest. None of the other authors have identified a potential conflict of interest. © SIR, 2005 DOI: 10.1097/01.RVI.0000153923.38343.72
significant obstruction occurs (1). As nonsurgical treatment for benign postoperative stricture or stricture of the gastric outlet, endoscopically or fluoroscopically guided balloon dilation has been a safe and effective modality and alternative to surgery according to numerous literature reports (1–12). It is a quick procedure with relatively low cost and involving less time than surgery. Fluoroscopically guided balloon dilation was introduced more recently than endoscopically balloon dilation and has advantages over the endoscopically guided method (6). In brief, fluoroscopy allows not only identification of the proximal and distal ends of a stricture
but also fluoroscopic control of the entire balloon catheter during its placement and inflation. As endoscopy cannot visualize the distal end of a stricture, endoscopically guided balloon dilation can potentially cause severe laceration or perforation. There are a few reports focusing on fluoroscopically guided balloon dilation for gastric outlet obstruction due to benign anastomotic strictures (1,6); moreover, their most indication for balloon dilation was gastric outlet obstruction after surgery for morbid obesity. The purpose of our study was to evaluate the clinical efficacy and safety of fluoroscopically guided balloon di-
699
700
•
Balloon Dilation for Benign Gastric Outlet Anastomotic Obstruction
lation in the treatment of patients with gastric outlet obstruction caused by benign anastomotic stricture.
MATERIALS AND METHODS Patients From March 2001 to December 2003, 17 patients with benign anastomotic stricture after gastric surgery were referred to our department (Table; available online at www.jvir.org). Fourteen patients underwent surgery for malignant disease and three patients for complication of benign gastric ulcer. Our institution does not require institutional review board approval for retrospective review of patient records or images. Diagnosis was established in all patients by means of endoscopic biopsy and was proved to be benign anastomotic stricture without any other cause such as marginal ulcer or malignancy. There were 11 male and six female patients in our study, with an average age of 61.9 years (range, 47–76 years). The sites of anastomotic stricture were gastrojejunal (n ⫽ 12) or gastroduodenal (n ⫽ 5). Their major symptoms were vomiting or dysphagia. Upper gastrointestinal (UGI) series and endoscopy were performed within 2 weeks prior to the balloon dilation to confirm the degree and location of the stricture. Balloon Dilation Technique Informed consent was obtained from all study patients at the time of the procedure. Balloon dilation was performed by one of two interventional radiologists with more than 2 years of experience with this technique. Strictures were initially treated with balloon dilation 2 weeks to 7.6 years (mean, 9.4 months) after surgery. Topical anesthesia of the pharynx was routinely achieved prior to the procedure with an aerosol spray of lidocaine hydrochloride (Dai Han, Seoul, Korea). Neither sedatives nor general anesthesia was used. A nasogastric tube was placed in all patients 24 hours before the procedure to empty the stomach. With fluoroscopic guidance, a 0.035inch exchange guide wire (Terumo, Tokyo, Japan) was inserted through the patient’s mouth and down the esopha-
gus into the remnant stomach. When intubation of the stricture was difficult with fluoroscopic guidance alone, we performed it with the aid of endoscopy or a gastric sheath to provide the stability for cannulation of the stricture. The gastric sheath was made with a polytetrafluoroethylene (PTFE) tube (6 mm in diameter, 70 cm long) with a bent tip (3 cm long, 60° angle). It was designed to effectively guide the guide wire, balloon catheter or stent introducer toward the stricture site of the gastric outlet or duodenum. A multifunctional coil catheter (S & G biotec, Seoul, Korea) was then passed over the guide wire into the distal part of the stricture. Through the multifunctional coil catheter, we injected contrast medium to opacify the area of interest while a guide wire was in place and measured the diameter and length of the strictures as described previously (13,14). The coil catheter was then removed with the guide wire left in place. Then an angioplasty balloon catheter (Cordis, Roden, The Netherlands) was passed over the guide wire to a position over the stricture. The balloon was slowly inflated with fluoroscopic guidance with hand pressure with diluted water-soluble contrast medium for 1 to 3 minutes until the “hourglass deformity” created by the stricture disappeared from the balloon contour or the patient could not tolerate further inflation. A pressure gauge was not used. The ultimate diameter of the balloon was chosen on the basis of our projection of the desirable anastomotic diameter (usually 20 mm) to be achieved. Usually, a 10- or 15-mm balloon was initially used. If dilation with a 10- or 15-mm balloon was easily accomplished and the patient did not experience severe pain during the dilation, we progressed to a 20-mm balloon. However, in three patients (patients 3, 6, 7), the maximum balloon diameter used was 15 mm because of tightness of the stricture and our concern that 20-mm balloon dilation might increase the risk of perforation. In one patient (patient 15) with suspected functional gastric outlet obstruction, the maximum balloon diameter used was 25 mm because the stricture in this patient was mild and the balloon showed no waist during the 20-mm-diameter balloon dilation. Immediately after balloon dilation, a UGI series was performed with water-soluble contrast medium to con-
May 2005
JVIR
firm whether there was a perforation. If there was no evidence of perforation using water-soluble contrast medium, a UGI series with barium was performed to evaluate the degree of contrast passage. Follow-up All patients underwent a UGI series with barium 1 month after balloon dilation to verify the status of the stricture and the presence of passage disturbance. A further follow-up UGI series was only performed in patients with recurrent symptoms. When study patients did not visit our hospital during the follow-up period, the patients or their families were contacted by telephone for information concerning vomiting or dysphagia. Analysis of Results According to the Society of Interventional Radiology (SIR) reporting standards (15), we defined major complications as those that required further treatment or more hospitalization and minor complications as those that resolved spontaneously or with conservative treatment. Patient ability to swallow was expressed as a dysphagia score similar to that used in patients with malignant dysphagia (16,17) (online Table). The pre- and postballoon dilation scores were analyzed with the Wilcoxon signed rank test; P ⬍ .05 was considered statistically significant. The improvement of dysphagia was defined as a decrease of more than one grade in the dysphagia score 1 month after balloon dilation. Technical success was defined as successful dilation without any major complications. Clinical success was defined as improvement of dysphagia and good gastric emptying as demonstrated on a UGI series performed one month after balloon dilation. Recurrence was defined as the return of symptoms.
RESULTS The results are summarized in the online Table. In all patients, fluoroscopically guided balloon dilation was performed in one (n ⫽ 15) or two (n ⫽ 2) sessions and was technically successful in all patients (100%) (Figure). The diameter of the balloon catheter
Volume 16
Number 5
Kim et al
•
701
Figure. Fluoroscopically guided balloon dilation (patient 2) for anastomotic stricture at gastroduodenostomy. (a) UGI series before balloon dilation showed severe anastomotic stricture (arrow) at gastroduodenostomy. (b) Intubation of the guide wire with adjuvant endoscopy with fluoroscopic guidance failed in this patient. After use of the gastric sheath (arrowheads), the guide wire and coil catheter were successfully inserted through the stricture (arrows). (c, d) A 20-mm-diameter balloon was placed and inflated until the waist formed by the stricture disappeared. In addition to its assistance for intubation of the guide wire or catheter, the gastric sheath also gives extra stability during the balloon inflation. (e) UGI series with water-soluble nonionic contrast medium immediately after balloon dilation showed improvement of the luminal diameter (arrow).
used was 15 mm (n ⫽ 4), 20 mm (n ⫽ 14), and 25 mm (n ⫽ 1) (mean: 19.5 mm) in a total of 19 sessions. In five sessions, insertion of the guide wire was difficult with fluoroscopic guidance because of the severe stricture and dilated stomach. The guide wire was successfully inserted in one session with the help of endoscopy. In the remaining four sessions in which ad-
juvant endoscopy failed, the gastric sheath was effective for successful insertion of the guide wire. One month after balloon dilation, all patients showed improvement of their presenting symptoms and good contrast passage on UGI series. Therefore, clinical success was achieved in all patients (100%) and they all experienced improvement of more than
one grade in their level of dietary intake (online Table). The median dysphagia score improved from 3 to 0. When pre- and post- procedure scores were compared, a statistically significant improvement in overall scores was seen (Wilcoxon signed rank test, P ⬍ .001). Fifteen patients (88%) required only one session of dilation for sustained
702
•
Balloon Dilation for Benign Gastric Outlet Anastomotic Obstruction
relief of their clinical symptoms during the follow-up period (5ⵑ39 months). In three of these 15 patients (patient 1, 4, 15), the waist of the balloon formed by the stricture was not visible and showed easier distensibility on 20-mm or 25-mm-diameter balloon inflation. A presumptive diagnosis of functional gastric outlet obstruction was made in these three patients. Two patients (patients 3 and 7) required second balloon dilations caused by their recurrent symptoms nine and 15 months after the initial balloon dilation, respectively. During the second attempted procedure in patient 7, the lumen of the stricture site had been dilated to 15 mm without resistance; we then used a 20-mm-diameter balloon in this patient and dilated until the mild waist formation disappeared. This patient obtained sustained symptom relief during the follow-up period until the end of this study (24 months) after the second balloon dilation. In patient 3, the stricture seemed resistant to the initial balloon dilation because the stricture site of the gastrojejunostomy was tortuous and twisted. This patient also showed resistance to the second balloon dilation. In contrast to the initial balloon dilation, this patient showed little symptom improvement after the second procedure and eventually underwent surgical revision. Overall, 16 patients (94%) experienced good results and no recurrence during a mean follow-up period of 13.5 months (range, 5–39 months). There were no major complications associated with balloon dilation. As for minor complications, a small amount of mucosal bleeding occurred in two patients (13%) immediately after balloon dilation. The balloons were tinged with blood in these patients. However, this bleeding resolved spontaneously within one hour without significant clinical sequelae.
DISCUSSION It is well known that stricture of the gastric outlet is a common complication after gastric surgery and occurs in 3% to 13% of cases (18 –20). In most cases, the stricture occurs soon after surgery, usually within the first 2 months (1). The causes of stricture after surgery include postoperative
anastomotic ischemia, anastomotic edema, and fibrosis. Since its initial use in the esophagus, fluoroscopically guided balloon dilation has been a safe and effective treatment for a variety of strictures in the upper gastrointestinal tract, including lysis of anastomotic strictures (21). Balloon dilation is a simple and quick procedure and is linked to low morbidity and no mortality. Alternative therapeutic modalities, such as bougienage or surgical revision, involve considerably more time and risk. An anastomotic stricture is usually a short lesion resulting from a single, discrete event, and it would thus appear that these lesions are most ideally suited to balloon therapy (22). Over the past decade, endoscopically or fluoroscopically guided balloon dilation has been effective for treating gastric outlet obstruction caused by benign anastomotic strictures. In one series, endoscopic balloon dilation was performed for gastric outlet obstruction in 40 patients who had undergone either vertical banded gastroplasty or gastric bypass surgery for morbid obesity (23). Endoscopic balloon dilation was effective in 27 patients (68%), and surgical revision was necessary in the other 13 patients (32%) during their follow-up of 4 months to 4 years. In another series, 18 of 24 patients (75%) with anastomotic strictures or pyloric narrowing after gastric surgery were successfully treated by fluoroscopically guided balloon dilation; the other six patients (25%) required surgery during the follow-up period ranging from 1 to 36 months (1). The reported results of endoscopically or fluoroscopically guided balloon dilation were both effective. However, fluoroscopically guided balloon dilation has advantages over endoscopically guided dilation. Although endoscopy can directly visualize the proximal end of the stricture and can confirm the diagnosis by means of biopsy, endoscopy cannot visualize the distal end of the stricture; therefore, the interventional devices are passed distally without visual control and perforation by the tip of the dilator may occur (2,21). In contrast, fluoroscopy allows not only identification of the proximal and distal ends of the stricture but also visual control of the entire balloon catheter during its
May 2005
JVIR
placement and inflation. Complete visual control is more important when treating anastomotic strictures which occur at an acute angled site such as a gastroenterostomy. When we reviewed the literature regarding balloon therapy for benign gastric outlet obstruction, serious complications, such as arterial bleeding or immediate perforation requiring surgery, occurred in patients who underwent endoscopically guided balloon dilation (2,4,7,11,12), while no serious complications occurred in patients who underwent fluoroscopically guided balloon dilation (1,6,22,24). Stricture occurring at gastroenterostomies should be dilated enough to prevent symptoms of obstruction but not so much as to allow excessively rapid dumping of luminal contents into the anastomosed distal bowel (24). It is therefore important to find the optimal diameter. McLean et al (22,24) have targeted a luminal diameter of 12 mm or 15 mm for 22 patients with anastomotic strictures at the gastrojejunostomy (ie, 12 mm for patients who have undergone gastrojejunostomy for morbid obesity and a diameter of 15 mm for those who have undergone gastrojejunostomy for other reasons). Among their 22 patients, six patients (27%) did not show symptom improvement, and they did not provide the long-term results and any data of the remaining 16 patients (22,24). Kozarek et al (2) used a mean 15 mm diameter of balloon for 23 patients with benign gastric outlet obstruction including seven benign anastomotic strictures. Only three (43%) of the seven patients with anastomotic strictures obtained sustained symptom relief during their long-term follow-up. In our study, we used a larger balloon (mainly 20 mm in diameter) and achieved better results in patients with benign anastomotic strictures causing gastric outlet obstruction than those results in the previous reports (1,2,22–24) without notable complications. Among all our study patients except one who showed resistance to balloon dilation, 13 patients who underwent 20-mm-diameter balloon dilation showed sustained symptom relief and no recurrence. One of the three patients who underwent 15-mm balloon dilation showed symptom recurrence 15 months after first balloon dilation although the full 15-mm lumi-
Volume 16
Number 5
nal diameter had been achieved. After achieving 20-mm luminal diameter at the stricture in this patient, her symptoms improved and symptom recurrence did not occur during the follow-up up to 24 months after the second attempt. In addition, in cases of functional gastric outlet obstruction suspected because the stricture was mild compared with their symptoms and showed easier distensibility on balloon inflation, treatment with lager balloon (20 –25 mm) catheters was effective in this study as it was in other reports (5,12). Therefore, our study shows that a luminal diameter of at least 20 mm should be achieved to prevent symptoms of obstruction in benign anastomotic strictures at gastroenterostomy. Intubation of the guide wire seems to be difficult in severe strictures on gastroenterostomies because of its angulation and the little side support of the capacious stomach. In this situation, adjuvant endoscopy may be helpful because it gives extra-stability for the guide wire or balloon catheter passing through the stricture. In addition, the gastric sheath may be effective for inserting the guide wire when intubation of the guide wire fails despite the use of adjuvant endoscopy, as shown in this study. Fluoroscopically guided balloon dilation failed to obtain the sustained symptom relief in one of our 17 study patients (6%). In this patient, the stricture at the gastrojejunostomy was resistant to both the initial and second balloon dilations because of its tortuousness and twisting and surgery was finally required. We agree that patients who do not respond well to an initial dilation procedure may be unlikely to respond more favorably to subsequent dilations and may require early surgery (1,7). As an alternative to surgery, temporary placement of a retrievable expandable metallic stent can be effective for those patients who show resistance to balloon therapy. Bae et al (25) attempted temporary placement of a polytetrafluoroethylene (PTFE)-covered retrievable expandable nitinol stent for 2 months to treat a benign anastomotic duodenojejunal stricture which was refractory to repeated balloon dilations; they achieved a favorable outcome without any complications up to 6 months after the stent removal.
Kim et al
The principal limitation of this study is the nonrandomized and retrospective fashion, which may decrease the statistical strength. Nevertheless, this study may provide an attractive hypothesis that supports future prospective randomized studies with proper methodologic designs. In conclusion, fluoroscopically guided balloon dilation seems to be effective and safe for patients with benign anastomotic stricture causing gastric outlet obstruction. In addition, a luminal diameter of 20 mm seems to be optimal to be achieved in benign anastomotic strictures at gastroenterostomies to prevent recurrent symptoms with the fewest complications. Acknowledgments: The authors thank Bonnie Hami, MA, of the Department of Radiology, University Hospitals Health System, Cleveland, OH, for her editorial assistance in the preparation of this manuscript.
References 1. Holt PD, de Lange EE, Shaffer HA. Strictures after gastric surgery: treatment with fluoroscopically guided balloon dilatation. AJR Am J Roentgenol 1995; 164:895– 899. 2. Kozarek RA, Botoman VA, Patterson DJ. Long-term follow-up in patients who have undergone balloon dilation for gastric outlet obstruction. Gastrointest Endosc 1990; 36:558 –561. 3. Kuwada KS, Alexander GL. Longterm outcome of endoscopic dilation of nonmalignant pyloric stenosis. Gastrointest Endosc 1995; 41:15–17. 4. Lau JYW, Chung SCS, Sung JJY, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc 1996; 43:98 –101. 5. Glaser D, Mason A, Le Port P. Balloon dilation in functional gastric outlet obstruction. J Clin Gastroenterol 1995; 20:178. 6. Vance PL, de Lange EE, Shaffer HA, Schirmer B. Gastric outlet obstruction following surgery for morbid obesity: efficacy of fluoroscopically guided balloon dilation. Radiology 2002; 222:70 –72. 7. Perng CL, Lin HJ, Lo WC, Lai CR, Guo WS, Lee SD. Characteristics of patients with benign gastric outlet obstruction requiring surgery after endoscopic balloon dilation. Am J Gastroenterol 1996; 91:987–990. 8. Hogan RB, Hamilton JK, Polter DE. Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction. Gastrointest Endosc 1986; 32:71–74.
•
703
9. Misra SP, Dwivedi M. Long-term follow-up of patients undergoing balloon dilation for benign pyloric stenoses. Endoscopy 1996; 28:552–554. 10. Hewitt PM, Krige JEJ, Funnell IC, Wilson C, Bornman PC. Endoscopic balloon dilatation of peptic pyloroduodenal strictures. J Clin Gastroenterol 1999; 28:33–35. 11. DiSario JA, Fennerty MB, Tietze CC, Hutson WR, Burt RW. Endoscopic balloon dilation for ulcer-induced gastric outlet obstruction. Am J Gastroenterol 1994; 89:868 – 871. 12. Solt J, Bajor J, Szabó M, Horváth ÖP. Long-term results of balloon catheter dilation for benign gastric outlet stenosis. Endoscopy 2003; 35:490 – 495. 13. Song HY, Shin JH, Lim JO, Kim TH, Lee GH, Lee SK. Use of a newly designed multifunctional coil catheter for stent placement in the upper gastrointestinal tract. J Vasc Interv Radiol 2004; 15:369 –373. 14. Shin JH, He X, Lee JH, et al. Newly designed multifunctional coil catheter for gastrointestinal intervention: feasibility determined by experimental study in dogs. Invest Radiol 2003; 38: 796 – 801. 15. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of interventional radiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14:S199 –S202. 16. Jung GS, Song HY, Seo TS, et al. Malignant gastric outlet obstructions: treatment by means of coaxial placement of uncovered and covered expandable nitinol stents. J Vasc Interv Radiol 2002; 13:275–283. 17. Song HY, Shin JH, Yoon CJ, et al. A dual expandable nitinol stent: experience in 102 patients with malignant gastroduodenal strictures. J Vasc Interv Radiol 2004; 15:1443–1449. 18. Kretzschmar CS, Hamilton JW, Wissler DW, Yale CE, Morrissey JF. Balloon dilatation for the treatment of stomal stenosis complicating gastric surgery for morbid obesity. Surgery 1987; 102: 443– 446. 19. Buckwalter JA, Herbst CA. Perioperative complications of gastric restrictive operations. Am J Surg 1983; 146: 613– 618. 20. Wolper JC, Messmer JM, Turner MA, Sugerman HJ. Endoscopic dilation of late stomal stenosis. Arch Surg 1984; 119:836 – 837. 21. de Lange EE, Shaffer HA. Anastomotic strictures of the upper gastrointestinal tract: results of balloon dilation. Radiology 1988; 167:45–50. 22. McLean GK, Cooper GS, Hartz WH, Burke DR, Meranze SG. Radiologically guided balloon dilation of gastrointestinal strictures. II. Results of long-
704
•
Balloon Dilation for Benign Gastric Outlet Anastomotic Obstruction
term follow-up Radiology 1987; 165:41– 43. 23. Sataloff DM, Lieker CP, Seinige UL. Strictures following gastric stapling for morbid obesity: results of endoscopic dilatation. Am Surg 1990; 56:167–174.
24. McLean GK, Cooper GS, Hartz WH, Burke DR, Meranze SG. Radiologically guided balloon dilation of gastrointestinal strictures. I. Technique and factors influencing procedural success. Radiology 1987; 165:35– 40.
May 2005
JVIR
25. Bae JI, Shin JH, Song HY, Lee GH. Treatment a benign anastomotic duodenojejunal stricture with a polytetrafluoroethylene-covered retrievable expandable nitinol stent. J Vasc Interv Radiol 2004; 15:769 –772.