- Email: [email protected]
Management of transmesenteric tunnel jejunal strictures with endoscopic dilation by using achalasia balloons (with videos)
NEW METHODS: Clinical Endoscopy
Management of transmesenteric tunnel jejunal strictures with endoscopic dilation by using achalasia balloons (with videos) Shou-jiang Tang, MD, David A. Provost, MD, Edward Livingston, MD, Daniel J. Scott, MD Dallas, Texas, USA
Background: Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Transmesenteric tunnel (TMT) or mesocolic jejunal stricture is an unusual postoperative complication that requires another operation. We hypothesize that endoscopic dilation by using achalasia dilatation balloons can be used to treat some TMT jejunal strictures. Patients: This study involved 6 consecutive cases of TMT stricture. Intervention: The TMT strictures were dilated by using achalasia balloons (30-40 mm) under fluoroscopic and endoscopic guidance. Results: With endotherapy, 4 patients with late onset of symptoms (O3 weeks after Roux-en-Y gastric bypass) have not required another operation to date, with a follow-up of at least 5 to 12 months. Two patients with early onset of symptoms (!3 weeks after surgery) required operations, and 1 of these patients (symptoms onset !7 days after surgery) developed jejunal perforation within the stricture during dilation due to underlying jejunal ischemia within the stricture. Limitations: Small case number and limited follow-up period. Conclusion: Endoscopic dilation by using achalasia balloons can be used to treat some TMT jejunal strictures without another operation. Surgery should be considered in patients with early onset of obstructive symptoms and/or with jejunal ischemia within the stricture.
Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.02.011
passes through the transverse mesocolon. This condition requires surgical revision. Recently, we described endoscopic dilation by using achalasia balloons in 1 patient (patient 1) with TMT stricture with early onset of symptoms.6 The patient had complete but short-term symptomatic relief. She ultimately needed surgical revision because of a thick, fibrous band around the stricture site. In this patient, TMT stricture developed 2 to 3 weeks after RYGBP, and achalasia balloons were used after failure of prior sessions of dilation that used through-the-scope (TTS) endoscopic balloons. Because of probable traction by the mesocolon and the asymmetrical location of the jejunal lumen within the stricture, endoscopic dilation by using TTS balloons is likely to fail. A larger transmesenteric tunnel and hence jejunal lumen cannot be created even by the largest available TTS balloons (!20 mm). We hypothesize that initial endoscopic dilation by using achalasia balloons can be used to treat some TMT strictures. Here, we report 6 consecutive cases, including that of patient 1, that were managed with endoscopic dilation by using achalasia
154 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 1 : 2009
www.giejournal.org
Because of the high prevalence of obesity, the use of bariatric surgery has increased dramatically in the United States.1,2 Bariatric surgery appears to increase overall life expectancy and decrease the rate of obesity-related comorbidities such as hypertension and diabetes.2 Rouxen-Y gastric bypass (RYGBP) has become the most commonly performed bariatric operation in the United States.1,2 During bypass surgery, the Roux limb is brought to the upper abdomen either in a retrocolic fashion through a transmesenteric or an antecolic retro-omental tunnel.3-6 Transmesenteric tunnel (TMT) or mesocolic jejunal stricture infrequently develops as the Roux limb
Abbreviations: GJ, gastrojejunal; RYGBP, Roux-en-Y gastric bypass; TMT, transmesenteric tunnel; TTS, through-the-scope. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
Tang et al
balloons. To the best of our knowledge, this method has not been reported in the medical literature.
Transmesenteric tunnel jejunal strictures
Capsule Summary What is already known on this topic
PATIENTS AND METHODS d
Patients This was a retrospective study over a 1-year period (September 2007 to October 2008) at the UT Southwestern Medical Center. All consecutive patients (n Z 6) with symptomatic TMT were included. The clinical data for all patients are presented in Table 1. We previously reported the case of patient 1.6 The endoscopic findings and endotherapy in all cases were video recorded and are presented in Table 2 and Videos 1 through 3 (available online at www.giejournal.org). All patients gave informed consent regarding the treatment options for TMT strictures and the risks of endoscopic dilation with achalasia balloons. Information including patient history, hospital course, and outcomes was retrieved through chart review. TMT stricture is defined as significant narrowing of the jejunum when it passes through the mesenteric tunnel (Fig. 1). It is usually located 10 to 20 cm distal to the gastrojejunal (GJ) stoma. Because of the surrounding organs and probable traction by the mesocolon, the opening of the stricture is usually asymmetrically located close to one side of the jejunal wall. We arbitrarily classified these strictures as either significant (not allowing the passage of a diagnostic gastroscope without dilation) or moderate (allowing the passage of a diagnostic gastroscope with gentle gastroscope advance), based on their internal diameters. The length of the stricture was about 2 cm, and the opening of the stricture was usually located close to one side of the jejunal wall (Fig. 2). The symptoms included constant nausea, postprandial nausea and vomiting, or a combination of both. Postprandial vomiting usually developed 5 to 15 minutes after meals. Abdominal pain was usually not present or prominent among these patients with obstructive symptoms.
Endoscopic techniques and methods
Transmesenteric tunnel or mesocolic jejunal stricture is an unusual postoperative complication of Roux-en-Y gastric bypass that requires another operation.
What this study adds to our knowledge d
Endoscopic dilation by using achalasia balloons was successful in treating transmesenteric tunnel jejunal strictures without another operation in 4 of 6 consecutive cases.
of the endoscope and subsequent achalasia balloon. Then a Savary-Gilliard (Cook Medical, Winston-Salem, NC) guidewire was placed in the Roux limb for achalasia balloon insertion. We used an achalasia balloon (Cook Medical) for definitive dilation. The balloon was inflated with a quarter-strength contrast medium so the dilation could be monitored fluoroscopically. The dilation was performed under fluoroscopic and endoscopic guidance by using an ultrathin endoscope (Olympus GIF-N30 or GIF-XP 160) placed proximal to the balloon. Adequate dilation was evidenced by the complete effacement of the waist of the balloon (Fig. 3B and C). The balloon was fully inflated for 60 seconds, and dilation was performed once or twice. During balloon dilation, careful inspection was performed to ensure enough space within the jejunum surrounding the inflating achalasia balloon. After dilation and removal of the balloon, endoscopy was performed to ensure that there were no transmucosal tears or perforation within and around the treated stricture. The patient was started on an oral diet within 6 hours.
RESULTS The case of patient 1 was reported previously.6 Results for the other patients follow.
We have previously described the endoscopic methods and techniques.6 In summary, initial endoscopy was performed by using a diagnostic gastroscope (Olympus GIF160; Olympus America Inc, Center Valley, Pa). Procedure time was less than 45 minutes in all cases. In each case, the patient was placed on the fluoroscopy table in a supine position and was given intravenous sedation with propofol administered by a nurse anesthetist. If the TMT stricture significantly prevented the passage of the endoscope, even with gentle manipulation, the stricture was cannulated with a standard ERCP guidewire followed by a double-lumen ERCP catheter (Fig. 3A). After the intraluminal location of the catheter was confirmed with contrast medium injection, the stricture was first dilated to 18 to 20 mm by using a TTS balloon to allow easy passage
During upper endoscopy, the GJ stoma was patent, with an internal diameter of 13 mm. On endoscopy, a moderate TMT stricture was seen, with an internal diameter of about 4 to 5 mm (Video 2). Two weeks after dilation, the patient’s obstructive symptoms recurred. Endoscopic dilation was
www.giejournal.org
Volume 70, No. 1 : 2009 GASTROINTESTINAL ENDOSCOPY 155
Patient 2 During upper endoscopy, a significant TMTstricture was seen, without obvious opening (Figs. 2 and 3, Video 1). After dilation, the patient’s symptoms resolved, and a routine abdominal CT scan with oral contrast medium showed resolution of the TMT stricture. The patient has lost 160 pounds since the RYGBP and has no further complications.
Patient 3
Transmesenteric tunnel jejunal strictures
Tang et al
TABLE 1. Laparoscopic Roux-en-Y gastric bypass and clinical data
Patient
Age (years),sex
Baseline BMI (kg/m2)
Device for mesentery division
Roux limb length (cm)
Intraoperative/immediate postop complications
Onset of symptoms (days postop)
1*
38, female
38
Ultrasonic dissector
100
0
!20
2
51, female
50
Ultrasonic dissector
120
0
60
3
39, male
35
Ultrasonic dissector
100
0
30
4
28, female
48
Ultrasonic dissector
75
0
40
5
36, female
78
ultrasonic dissector
150
0
14y
6
55, female
41
Ultrasonic dissector
75
0
7
BMI, Body mass index; post-op, post-operation. *Case was previously reported in reference 6. yPatient had coexisting gastrojejunal stricture (!5 mm).
TABLE 2. Endoscopic findings, dilation, and outcomes
Patient
Distance from TMT stricture to GJ stoma (cm)
Passage of a diagnostic gastroscope
1*,y
15
No
Normal
TTS balloons & 30 mm
Operation
2
17 (Video 1)
No
Normal
18 mm TTS & 30 mm
Symptoms resolved
12
3
10 (Video 2)
Yes
Normal
35 mm and 40 mm
Symptoms resolved
12
4
12
Yes
Normal
35 mm
Symptoms resolved
8
5*
15
No
Normal
35 mm
Symptoms resolved
5
6
15 (Video 3)
Yes
Ischemic(erythema)
35 mm
Perforation and operation
Jejunal mucosa within the stricture
Dilation (achalasia balloon size)
Follow up (months)
Outcomes
O12
n/a
TMT, Transmesenteric stricture; GJ, gastrojejunal; TTS, through-the-scope; n/a, not available. *Case was previously reported in reference 6. yPatient had a coexisting gastrojejunal stricture (!5 mm).
performed by using a 40-mm achalasia balloon (Video 2). The patient denied further nausea and vomiting at 12 months after dilation, has lost 75 pounds since the RYGBP, and is without further complications.
Patient 4 During endoscopy, a moderate TMT stricture was seen (Fig. 4). After dilation, there was some mucosal trauma within the treated stricture (Fig. 5). The patient started an oral diet, and her symptoms completely resolved within 5 days after dilation. One week after dilation, follow-up endoscopy noted resolution of the TMT stricture (Fig. 6). The patient denied further nausea and vomiting at 8 months after dilation. She has lost 70 pounds since the RYGBP and is without further complications.
Patient 5
and vomiting resolved. Five months after dilation, she has lost 130 pounds since the RYGBP.
Patient 6 On endoscopy, a moderate TMT stricture was seen (Video 3). The jejunal mucosa within the stricture appeared erythematous and mildly edematous, suggestive of early ischemia. After dilation with a 35-mm achalasia balloon was performed, a 15-mm jejunal perforation was noted within the treated stricture. The patient underwent emergent surgery, and a very dense adhesion was noted around the TMT stricture and perforation site.
DISCUSSION
During upper endoscopy, the GJ stoma was narrowed, with an internal diameter of 5 mm. The GJ stoma was dilated to 15 mm with a TTS balloon. In addition, a severe TMT stricture was seen. After dilation, the patient’s nausea
During bypass surgery, the Roux limb is brought to the upper abdomen either in a retrocolic fashion through a transmesenteric or an antecolic yet retro-omental tunnel. One study suggests that, compared with antecolic tunneling, retrocolic tunneling is associated with a higher
156 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 1 : 2009
www.giejournal.org
Tang et al
Transmesenteric tunnel jejunal strictures
Figure 2. Endoscopic view of the transmesenteric tunnel stricture (patient 2). The internal diameter of the stricture is about 1-2 mm.
incidence of bowel obstruction.4 Tunnels made too small, sutures placed too tightly, and scarring or adhesion around the tunnel can cause TMT jejunal stricture. In cases of small tunnels or sutures placed too tightly, the obstructive symptoms generally develop during the early postoperative period. If these strictures are caused by adhesive bands, patients generally have later onset of symptoms.6 In our observation, these patients usually develop constant nausea or nausea and vomiting with drinking and meals. The emesis develops about 5 to 15 minutes after meals, whereas patients with GJ stomal stenosis develop obstructive symptoms within 5 minutes after meals. The more distal location of the obstruction probably explains the longer latency of symptoms after meals. Small-bowel contrast study can be used for the diagnosis of mesocolic strictures. However, endoscopy offers the advantage of a therapeutic option, as we demonstrate. In accordance with our approach to GJ stomal stenosis, we do not think other imaging studies are absolutely necessary before attempting dilation of the symptomatic TMT stricture. Traditionally, dilation of TMT strictures has not been recommended because of the risk of jejunal injury. Surgical repair with adhesion lysis has been described as mandatory.3-5 Based on our experience, we think it is feasible to perform endoscopic jejunal dilation by using achalasia balloons in some TMT strictures in cases without jejunal ischemia and with late onset of obstructive symptoms
(O3 weeks after surgery). The involved jejunal segment should be intact without intrinsic fibrosis and ischemia, as we discovered in the case of patient 6. Biopsy is not recommended to diagnose fibrosis and ischemia. Biopsy can potentially increase the risk of perforation during subsequent dilation. In TMT stricture, any mucosal abnormalities that suggest ischemia should be considered a contraindication to dilation, including mucosal erythema, edema, blanching, erosions, or ulceration. Development of obstructive symptoms in patients with TMT stricture during the early postoperative period (!3 weeks after surgery) is probably related to the failure of endoscopic dilations, as in the case of patient 1. Early onset of symptoms (!7 days after surgery) and underlying bowel ischemia within the stricture in patient 6 contributed to the jejunal perforation during dilation. Although patient 5 developed obstructive symptoms within 2 weeks after RYGBP, she was the only patient in this series who had a coexisting GJ stomal stricture (!5 mm). The GJ stomal stenosis or that in combination with TMT stricture explains her early onset of symptoms. In patients with late onset of obstructive symptoms (O3 weeks after surgery), we propose that endoscopic dilation by using achalasia balloons be tried first, before surgical revision. In our proposed method, the techniques involved are similar to that during achalasia dilation. We recommend the following 4 points in considering this novel method. (1) Appropriate patients should be selected. (2) Contraindications, including stricture or ischemia, should be identified. (3) In unselected patients, the perforation risk is 17%. Only endoscopists familiar with advanced endoscopy methods should perform these procedures. (4) The risks and benefits of this novel approach must be communicated to the patient, and close communication between surgical and gastroenterology services is required in managing these complications. Finally, we strongly advocate gathering of more data by other centers before this novel method is considered the standard of care in managing TMT stricture.
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Volume 70, No. 1 : 2009 GASTROINTESTINAL ENDOSCOPY 157
Figure 1. Diagram of the transmesenteric tunnel.
Transmesenteric tunnel jejunal strictures
Tang et al
Figure 3. Fluoroscopic images showing endoscopic dilation using a 30-mm achalasia dilating balloon (Cook Medical, Winston-Salem, NC) (patient 2). The stricture was cannulated with a guidewire and was confirmed with contrast medium injection (A). Adequate dilation is evidenced by the complete effacement of the waist (B and C) of the balloon.
Figure 4. Endoscopic view of the transmesenteric tunnel jejunal stricture in patient 4.
Figure 6. Endoscopic view of the treated transmesenteric tunnel jejunal stricture 2 weeks after dilation (patient 4). 2. Perry CD, Hutter MM, Smith DB, et al. Survival and changes in comorbidities after bariatric surgery. Ann Surg 2008;247:21-7. 3. Wetter A. Role of endoscopy after Roux-en-Y gastric bypass surgery. Gastrointest Endosc 2007;66:253-5. 4. Hwang RF, Swartz DE, Felix EL. Causes of small bowel obstruction after laparoscopic gastric bypass. Surg Endosc 2004;18:1631-5. 5. Nguyen NT, Huerta S, Gelfand D, et al. Bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2004;14:190-6. 6. Tang SJ, Tang L, Jazrawi SF, et al. Endotherapy in unusual bariatric surgical complications (with videos). Obesity Surg 2008;18:423-8.
Received November 11, 2008. Accepted February 11, 2009.
Figure 5. Endoscopic view of the TMTstricture after 35-mm balloon dilatation (patient 4). There is some mucosal trauma within the dilated stricture.
Current affiliations: Department of Gastroenterology, Hepatology, and Endoscopy (S.T.), Trinity Mother Frances Hospitals and Clinics, Tyler, Texas, Department of Surgery (D.P., E.L., D.S.), UT Southwestern Medical Center, Dallas, Texas.
REFERENCES
Reprint requests: Shou-jiang Tang, MD, Department of Gastroenterology, Hepatology, and Endoscopy, Trinity Mother Frances Hospitals and Clinics, 910 E. Houston, Suite 550, Tyler, TX 75702.
1. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med 2007;356: 2176-83.
If you want to chat with an author of this article, you may contact him at [email protected].
158 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 1 : 2009
www.giejournal.org
Management of transmesenteric tunnel jejunal strictures with endoscopic dilation by using achalasia balloons (with videos) Shou-jiang Tang, MD, David A. Provost, MD, Edward Livingston, MD, Daniel J. Scott, MD Dallas, Texas, USA
Background: Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Transmesenteric tunnel (TMT) or mesocolic jejunal stricture is an unusual postoperative complication that requires another operation. We hypothesize that endoscopic dilation by using achalasia dilatation balloons can be used to treat some TMT jejunal strictures. Patients: This study involved 6 consecutive cases of TMT stricture. Intervention: The TMT strictures were dilated by using achalasia balloons (30-40 mm) under fluoroscopic and endoscopic guidance. Results: With endotherapy, 4 patients with late onset of symptoms (O3 weeks after Roux-en-Y gastric bypass) have not required another operation to date, with a follow-up of at least 5 to 12 months. Two patients with early onset of symptoms (!3 weeks after surgery) required operations, and 1 of these patients (symptoms onset !7 days after surgery) developed jejunal perforation within the stricture during dilation due to underlying jejunal ischemia within the stricture. Limitations: Small case number and limited follow-up period. Conclusion: Endoscopic dilation by using achalasia balloons can be used to treat some TMT jejunal strictures without another operation. Surgery should be considered in patients with early onset of obstructive symptoms and/or with jejunal ischemia within the stricture.
Copyright ª 2009 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2009.02.011
passes through the transverse mesocolon. This condition requires surgical revision. Recently, we described endoscopic dilation by using achalasia balloons in 1 patient (patient 1) with TMT stricture with early onset of symptoms.6 The patient had complete but short-term symptomatic relief. She ultimately needed surgical revision because of a thick, fibrous band around the stricture site. In this patient, TMT stricture developed 2 to 3 weeks after RYGBP, and achalasia balloons were used after failure of prior sessions of dilation that used through-the-scope (TTS) endoscopic balloons. Because of probable traction by the mesocolon and the asymmetrical location of the jejunal lumen within the stricture, endoscopic dilation by using TTS balloons is likely to fail. A larger transmesenteric tunnel and hence jejunal lumen cannot be created even by the largest available TTS balloons (!20 mm). We hypothesize that initial endoscopic dilation by using achalasia balloons can be used to treat some TMT strictures. Here, we report 6 consecutive cases, including that of patient 1, that were managed with endoscopic dilation by using achalasia
154 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 1 : 2009
www.giejournal.org
Because of the high prevalence of obesity, the use of bariatric surgery has increased dramatically in the United States.1,2 Bariatric surgery appears to increase overall life expectancy and decrease the rate of obesity-related comorbidities such as hypertension and diabetes.2 Rouxen-Y gastric bypass (RYGBP) has become the most commonly performed bariatric operation in the United States.1,2 During bypass surgery, the Roux limb is brought to the upper abdomen either in a retrocolic fashion through a transmesenteric or an antecolic retro-omental tunnel.3-6 Transmesenteric tunnel (TMT) or mesocolic jejunal stricture infrequently develops as the Roux limb
Abbreviations: GJ, gastrojejunal; RYGBP, Roux-en-Y gastric bypass; TMT, transmesenteric tunnel; TTS, through-the-scope. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
Tang et al
balloons. To the best of our knowledge, this method has not been reported in the medical literature.
Transmesenteric tunnel jejunal strictures
Capsule Summary What is already known on this topic
PATIENTS AND METHODS d
Patients This was a retrospective study over a 1-year period (September 2007 to October 2008) at the UT Southwestern Medical Center. All consecutive patients (n Z 6) with symptomatic TMT were included. The clinical data for all patients are presented in Table 1. We previously reported the case of patient 1.6 The endoscopic findings and endotherapy in all cases were video recorded and are presented in Table 2 and Videos 1 through 3 (available online at www.giejournal.org). All patients gave informed consent regarding the treatment options for TMT strictures and the risks of endoscopic dilation with achalasia balloons. Information including patient history, hospital course, and outcomes was retrieved through chart review. TMT stricture is defined as significant narrowing of the jejunum when it passes through the mesenteric tunnel (Fig. 1). It is usually located 10 to 20 cm distal to the gastrojejunal (GJ) stoma. Because of the surrounding organs and probable traction by the mesocolon, the opening of the stricture is usually asymmetrically located close to one side of the jejunal wall. We arbitrarily classified these strictures as either significant (not allowing the passage of a diagnostic gastroscope without dilation) or moderate (allowing the passage of a diagnostic gastroscope with gentle gastroscope advance), based on their internal diameters. The length of the stricture was about 2 cm, and the opening of the stricture was usually located close to one side of the jejunal wall (Fig. 2). The symptoms included constant nausea, postprandial nausea and vomiting, or a combination of both. Postprandial vomiting usually developed 5 to 15 minutes after meals. Abdominal pain was usually not present or prominent among these patients with obstructive symptoms.
Endoscopic techniques and methods
Transmesenteric tunnel or mesocolic jejunal stricture is an unusual postoperative complication of Roux-en-Y gastric bypass that requires another operation.
What this study adds to our knowledge d
Endoscopic dilation by using achalasia balloons was successful in treating transmesenteric tunnel jejunal strictures without another operation in 4 of 6 consecutive cases.
of the endoscope and subsequent achalasia balloon. Then a Savary-Gilliard (Cook Medical, Winston-Salem, NC) guidewire was placed in the Roux limb for achalasia balloon insertion. We used an achalasia balloon (Cook Medical) for definitive dilation. The balloon was inflated with a quarter-strength contrast medium so the dilation could be monitored fluoroscopically. The dilation was performed under fluoroscopic and endoscopic guidance by using an ultrathin endoscope (Olympus GIF-N30 or GIF-XP 160) placed proximal to the balloon. Adequate dilation was evidenced by the complete effacement of the waist of the balloon (Fig. 3B and C). The balloon was fully inflated for 60 seconds, and dilation was performed once or twice. During balloon dilation, careful inspection was performed to ensure enough space within the jejunum surrounding the inflating achalasia balloon. After dilation and removal of the balloon, endoscopy was performed to ensure that there were no transmucosal tears or perforation within and around the treated stricture. The patient was started on an oral diet within 6 hours.
RESULTS The case of patient 1 was reported previously.6 Results for the other patients follow.
We have previously described the endoscopic methods and techniques.6 In summary, initial endoscopy was performed by using a diagnostic gastroscope (Olympus GIF160; Olympus America Inc, Center Valley, Pa). Procedure time was less than 45 minutes in all cases. In each case, the patient was placed on the fluoroscopy table in a supine position and was given intravenous sedation with propofol administered by a nurse anesthetist. If the TMT stricture significantly prevented the passage of the endoscope, even with gentle manipulation, the stricture was cannulated with a standard ERCP guidewire followed by a double-lumen ERCP catheter (Fig. 3A). After the intraluminal location of the catheter was confirmed with contrast medium injection, the stricture was first dilated to 18 to 20 mm by using a TTS balloon to allow easy passage
During upper endoscopy, the GJ stoma was patent, with an internal diameter of 13 mm. On endoscopy, a moderate TMT stricture was seen, with an internal diameter of about 4 to 5 mm (Video 2). Two weeks after dilation, the patient’s obstructive symptoms recurred. Endoscopic dilation was
www.giejournal.org
Volume 70, No. 1 : 2009 GASTROINTESTINAL ENDOSCOPY 155
Patient 2 During upper endoscopy, a significant TMTstricture was seen, without obvious opening (Figs. 2 and 3, Video 1). After dilation, the patient’s symptoms resolved, and a routine abdominal CT scan with oral contrast medium showed resolution of the TMT stricture. The patient has lost 160 pounds since the RYGBP and has no further complications.
Patient 3
Transmesenteric tunnel jejunal strictures
Tang et al
TABLE 1. Laparoscopic Roux-en-Y gastric bypass and clinical data
Patient
Age (years),sex
Baseline BMI (kg/m2)
Device for mesentery division
Roux limb length (cm)
Intraoperative/immediate postop complications
Onset of symptoms (days postop)
1*
38, female
38
Ultrasonic dissector
100
0
!20
2
51, female
50
Ultrasonic dissector
120
0
60
3
39, male
35
Ultrasonic dissector
100
0
30
4
28, female
48
Ultrasonic dissector
75
0
40
5
36, female
78
ultrasonic dissector
150
0
14y
6
55, female
41
Ultrasonic dissector
75
0
7
BMI, Body mass index; post-op, post-operation. *Case was previously reported in reference 6. yPatient had coexisting gastrojejunal stricture (!5 mm).
TABLE 2. Endoscopic findings, dilation, and outcomes
Patient
Distance from TMT stricture to GJ stoma (cm)
Passage of a diagnostic gastroscope
1*,y
15
No
Normal
TTS balloons & 30 mm
Operation
2
17 (Video 1)
No
Normal
18 mm TTS & 30 mm
Symptoms resolved
12
3
10 (Video 2)
Yes
Normal
35 mm and 40 mm
Symptoms resolved
12
4
12
Yes
Normal
35 mm
Symptoms resolved
8
5*
15
No
Normal
35 mm
Symptoms resolved
5
6
15 (Video 3)
Yes
Ischemic(erythema)
35 mm
Perforation and operation
Jejunal mucosa within the stricture
Dilation (achalasia balloon size)
Follow up (months)
Outcomes
O12
n/a
TMT, Transmesenteric stricture; GJ, gastrojejunal; TTS, through-the-scope; n/a, not available. *Case was previously reported in reference 6. yPatient had a coexisting gastrojejunal stricture (!5 mm).
performed by using a 40-mm achalasia balloon (Video 2). The patient denied further nausea and vomiting at 12 months after dilation, has lost 75 pounds since the RYGBP, and is without further complications.
Patient 4 During endoscopy, a moderate TMT stricture was seen (Fig. 4). After dilation, there was some mucosal trauma within the treated stricture (Fig. 5). The patient started an oral diet, and her symptoms completely resolved within 5 days after dilation. One week after dilation, follow-up endoscopy noted resolution of the TMT stricture (Fig. 6). The patient denied further nausea and vomiting at 8 months after dilation. She has lost 70 pounds since the RYGBP and is without further complications.
Patient 5
and vomiting resolved. Five months after dilation, she has lost 130 pounds since the RYGBP.
Patient 6 On endoscopy, a moderate TMT stricture was seen (Video 3). The jejunal mucosa within the stricture appeared erythematous and mildly edematous, suggestive of early ischemia. After dilation with a 35-mm achalasia balloon was performed, a 15-mm jejunal perforation was noted within the treated stricture. The patient underwent emergent surgery, and a very dense adhesion was noted around the TMT stricture and perforation site.
DISCUSSION
During upper endoscopy, the GJ stoma was narrowed, with an internal diameter of 5 mm. The GJ stoma was dilated to 15 mm with a TTS balloon. In addition, a severe TMT stricture was seen. After dilation, the patient’s nausea
During bypass surgery, the Roux limb is brought to the upper abdomen either in a retrocolic fashion through a transmesenteric or an antecolic yet retro-omental tunnel. One study suggests that, compared with antecolic tunneling, retrocolic tunneling is associated with a higher
156 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 1 : 2009
www.giejournal.org
Tang et al
Transmesenteric tunnel jejunal strictures
Figure 2. Endoscopic view of the transmesenteric tunnel stricture (patient 2). The internal diameter of the stricture is about 1-2 mm.
incidence of bowel obstruction.4 Tunnels made too small, sutures placed too tightly, and scarring or adhesion around the tunnel can cause TMT jejunal stricture. In cases of small tunnels or sutures placed too tightly, the obstructive symptoms generally develop during the early postoperative period. If these strictures are caused by adhesive bands, patients generally have later onset of symptoms.6 In our observation, these patients usually develop constant nausea or nausea and vomiting with drinking and meals. The emesis develops about 5 to 15 minutes after meals, whereas patients with GJ stomal stenosis develop obstructive symptoms within 5 minutes after meals. The more distal location of the obstruction probably explains the longer latency of symptoms after meals. Small-bowel contrast study can be used for the diagnosis of mesocolic strictures. However, endoscopy offers the advantage of a therapeutic option, as we demonstrate. In accordance with our approach to GJ stomal stenosis, we do not think other imaging studies are absolutely necessary before attempting dilation of the symptomatic TMT stricture. Traditionally, dilation of TMT strictures has not been recommended because of the risk of jejunal injury. Surgical repair with adhesion lysis has been described as mandatory.3-5 Based on our experience, we think it is feasible to perform endoscopic jejunal dilation by using achalasia balloons in some TMT strictures in cases without jejunal ischemia and with late onset of obstructive symptoms
(O3 weeks after surgery). The involved jejunal segment should be intact without intrinsic fibrosis and ischemia, as we discovered in the case of patient 6. Biopsy is not recommended to diagnose fibrosis and ischemia. Biopsy can potentially increase the risk of perforation during subsequent dilation. In TMT stricture, any mucosal abnormalities that suggest ischemia should be considered a contraindication to dilation, including mucosal erythema, edema, blanching, erosions, or ulceration. Development of obstructive symptoms in patients with TMT stricture during the early postoperative period (!3 weeks after surgery) is probably related to the failure of endoscopic dilations, as in the case of patient 1. Early onset of symptoms (!7 days after surgery) and underlying bowel ischemia within the stricture in patient 6 contributed to the jejunal perforation during dilation. Although patient 5 developed obstructive symptoms within 2 weeks after RYGBP, she was the only patient in this series who had a coexisting GJ stomal stricture (!5 mm). The GJ stomal stenosis or that in combination with TMT stricture explains her early onset of symptoms. In patients with late onset of obstructive symptoms (O3 weeks after surgery), we propose that endoscopic dilation by using achalasia balloons be tried first, before surgical revision. In our proposed method, the techniques involved are similar to that during achalasia dilation. We recommend the following 4 points in considering this novel method. (1) Appropriate patients should be selected. (2) Contraindications, including stricture or ischemia, should be identified. (3) In unselected patients, the perforation risk is 17%. Only endoscopists familiar with advanced endoscopy methods should perform these procedures. (4) The risks and benefits of this novel approach must be communicated to the patient, and close communication between surgical and gastroenterology services is required in managing these complications. Finally, we strongly advocate gathering of more data by other centers before this novel method is considered the standard of care in managing TMT stricture.
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Figure 1. Diagram of the transmesenteric tunnel.
Transmesenteric tunnel jejunal strictures
Tang et al
Figure 3. Fluoroscopic images showing endoscopic dilation using a 30-mm achalasia dilating balloon (Cook Medical, Winston-Salem, NC) (patient 2). The stricture was cannulated with a guidewire and was confirmed with contrast medium injection (A). Adequate dilation is evidenced by the complete effacement of the waist (B and C) of the balloon.
Figure 4. Endoscopic view of the transmesenteric tunnel jejunal stricture in patient 4.
Figure 6. Endoscopic view of the treated transmesenteric tunnel jejunal stricture 2 weeks after dilation (patient 4). 2. Perry CD, Hutter MM, Smith DB, et al. Survival and changes in comorbidities after bariatric surgery. Ann Surg 2008;247:21-7. 3. Wetter A. Role of endoscopy after Roux-en-Y gastric bypass surgery. Gastrointest Endosc 2007;66:253-5. 4. Hwang RF, Swartz DE, Felix EL. Causes of small bowel obstruction after laparoscopic gastric bypass. Surg Endosc 2004;18:1631-5. 5. Nguyen NT, Huerta S, Gelfand D, et al. Bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2004;14:190-6. 6. Tang SJ, Tang L, Jazrawi SF, et al. Endotherapy in unusual bariatric surgical complications (with videos). Obesity Surg 2008;18:423-8.
Received November 11, 2008. Accepted February 11, 2009.
Figure 5. Endoscopic view of the TMTstricture after 35-mm balloon dilatation (patient 4). There is some mucosal trauma within the dilated stricture.
Current affiliations: Department of Gastroenterology, Hepatology, and Endoscopy (S.T.), Trinity Mother Frances Hospitals and Clinics, Tyler, Texas, Department of Surgery (D.P., E.L., D.S.), UT Southwestern Medical Center, Dallas, Texas.
REFERENCES
Reprint requests: Shou-jiang Tang, MD, Department of Gastroenterology, Hepatology, and Endoscopy, Trinity Mother Frances Hospitals and Clinics, 910 E. Houston, Suite 550, Tyler, TX 75702.
1. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med 2007;356: 2176-83.
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