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How to treat stenosis after sleeve gastrectomy?
Author’s Accepted Manuscript How to treat stenosis after sleeve gastrectomy? Thierry Manos, Marius Nedelcu, Adrian Cotirlet, Imane Eddbali, Michel Gagner, Patrick Noel
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PII: DOI: Reference:
S1550-7289(16)30673-6 http://dx.doi.org/10.1016/j.soard.2016.08.491 SOARD2742
To appear in: Surgery for Obesity and Related Diseases Received date: 14 May 2016 Revised date: 7 August 2016 Accepted date: 19 August 2016 Cite this article as: Thierry Manos, Marius Nedelcu, Adrian Cotirlet, Imane Eddbali, Michel Gagner and Patrick Noel, How to treat stenosis after sleeve g a stre c to my ? , Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2016.08.491 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
How to treat stenosis after sleeve gastrectomy? Thierry MANOS1, Marius NEDELCU2,3, Adrian COTIRLET4, Imane EDDBALI5, Michel GAGNER6, Patrick NOEL5 1
Bouchard Clinic, Marseille, France
2
Sfantul Constantin Hospital, Brasov, Romania
3
Centre Hospitalier Universitaire Montpellier, France
4
Moinesti Emergency Hospital, Moinesti, Romania
5
The American Surgecenter, Abu Dhabi, UAE
6
Sacre Cœur Hospital, Montreal, Canada
Corresponding author: Marius NEDELCU Digestive Surgery University Hospital of Montpellier 80, Avenue Augustin Fliche, 34295, Montpellier, France [email protected] TM and MN contributed equally to this work.
1
ABSTRACT:
Introduction: Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Numerous articles have been written about the different approaches to the management of gastric fistulas, but limited data can be found concerning gastric stenosis after LSG.
Setting: Private hospital, France
Methods: A total of 18 patients received endoscopic treatment of stenosis after LSG between May 2007 and June 2015. The stenosis was classified according to the endoscopic findings: functional (the passage of the endoscope was possible but the sleeve was twisted with various degrees of rotation) or mechanical stenosis (when the passage of the endoscope was very difficult or impossible).
Results: There were 13 women and 5 men, with an average age of 37.2 years (± 8.4) and an average Body Mass Index (BMI) of 41.6 kg/m2 (± 8.7). The average number of endoscopic procedures was 1.3 (range 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4 % with one patient requiring conversion to Roux-en-Y gastric bypass. The mean time from the LSG to the first endoscopic intervention was 28.2 days. All patients presented with mid-sleeve stricture, located near the incisura angularis and no patient showed a stenosis in the upper part of the gastric tube.
Conclusions: The treatment of stenosis following LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilatation and stent deployment are useful and safe tools and must be used when appropriate.
2
Keywords: sleeve – stenosis – stent – endoscopic dilatation
INTRODUCTION:
Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Initially, LSG was accepted as a first-stage procedure in high-risk or super-obese patients, but the popularity of the procedure increased as it started to be used as a single-stage procedure. LSG became the most frequent bariatric procedure both in France in 2011 and in the United States in 2013
(1,2)
. LSG is generally considered a
straightforward procedure, but the surgical technique is one of the major determinants of the postoperative complications. Besides the staple line leak, the other severe complication after LSG is represented by the gastric stenosis, with an incidence of 0.5 – 1 % (3). Numerous articles have been written about the different approaches to the management of gastric leaks, but limited data can be found concerning gastric stenosis after LSG (4-9).
The purpose of the present study was to evaluate the efficacy and safety of endoscopic treatment of stenosis after LSG in order to reduce the frequency of endoscopic interventions.
METHODS:
A total of 18 patients received endoscopic treatment for stenosis after LSG between May 2007 and June 2015 in Bouchard Clinic (Marseille, France). Patient demographics are summarized in Table 1. There were 13 women and 5 men, with an average age of 37.2 years and an average Body Mass Index (BMI) of 41.6 kg/m2.
3
The stenosis was classified according to the endoscopic findings. When a stenosis occurs, it is usually of two types: a functional one (the passage of the endoscope was possible but the sleeve was twisted with various degrees of rotation needing to pass the scope through the gastric lumen—the so-called Helix stenosis) or a mechanical one (when the passage of the endoscope was very difficult or impossible).
A new algorithm (Fig. 1) was used with the purpose to reduce endoscopic procedures. In case of functional stenosis, achalasia balloon dilators (Rigiflex II by Boston Scientific Corporation, USA) were used. The achalasia balloons were dilated to achieve 25 psi pneumatic pressure, and the pressure was maintained for a minimum of 60 s. A liquid alimentation was started the following day after radiologic control, for both for stent deployment and balloon dilatation. An endoscopic control is performed after 3 weeks. If the stenosis is complete with no possibility to pass the endoscope through, a 120–150-mm-long and 18-mm-wide Niti-S oesophageal stent (Taewoong Medical) is used for 3 weeks. After this period the self-expandable metal stent (SEMS) is removed. If a partial improvement of the stenosis is noticed another session with achalasia balloon dilators is performed. If no improvement is observed the surgical treatment is proposed. All patients were reviewed in a clinic visit 7 days after discharge to monitor their tolerance to the stent deployment. Informed consent was obtained from all individual participants included in the study.
4
RESULTS:
The average number of endoscopic procedures was 1.3 (range 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4 %,; one patient necessitated an additional surgical procedure. After 3 unsuccessful endoscopic sessions for a long functional stenosis, the sleeve was converted to Laparoscopic Roux-en-Y Gastric Bypass with partial gastrectomy of the gastric remnant.
The mean time from the LSG to the first endoscopic intervention was 28.2 days (± 12.6). For the group with complete stenosis the mean time of diagnosis was 9.5 days (± 4.3) and for the group with functional stenosis 43.2 days (± 14.2). The stenosis was also evaluated radiologically in 15 patients (83.3 %) and confirmed endoscopically. All patients presented with mid-sleeve stricture, located near the incisura angularis and no patient showed a stenosis in the upper part of the gastric tube.
In the presence of associated leak (3 cases), the deployment of a covered prosthesis, 20–23 cm in length and 24 French in diameter (HANAROSTENT, M.I. Tech, Seoul, Korea) was performed in order to expand the stenosis and reduce pressure inside the gastric sleeve. This approach is based on the algorithm of treatment of leak after LSG addressing leak size and gastric stenosis
(10)
.
After 4 weeks, the endoscopic reevaluation showed no stenosis and the leak fistulous site needed an additional session with a pigtail drain insertion.
Eleven patients (61.1 %) experienced nausea and/or vomiting during the first week, requiring IV antiemetics, but no prosthesis had to be removed for clinical intolerance.
5
DISCUSSIONS:
The reported incidence of stenosis ranges from 0.1 to 3.9 %
(3,11,12)
. The mechanism of the
stenosis after LSG could involve either a misalignement of the staple line, or resulting from an anatomical stricture of the gastric tube. Stricture and kinking may be avoided by keeping a safe distance between the incisura angularis and the edge where the staples are applied. It is mandatory to put a bougie in place while stapling at the point where the stomach turns. In our experience, the left hand stapling offers the correct direction “to respect the incisura angularis.” By the left hand stapling, the device will be parallel with the lesser curvature and not perpendicular, which is the case when performing a right hand stapling. All these technical aspects are detailed in the previous manuscript
(13)
. Keeping the staple line straight by resecting
symmetrically anterior and posterior walls of the stomach represent another important technical point of LSG. An excess volume of stomach from the back wall may twist the sleeve as the stapler is applied, leaving an uneven line of staples. Symmetrical lateral traction while stapling is of the utmost importance. Asymmetrical traction might lead to twist the staple line that may cause functional stenosis of LSG. Nimeri et al. (14) recommended the routine use of intraoperative endoscopy in LSG that can lead to a change in the operative strategy. In their experience intraoperative endoscopy showed stenosis in 10 LSG cases (3.2 %), which resolved after removing over-sewing sutures. Their clinical stenosis after LSG was 0 %. We are not performing the over-sewing of the staple line. Other authors (15, 16) have recommended fixing the “new” greater curvature with a few stitches to the omentum, since the connection to it was interrupted and the greater omentum helps to keep the stomach in the correct position. They reported that the gastric tube does not present proper
6
peristalsis, and that the fixation will avoid this coil shape may cause symptoms. In our experience, symmetrical anterior and posterior walls resection of the stomach is of the utmost importance for the gastric peristalsis.
Clinical presentation of stenosis is variable from difficulty in the passage of food through the gastric lumen, with regurgitation of retained food, vomiting, persistent nausea, to high-grade dysphagia manifested by sialorrhea. An important aspect for the stricture management is the timing of diagnosis and treatment. During the International Sleeve Gastrectomy Expert Panel Consensus statement, all experts agreed on the fact that most strictures were symptomatic in the first 6 weeks after surgery
(17)
. Postoperative radiological evaluation by upper gastrointestinal
study is important for the diagnosis and early management of stenosis following LSG. Zacharoulis et al. (18) reported five patients in which the contrast swallow studies showed a wide, dilated fundus with a relatively narrow proximal or mid-stomach, but without complete obstruction. In our experience, the two types of stenosis are also different by the moment of the diagnosis. For complete, mechanical type stenosis the diagnosis is early at a mean of 9.5 days after the initial procedure contrary to functional stenosis with a late diagnosis after 43.2 days after LSG.
Endoscopic management is generally one of the best alternatives to identify the characteristics of a stenosis and simultaneously to treat this complication. The majority of bariatric centers recommend the early management of sleeve stenosis using esophagogastroduodenoscopy balloon dilation as the first therapeutic option
(19-23)
. However, according to Shnell et al.
(5)
, balloon
dilation has an overall modest success rate of 44%. They have used either through-the-scope
7
balloon dilatation (3 cases) or pneumatic balloon dilatations (14 cases). They have also reported difficulty of insertion of the achalasia balloon dilator in some cases.
The use of an endoscopically placed cSEMS has been also documented
(6,8,24)
Eubanks et al.
(8)
used endoscopic covered stent placement to treat strictures. In a 7-day period of stenting, 6 patients had a success rate of 83%. The period the stent remained in place was only a week because it produced pain and had to be removed. However, they consider that the stent improved the chance of the stricture to be corrected as compared with dilation alone. Other authors (6) have reported the use of fully covered removable stents to manage the stenosis in five (19.2 %) patients who had failed balloon dilatation. All of these patients had long-segment stenosis at the incisura. However, results in the literature are not consistent because of migration or poor tolerance of the prosthesis, which seems to be quite common. Marquez et al (25) assume that these migrations were frequent due to the use of unsuitable material as originally planned for the treatment of esophageal strictures.
In case of associated leak with stenosis, the endoscopic pneumatic dilatation represents an interesting option
(26)
. The procedure must be performed with an achalasia balloon (Rigiflex®
balloon 30– 35 mm) over a stainless steel or super-stiff guide wire in consecutive dilation sessions with stepwise increments in dilation pressure from 15 to 25 psi. To be efficient, the procedure must be aggressive, and once the balloon is inflated under radiological guidance, the correction of the axis of the gastric tube is easily observed.
Different surgical approaches have been used to correct post-LSG stenosis not responsive to endoscopic treatment. Weiner et al.
(27)
described different surgical approach from simple
dissection of the adherences to complete release the gastric tube to conversion to Roux en Y
8
Gastric Bypass, the same approach reported early on by Lacy or Bellorin (28, 29) and probably the most common revisional procedure for stenosis after LSG. More conservative approaches include the circular gastro-gastrostomy described by Gagner et al. gastrectomy by Ammori et al.
(30)
or laparoscopic median
(31)
. Other surgical procedures have also been reported. Sudan et
al. (32) described the stricturoplasty performed in two patients; the stricture was incised along the longitudinal axis, incorporating the entire length of the stricture. The incision was then closed in the transverse axis in a single layer with permanent suture, resulting in a wider lumen, using the principles of the Heineke–Miculicz technique. Himpens et al.
(33)
have reported another surgical
procedure for long stenosis—laparoscopic seromyotomy.
CONCLUSIONS: The best method to treat a complication is to prevent it. In the case of stenosis particular attention must be offered to the incisura angularis during the initial procedure. We believe that the contrast study could be used as a first line investigation for diagnosing a stricture and assessing the length, alongside possible proximal dilatation of the sleeve. Still the upper endoscopy remains the gold standard to offer a detailed description of the stenosis and in the same time to offer the initial treatment. The treatment of stenosis following LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilatation and stent deployment are useful and safe tools and must be used when appropriate.
9
Disclosures: Author 1, Author 2, Author 4, have no conflicts of interest or financial ties to disclose. Author 3 has honorarium for speaking engagements from Ehicon Endosurgery, Covidien, Olympus, MID, Transenterix, Gore, Boehringer Labs. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required REFERENCES: 1. Lazzati A, Guy-Lachuer R, Delaunay V, Szwarcensztein K, Azoulay D. Bariatric surgery trends in France: 2005–2011. Surg Obes Relat Dis. 2014;10(2):328–334. 2. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–436. 3. Gagner M, Deitel M, Erickson AL, Crosby RD.Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013 Dec;23(12):2013-7. 4. Burgos AM, Csendes A, Braghetto I.Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg. 2013 Sep;23(9):1481-6. 5. Shnell M, Fishman S, Eldar S, Goitein D, Santo E.Balloon dilatation for symptomatic gastric sleeve stricture. Gastrointest Endosc. 2014 Mar;79(3):521-4. 6. Ogra R, Kini GP.Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand. Obes Surg. 2015 Feb;25(2):242-8.
10
7. Zundel N, Hernandez JD, Galvao Neto M, Campos JStrictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010 Jun;20(3):154-8. 8. Eubanks S, Edwards CA, Fearing NM, Ramaswamy A, de la Torre RA, Thaler KJ, Miedema BW, Scott JS. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008 May;206(5):935-8; 9. Rebibo L, Hakim S, Dhahri A, Yzet T, Delcenserie R, Regimbeau JMGastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management. Obes Surg. 2015 Sep 12. [Epub ahead of print] 10. Nedelcu M, Manos T, Cotirlet A, Noel P, Gagner M. Outcome of leaks after sleeve gastrectomy based on a new algorithm adressing leak size and gastric stenosis. Obes Surg. 2015 Mar;25(3):559-63. 11. Boza C, Salinas J, Salgado N, et al. Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: Report of 1,000 cases and 3-year follow-up. Obes Surg. 2012;22:866–71. 12. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–63. 13. Noel P, Nedelcu M, Gagner M. Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2015 Dec 28. [Epub ahead of print] 14. Nimeri A, Maasher A, Salim E, Ibrahim M, Al Hadad M. The Use of Intraoperative Endoscopy Decreases Postoperative Stenosis in Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016 Apr;26(4):864.
11
15. Gero D, Ribeiro-Parenti L, Marmuse JP. A Simple Trick to Prevent VOMIT After Sleeve Gastrectomy. Obes Surg. 2015 Jul;25(7):1252-3. 16. Santoro S. Technical aspects in sleeve gastrectomy. Obes Surg. 2007 Nov;17(11):1534-5. 17. Rosenthal RA. International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of 12,000 cases. Surg Obes Relat Dis. 2012;8:8– 19. 18. Triantafyllidis G, Lazoura O, Sioka E, et al. Anatomy and complications following laparoscopic sleeve gastrectomy: radiological evaluation and imaging pitfalls. Obes Surg. 2011;21:473–8. 19. Kupec JT, Goebel SU, Akkary E. The role of endoscopy in the treatment of obesity: current and future concepts. Pract Gastroenterol 2009;XXXIII:21–36. 20. Göttig S, Daskalakis M, Weiner S, Weiner R. Analysis of safety and efficacy of intragastric balloon in extremely obese patients. Obes Surg 2009;19:677– 83. 21. Gumbs A, Gagner M, Dakin G, Pomp A. Sleeve gastrectomy for morbid obesity. Obes Surg 2007;17:962–9. 22. Papailiou J, Albanopoulos K, Toutouzas K, Tsigris C, Nikiteas N, Zografos G. Morbid obesity and sleeve gastrectomy: how does it work? Obes Surg 2010;20:1448 –55. 23. Tang SJ, Rockey DC. The role of endoscopy in bariatrics. Clin Update 2008;16:1– 4. 24. Jones M, Healey AJ, Efthimiou E. Early use of self expanding metallic stents to relieve sleeve gastrectomy stenosis after intragastric balloon removal. Surg Obes Relat Dis. 2011 Sep-Oct;7(5):e16-7 25. Marquez M, Ayza FM, Belda LR, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20:1306–11.
12
26. Baretta G, Campos J, Correia S, Alhinho H, Marchesini JB, Lima JH, Neto MG. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc. 2015 Jul;29(7):1714-20. 27. Scheffel O, Weiner RA. Therapy of stenosis after sleeve gastrectomy: stent and surgery as alternativesdcase reports. Obes Facts 2011;4(suppl 1):47-9. 28. Lacy A, Ibarzabal A,ObearzabalA, et al. Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20:351–6. 29. Bellorin O, Lieb J, Szomstein S, et al. Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for acute gastric outlet obstruction after laparoscopic sleeve gastrectomy for morbid obesity. Surg Obes Relat Dis. 2010;6:566–8. 30. Parikh M, Gagner M. Laparoscopic revision of gastrogastric stricture with a transoral circular stapler. Surg Innov. 2007 Sep;14(3):225-30. 31. Kalaiselvan R, Ammori BJ. Laparoscopic median gastrectomy for stenosis following sleeve gastrectomy. Surg Obes Relat Dis. 2015 Mar-Apr;11(2):474-7. 32. Sudan R, Kasotakis G, Betof A, et al. Sleeve gastrectomy strictures: technique for robotic-assisted strictureplasty. Surg Obes Relat Dis. 2010;6:434–6. 33. Vilallonga R, Himpens J, van de Vrande S. Laparoscopic management of persistent strictures after laparoscopic sleevegastrectomy. Obes Surg. 2013 Oct;23(10):1655-61.
13
Table 1 – Demographic data
Gender:
n
%
Male
5
27.8
Female
13
72.2
Age (Years) (mean (± SD))
37.2 (± 8.4)
BMI (kg/m2) (mean (± SD))
41.6 (± 8.7)
BMI – Body Mass Index;
14
Table 2 – Review of the literature Team - year
No
Endoscopy
Surgery
4 dilatations (1-4)
1 RYGBP
patients Braghetto et al. (4) – 2013
5
(20 %) Shnell et al. (5) - 2014
16
16 dilatations (1-3)
5 RYGBP + 1 resleeve (37.5%)
Kini et al (6) - 2015
26
10 dilatation with CRE
0
11 Achalasia balloon dilatation 5 Stents MG Neto et al (7) – 2010
9
7 pneumatic dilatations
1 total gastrectomy 1 RYGB (22.2 %)
Eubanks et al (8) – 2008
6
6 stents after dilatation
1
undefined
surgery (17%) Rebibo et al (9) -2015
17
13 balloon dilatation 2 stents
2 RYGBP (11.7 %)
RYGB – Roux-en-Y Gastric Bypass; CRE – controlled radial expansion
15
Fig. 1 - Algorithm of endoscopic treatment of stenosis after LSG
16
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(16)30673-6 http://dx.doi.org/10.1016/j.soard.2016.08.491 SOARD2742
To appear in: Surgery for Obesity and Related Diseases Received date: 14 May 2016 Revised date: 7 August 2016 Accepted date: 19 August 2016 Cite this article as: Thierry Manos, Marius Nedelcu, Adrian Cotirlet, Imane Eddbali, Michel Gagner and Patrick Noel, How to treat stenosis after sleeve g a stre c to my ? , Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2016.08.491 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
How to treat stenosis after sleeve gastrectomy? Thierry MANOS1, Marius NEDELCU2,3, Adrian COTIRLET4, Imane EDDBALI5, Michel GAGNER6, Patrick NOEL5 1
Bouchard Clinic, Marseille, France
2
Sfantul Constantin Hospital, Brasov, Romania
3
Centre Hospitalier Universitaire Montpellier, France
4
Moinesti Emergency Hospital, Moinesti, Romania
5
The American Surgecenter, Abu Dhabi, UAE
6
Sacre Cœur Hospital, Montreal, Canada
Corresponding author: Marius NEDELCU Digestive Surgery University Hospital of Montpellier 80, Avenue Augustin Fliche, 34295, Montpellier, France [email protected] TM and MN contributed equally to this work.
1
ABSTRACT:
Introduction: Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Numerous articles have been written about the different approaches to the management of gastric fistulas, but limited data can be found concerning gastric stenosis after LSG.
Setting: Private hospital, France
Methods: A total of 18 patients received endoscopic treatment of stenosis after LSG between May 2007 and June 2015. The stenosis was classified according to the endoscopic findings: functional (the passage of the endoscope was possible but the sleeve was twisted with various degrees of rotation) or mechanical stenosis (when the passage of the endoscope was very difficult or impossible).
Results: There were 13 women and 5 men, with an average age of 37.2 years (± 8.4) and an average Body Mass Index (BMI) of 41.6 kg/m2 (± 8.7). The average number of endoscopic procedures was 1.3 (range 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4 % with one patient requiring conversion to Roux-en-Y gastric bypass. The mean time from the LSG to the first endoscopic intervention was 28.2 days. All patients presented with mid-sleeve stricture, located near the incisura angularis and no patient showed a stenosis in the upper part of the gastric tube.
Conclusions: The treatment of stenosis following LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilatation and stent deployment are useful and safe tools and must be used when appropriate.
2
Keywords: sleeve – stenosis – stent – endoscopic dilatation
INTRODUCTION:
Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Initially, LSG was accepted as a first-stage procedure in high-risk or super-obese patients, but the popularity of the procedure increased as it started to be used as a single-stage procedure. LSG became the most frequent bariatric procedure both in France in 2011 and in the United States in 2013
(1,2)
. LSG is generally considered a
straightforward procedure, but the surgical technique is one of the major determinants of the postoperative complications. Besides the staple line leak, the other severe complication after LSG is represented by the gastric stenosis, with an incidence of 0.5 – 1 % (3). Numerous articles have been written about the different approaches to the management of gastric leaks, but limited data can be found concerning gastric stenosis after LSG (4-9).
The purpose of the present study was to evaluate the efficacy and safety of endoscopic treatment of stenosis after LSG in order to reduce the frequency of endoscopic interventions.
METHODS:
A total of 18 patients received endoscopic treatment for stenosis after LSG between May 2007 and June 2015 in Bouchard Clinic (Marseille, France). Patient demographics are summarized in Table 1. There were 13 women and 5 men, with an average age of 37.2 years and an average Body Mass Index (BMI) of 41.6 kg/m2.
3
The stenosis was classified according to the endoscopic findings. When a stenosis occurs, it is usually of two types: a functional one (the passage of the endoscope was possible but the sleeve was twisted with various degrees of rotation needing to pass the scope through the gastric lumen—the so-called Helix stenosis) or a mechanical one (when the passage of the endoscope was very difficult or impossible).
A new algorithm (Fig. 1) was used with the purpose to reduce endoscopic procedures. In case of functional stenosis, achalasia balloon dilators (Rigiflex II by Boston Scientific Corporation, USA) were used. The achalasia balloons were dilated to achieve 25 psi pneumatic pressure, and the pressure was maintained for a minimum of 60 s. A liquid alimentation was started the following day after radiologic control, for both for stent deployment and balloon dilatation. An endoscopic control is performed after 3 weeks. If the stenosis is complete with no possibility to pass the endoscope through, a 120–150-mm-long and 18-mm-wide Niti-S oesophageal stent (Taewoong Medical) is used for 3 weeks. After this period the self-expandable metal stent (SEMS) is removed. If a partial improvement of the stenosis is noticed another session with achalasia balloon dilators is performed. If no improvement is observed the surgical treatment is proposed. All patients were reviewed in a clinic visit 7 days after discharge to monitor their tolerance to the stent deployment. Informed consent was obtained from all individual participants included in the study.
4
RESULTS:
The average number of endoscopic procedures was 1.3 (range 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4 %,; one patient necessitated an additional surgical procedure. After 3 unsuccessful endoscopic sessions for a long functional stenosis, the sleeve was converted to Laparoscopic Roux-en-Y Gastric Bypass with partial gastrectomy of the gastric remnant.
The mean time from the LSG to the first endoscopic intervention was 28.2 days (± 12.6). For the group with complete stenosis the mean time of diagnosis was 9.5 days (± 4.3) and for the group with functional stenosis 43.2 days (± 14.2). The stenosis was also evaluated radiologically in 15 patients (83.3 %) and confirmed endoscopically. All patients presented with mid-sleeve stricture, located near the incisura angularis and no patient showed a stenosis in the upper part of the gastric tube.
In the presence of associated leak (3 cases), the deployment of a covered prosthesis, 20–23 cm in length and 24 French in diameter (HANAROSTENT, M.I. Tech, Seoul, Korea) was performed in order to expand the stenosis and reduce pressure inside the gastric sleeve. This approach is based on the algorithm of treatment of leak after LSG addressing leak size and gastric stenosis
(10)
.
After 4 weeks, the endoscopic reevaluation showed no stenosis and the leak fistulous site needed an additional session with a pigtail drain insertion.
Eleven patients (61.1 %) experienced nausea and/or vomiting during the first week, requiring IV antiemetics, but no prosthesis had to be removed for clinical intolerance.
5
DISCUSSIONS:
The reported incidence of stenosis ranges from 0.1 to 3.9 %
(3,11,12)
. The mechanism of the
stenosis after LSG could involve either a misalignement of the staple line, or resulting from an anatomical stricture of the gastric tube. Stricture and kinking may be avoided by keeping a safe distance between the incisura angularis and the edge where the staples are applied. It is mandatory to put a bougie in place while stapling at the point where the stomach turns. In our experience, the left hand stapling offers the correct direction “to respect the incisura angularis.” By the left hand stapling, the device will be parallel with the lesser curvature and not perpendicular, which is the case when performing a right hand stapling. All these technical aspects are detailed in the previous manuscript
(13)
. Keeping the staple line straight by resecting
symmetrically anterior and posterior walls of the stomach represent another important technical point of LSG. An excess volume of stomach from the back wall may twist the sleeve as the stapler is applied, leaving an uneven line of staples. Symmetrical lateral traction while stapling is of the utmost importance. Asymmetrical traction might lead to twist the staple line that may cause functional stenosis of LSG. Nimeri et al. (14) recommended the routine use of intraoperative endoscopy in LSG that can lead to a change in the operative strategy. In their experience intraoperative endoscopy showed stenosis in 10 LSG cases (3.2 %), which resolved after removing over-sewing sutures. Their clinical stenosis after LSG was 0 %. We are not performing the over-sewing of the staple line. Other authors (15, 16) have recommended fixing the “new” greater curvature with a few stitches to the omentum, since the connection to it was interrupted and the greater omentum helps to keep the stomach in the correct position. They reported that the gastric tube does not present proper
6
peristalsis, and that the fixation will avoid this coil shape may cause symptoms. In our experience, symmetrical anterior and posterior walls resection of the stomach is of the utmost importance for the gastric peristalsis.
Clinical presentation of stenosis is variable from difficulty in the passage of food through the gastric lumen, with regurgitation of retained food, vomiting, persistent nausea, to high-grade dysphagia manifested by sialorrhea. An important aspect for the stricture management is the timing of diagnosis and treatment. During the International Sleeve Gastrectomy Expert Panel Consensus statement, all experts agreed on the fact that most strictures were symptomatic in the first 6 weeks after surgery
(17)
. Postoperative radiological evaluation by upper gastrointestinal
study is important for the diagnosis and early management of stenosis following LSG. Zacharoulis et al. (18) reported five patients in which the contrast swallow studies showed a wide, dilated fundus with a relatively narrow proximal or mid-stomach, but without complete obstruction. In our experience, the two types of stenosis are also different by the moment of the diagnosis. For complete, mechanical type stenosis the diagnosis is early at a mean of 9.5 days after the initial procedure contrary to functional stenosis with a late diagnosis after 43.2 days after LSG.
Endoscopic management is generally one of the best alternatives to identify the characteristics of a stenosis and simultaneously to treat this complication. The majority of bariatric centers recommend the early management of sleeve stenosis using esophagogastroduodenoscopy balloon dilation as the first therapeutic option
(19-23)
. However, according to Shnell et al.
(5)
, balloon
dilation has an overall modest success rate of 44%. They have used either through-the-scope
7
balloon dilatation (3 cases) or pneumatic balloon dilatations (14 cases). They have also reported difficulty of insertion of the achalasia balloon dilator in some cases.
The use of an endoscopically placed cSEMS has been also documented
(6,8,24)
Eubanks et al.
(8)
used endoscopic covered stent placement to treat strictures. In a 7-day period of stenting, 6 patients had a success rate of 83%. The period the stent remained in place was only a week because it produced pain and had to be removed. However, they consider that the stent improved the chance of the stricture to be corrected as compared with dilation alone. Other authors (6) have reported the use of fully covered removable stents to manage the stenosis in five (19.2 %) patients who had failed balloon dilatation. All of these patients had long-segment stenosis at the incisura. However, results in the literature are not consistent because of migration or poor tolerance of the prosthesis, which seems to be quite common. Marquez et al (25) assume that these migrations were frequent due to the use of unsuitable material as originally planned for the treatment of esophageal strictures.
In case of associated leak with stenosis, the endoscopic pneumatic dilatation represents an interesting option
(26)
. The procedure must be performed with an achalasia balloon (Rigiflex®
balloon 30– 35 mm) over a stainless steel or super-stiff guide wire in consecutive dilation sessions with stepwise increments in dilation pressure from 15 to 25 psi. To be efficient, the procedure must be aggressive, and once the balloon is inflated under radiological guidance, the correction of the axis of the gastric tube is easily observed.
Different surgical approaches have been used to correct post-LSG stenosis not responsive to endoscopic treatment. Weiner et al.
(27)
described different surgical approach from simple
dissection of the adherences to complete release the gastric tube to conversion to Roux en Y
8
Gastric Bypass, the same approach reported early on by Lacy or Bellorin (28, 29) and probably the most common revisional procedure for stenosis after LSG. More conservative approaches include the circular gastro-gastrostomy described by Gagner et al. gastrectomy by Ammori et al.
(30)
or laparoscopic median
(31)
. Other surgical procedures have also been reported. Sudan et
al. (32) described the stricturoplasty performed in two patients; the stricture was incised along the longitudinal axis, incorporating the entire length of the stricture. The incision was then closed in the transverse axis in a single layer with permanent suture, resulting in a wider lumen, using the principles of the Heineke–Miculicz technique. Himpens et al.
(33)
have reported another surgical
procedure for long stenosis—laparoscopic seromyotomy.
CONCLUSIONS: The best method to treat a complication is to prevent it. In the case of stenosis particular attention must be offered to the incisura angularis during the initial procedure. We believe that the contrast study could be used as a first line investigation for diagnosing a stricture and assessing the length, alongside possible proximal dilatation of the sleeve. Still the upper endoscopy remains the gold standard to offer a detailed description of the stenosis and in the same time to offer the initial treatment. The treatment of stenosis following LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilatation and stent deployment are useful and safe tools and must be used when appropriate.
9
Disclosures: Author 1, Author 2, Author 4, have no conflicts of interest or financial ties to disclose. Author 3 has honorarium for speaking engagements from Ehicon Endosurgery, Covidien, Olympus, MID, Transenterix, Gore, Boehringer Labs. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required REFERENCES: 1. Lazzati A, Guy-Lachuer R, Delaunay V, Szwarcensztein K, Azoulay D. Bariatric surgery trends in France: 2005–2011. Surg Obes Relat Dis. 2014;10(2):328–334. 2. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427–436. 3. Gagner M, Deitel M, Erickson AL, Crosby RD.Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013 Dec;23(12):2013-7. 4. Burgos AM, Csendes A, Braghetto I.Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg. 2013 Sep;23(9):1481-6. 5. Shnell M, Fishman S, Eldar S, Goitein D, Santo E.Balloon dilatation for symptomatic gastric sleeve stricture. Gastrointest Endosc. 2014 Mar;79(3):521-4. 6. Ogra R, Kini GP.Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand. Obes Surg. 2015 Feb;25(2):242-8.
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7. Zundel N, Hernandez JD, Galvao Neto M, Campos JStrictures after laparoscopic sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010 Jun;20(3):154-8. 8. Eubanks S, Edwards CA, Fearing NM, Ramaswamy A, de la Torre RA, Thaler KJ, Miedema BW, Scott JS. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008 May;206(5):935-8; 9. Rebibo L, Hakim S, Dhahri A, Yzet T, Delcenserie R, Regimbeau JMGastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management. Obes Surg. 2015 Sep 12. [Epub ahead of print] 10. Nedelcu M, Manos T, Cotirlet A, Noel P, Gagner M. Outcome of leaks after sleeve gastrectomy based on a new algorithm adressing leak size and gastric stenosis. Obes Surg. 2015 Mar;25(3):559-63. 11. Boza C, Salinas J, Salgado N, et al. Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: Report of 1,000 cases and 3-year follow-up. Obes Surg. 2012;22:866–71. 12. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight loss procedure for high-risk patients with morbid obesity. Surg Endosc. 2006;20:859–63. 13. Noel P, Nedelcu M, Gagner M. Impact of the Surgical Experience on Leak Rate After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2015 Dec 28. [Epub ahead of print] 14. Nimeri A, Maasher A, Salim E, Ibrahim M, Al Hadad M. The Use of Intraoperative Endoscopy Decreases Postoperative Stenosis in Laparoscopic Sleeve Gastrectomy. Obes Surg. 2016 Apr;26(4):864.
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15. Gero D, Ribeiro-Parenti L, Marmuse JP. A Simple Trick to Prevent VOMIT After Sleeve Gastrectomy. Obes Surg. 2015 Jul;25(7):1252-3. 16. Santoro S. Technical aspects in sleeve gastrectomy. Obes Surg. 2007 Nov;17(11):1534-5. 17. Rosenthal RA. International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of 12,000 cases. Surg Obes Relat Dis. 2012;8:8– 19. 18. Triantafyllidis G, Lazoura O, Sioka E, et al. Anatomy and complications following laparoscopic sleeve gastrectomy: radiological evaluation and imaging pitfalls. Obes Surg. 2011;21:473–8. 19. Kupec JT, Goebel SU, Akkary E. The role of endoscopy in the treatment of obesity: current and future concepts. Pract Gastroenterol 2009;XXXIII:21–36. 20. Göttig S, Daskalakis M, Weiner S, Weiner R. Analysis of safety and efficacy of intragastric balloon in extremely obese patients. Obes Surg 2009;19:677– 83. 21. Gumbs A, Gagner M, Dakin G, Pomp A. Sleeve gastrectomy for morbid obesity. Obes Surg 2007;17:962–9. 22. Papailiou J, Albanopoulos K, Toutouzas K, Tsigris C, Nikiteas N, Zografos G. Morbid obesity and sleeve gastrectomy: how does it work? Obes Surg 2010;20:1448 –55. 23. Tang SJ, Rockey DC. The role of endoscopy in bariatrics. Clin Update 2008;16:1– 4. 24. Jones M, Healey AJ, Efthimiou E. Early use of self expanding metallic stents to relieve sleeve gastrectomy stenosis after intragastric balloon removal. Surg Obes Relat Dis. 2011 Sep-Oct;7(5):e16-7 25. Marquez M, Ayza FM, Belda LR, et al. Gastric leak after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20:1306–11.
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26. Baretta G, Campos J, Correia S, Alhinho H, Marchesini JB, Lima JH, Neto MG. Bariatric postoperative fistula: a life-saving endoscopic procedure. Surg Endosc. 2015 Jul;29(7):1714-20. 27. Scheffel O, Weiner RA. Therapy of stenosis after sleeve gastrectomy: stent and surgery as alternativesdcase reports. Obes Facts 2011;4(suppl 1):47-9. 28. Lacy A, Ibarzabal A,ObearzabalA, et al. Revisional surgery after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20:351–6. 29. Bellorin O, Lieb J, Szomstein S, et al. Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass for acute gastric outlet obstruction after laparoscopic sleeve gastrectomy for morbid obesity. Surg Obes Relat Dis. 2010;6:566–8. 30. Parikh M, Gagner M. Laparoscopic revision of gastrogastric stricture with a transoral circular stapler. Surg Innov. 2007 Sep;14(3):225-30. 31. Kalaiselvan R, Ammori BJ. Laparoscopic median gastrectomy for stenosis following sleeve gastrectomy. Surg Obes Relat Dis. 2015 Mar-Apr;11(2):474-7. 32. Sudan R, Kasotakis G, Betof A, et al. Sleeve gastrectomy strictures: technique for robotic-assisted strictureplasty. Surg Obes Relat Dis. 2010;6:434–6. 33. Vilallonga R, Himpens J, van de Vrande S. Laparoscopic management of persistent strictures after laparoscopic sleevegastrectomy. Obes Surg. 2013 Oct;23(10):1655-61.
13
Table 1 – Demographic data
Gender:
n
%
Male
5
27.8
Female
13
72.2
Age (Years) (mean (± SD))
37.2 (± 8.4)
BMI (kg/m2) (mean (± SD))
41.6 (± 8.7)
BMI – Body Mass Index;
14
Table 2 – Review of the literature Team - year
No
Endoscopy
Surgery
4 dilatations (1-4)
1 RYGBP
patients Braghetto et al. (4) – 2013
5
(20 %) Shnell et al. (5) - 2014
16
16 dilatations (1-3)
5 RYGBP + 1 resleeve (37.5%)
Kini et al (6) - 2015
26
10 dilatation with CRE
0
11 Achalasia balloon dilatation 5 Stents MG Neto et al (7) – 2010
9
7 pneumatic dilatations
1 total gastrectomy 1 RYGB (22.2 %)
Eubanks et al (8) – 2008
6
6 stents after dilatation
1
undefined
surgery (17%) Rebibo et al (9) -2015
17
13 balloon dilatation 2 stents
2 RYGBP (11.7 %)
RYGB – Roux-en-Y Gastric Bypass; CRE – controlled radial expansion
15
Fig. 1 - Algorithm of endoscopic treatment of stenosis after LSG
16