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STENOSIS AFTER BARIATRIC SURGERY
Riccardo BRACHET CONTULRiccardo BRACHET CONTUL MD, Adjunct Professor at Turin University Master of Laparoscopic Surgery, MD, Adjunct Professor at Turin University Master of Laparoscopic Surgery,
Unit of Bariatric Surgery Unit of Bariatric Surgery
P. MILLO, MD, Unit of Bariatric Surgery - Chief P. MILLO, MD, Unit of Bariatric Surgery - Chief
M. FABOZZI, MDM. FABOZZI, MD
Unit of Bariatric SurgeryUnit of Bariatric Surgery
DEPARTMENT OF LAPAROSCOPIC, BARIATRIC E COLORECTAL DEPARTMENT OF LAPAROSCOPIC, BARIATRIC E COLORECTAL SURGERY – CHIEF DR. R. ALLIETASURGERY – CHIEF DR. R. ALLIETA
AOSTA “U. PARINI” REGIONAL HOSPITAL - ITALYAOSTA “U. PARINI” REGIONAL HOSPITAL - ITALY
STENOSIS: SYMPTOMS
• Dysphagia (first with solids and progressing to intolerance even with liquids)
• Vomiting (sometimes with nausea)
• Symptoms of obstruction when moving from fluids to solid food
• Sticking to fluid comsumption, not progressing to solids
• Saliva or food regurgitation
• Impaction of food (especially meat or bread)
• De novo gastroesophageal reflux disease symptoms
• At times pain in the epigastric to retrosternal area.
STENOSIS: DEFINITIONAn abnormal narrowing or constriction of the diameter of a bodily passage or orifice (as from inflammation, cancer, or the
formation of scar tissue).
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
• Symptoms
• UGI-radiograms
• Endoscopy (narrowing of the anastomosis or suture or outlet that did not allow passage or afforded significant resistance to passage of the 9-mm endoscope in the symptomatic patients)
STENOSIS: DIAGNOSIS
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
• SAGB
• LAPAROSCOPIC VERTICAL BANDED
GASTROPLASTY
• LAPAROSCOPIC GASTRIC GREAT CURVATURE
PLICATION
• LAPAROSCOPIC SLEEVE GASTRECTOMY
• LAPAROSCOPIC GASTRIC BYPASS
• LAPAROSCOPIC BILIO-PANCREATIC DIVERSION
STENOSIS AND TYPE OF OPERATION
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
SAGBFUNCTIONAL STENOSIS RELATED TO
COMPLICATIONS (GASTRIC POUCH DILATATION,
SLIPPAGE, GASTRIC WALL EROSION/BAND
MIGRATION, TOO MUCH INFLATION OF THE BAND,
…)
THERAPY
TREATMENT OF THESE COMPLICATION
STENOSIS AND TYPE OF OPERATION
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
LAPAROSCOPIC VBG
(actually abandoned technique)
STENOSIS RELATED TO NARROW OUTLET,
EROSION, GASTRIC POUCH DILATION…
THERAPY
TREATMENT OF THESE COMPLICATION
STENOSIS AND TYPE OF OPERATION
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
STENOSIS is reported in 0.26-4% of operations
This rate is underestimated:
-Because early published series of LSG tended to use larger bougies with the intention of two-stage weight loss.
- Additionally, little literature exists regarding patient characteristics, operative techniques, and other variables that may contribute to the development of a sleeve stenosis
- Few reports have described the subsequent management of these patients
STENOSIS AFTER LSG
Due to the long staple line and altered
intragastric pressures.
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
CRONICIschemia of the pouch
Retraction due to scarring
Fistula
Inclusion of the gastroesophageal junction in the staple line
Conversion of Gastric Banding in Sleeve (or LRYGBP)
STENOSIS AFTER LSG - CAUSES
ACUTE• Gastric mucosal edema
• Kinking (specially when a very narrow sleeve makes an acute turn in the
middle, usually in relation to incisura angularis
• Narrowing owing to oversewing of the staple line
• Irregular staple line
LSG
FUNCTIONAL STENOSIS
AFTER LSG
Twisting of the sleeve
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
1. Keep a safe distance between the incisura angularis and edge where staples are applied (with boogie in place while stapling) - to avoid stricture and kinking
2. When cutting the adesions between stomach and posterior peritoneum over the pancreas, preserve the branches of the left gastric artery - to avoid ischemic lesions
3. Keeping the staple line straight, by resecting simmetrically anterior and posterior gastric walls (trick: pull the gastroepiploic margin of section) - to avoid kinking and twisting of the tube.
4. Also the reinforcement oversewing has to respect point 3.
STENOSIS AFTER LSG – HOW TO AVOID
Zundel N, et al. SURG LAPAROENDOSC PERCUTAN TECH 2010, 20(3): 154-8
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
1. EDEMA: NIL PER OS, HIDRATION, PPI + Escina ev, CLINICAL OBSERVATION
2. OTHER STENOSIS
- ENDOSCOPY with pneumatic balloon dilation (1- several sessions) or X-ray guided dilation
- STENTS (covered or partially covered): usually remain in place only a week (have to be removed for migration or pain)
- SURGERY (laparoscopy with cutting of a narrowing stitch, seromyotomy, stricturoplasty, conversion to RYGBP, total gastrectomy)
STENOSIS AFTER LSG - TREATMENT
Zundel N, et al. SURG LAPAROENDOSC PERCUTAN TECH 2010, 20(3): 154-8
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
STENOSIS AFTER LSG - TREATMENT
•Caution should be taken in performing LSG to avoid the creation of sleeve stenosis.•Clinically significant short-segment stenoses may be treated successfully with endoscopic balloon dilation. •Long-segment stenoses are less likely to respond to endoscopic techniques and may ultimately require conversion to Roux-en-Y gastric bypass.
230 LSG
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
1. Frequent but transitory (1-2 weeks) nausea and vomiting and/or sialorrea due to edema and congestion – about 30%
2. Only sometimes persisting symptoms (range 2-5%) linked to stricture due to stomach kinking or invaginated gastric fold or gastro-gastric hernia or serous fluid collection within the cavity formed by gastric plication ENDOSCOPIC AND/OR RADIOLOGIC DIAGNOSIS SURGICAL TREATMENT (reversal of plication, revision to sleeve gastrectomy, for ex.)
STENOSIS AFTER LGCP
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
Abdelbaki TN, et al. GASTRIC PLICATION FOR MORBID OBESITY: A SYSTEMATIC REVIEW; OB SURG 2012, 22:1633-9
Friede M, et al. LGCP FOR TREATMENT OF MORBID OBESITY – 244 PAT.S; OB SURG 2012, 22:1298-307
One of the most common complications.
The presentation is readily recognizable with symptoms of :
• Dysphagia (first with solids and progressing to intolerance even with liquids)
• Emesis
• At times pain in the epigastric to retrosternal area.
Diagnosis with:• UGI
• Endoscopy (narrowing of the anastomosis or suture that did not allow passage or afforded significant resistance to passage of the 9-mm endoscope in the symptomatic patients)
STENOSIS AFTER LRYGBP
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
Historically, rates of GJ strictures have varied considerably in the literature with some studies citing stricture rates of greater than 20 %. This discrepancy may be due to factors such as
• different surgical techniques for creating the GJ anastomosis (end-to-end, end-to-side, and side-to-side)
• size of the gastric pouch
• tension
• path of the Roux limb
• medications
• smoking
• how the strictures are defined and diagnosed.
STENOSIS AFTER LRYGBP - CAUSES
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
1. There is considerable variability in stricture rates between different techniques utilizing different size staplers.
2. Within one stapler category, however, there is still significant variability in GJ stricture rates.
3. This variation in rates may be partly explained by the difference in how some clinicians defined a stricture and how patients with clinical symptoms are worked up.
4. For ex. the variation in determining when a patient is appropriate for endoscopic evaluation is also accompanied with a variation of the overall date of presentation of strictures.
STENOSIS AFTER LRYGBP – ??
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Csendes A et al, Ob Surg 2008
Early stenosis
< 4 p.o. weeks
Late stenosis
Presence of fibrin
Presence of inflammatory material
Presence of submucosal hematoma
Fibrin + soft inflammatory tissue
Fibrotic tissue
MORE DIFFICULT TO BE DILATED BY ENDOSCOPE
Pathogenesis
STENOSIS AFTER LRYGBP XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
Csendes A et al, Ob Surg 2008
Results
STENOSIS AFTER LRYGBP XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
This is the largest series (835 pat.s) which report stratification and analysis of LRYGBP according to GJA technique. No significant differences in the rates of anastomotic stricture were found between the techniques, and rates are comparable to those previously reported in the literature.
This report suggests that the type of GJA technique does not affect the incidence of early
anastomotic complications.
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
(mean 5.5%)
• LSG 3/101 (3%)
• LRYGBP 18/503
(3.6%)
BARIATRIC SURGERY – U. PARINI HOSPITALAOSTA
STENOSIS
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
INCIDENCE AFTER Robotic RYGBP: 0-4.4%
STENOSIS AFTER Robotic RYGBP
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
Markar SR et al; ROBOTIC VS LAP RYGBP IN MORBIDLY OBESE PATIENTS; INT J ROB COM ASS SURG 2011, 7:393-400
Matthew M, et al. ROBOTIC BARIATRIC SURGERY: A SYSTEMATIC REVIEW; SURG OB REL DIS 2012, 8:483-8
1093 LRYGBP
vs
593 RRYGBP
105/1330 PAT.S (7.8%) TREATEDPREDICTORS for need of repeated dilations•Age•Gender•Basal BMI• Time interval between surgery and synmptoms• Previous anastomotic leak• Diameter of the stenosis• Presence of ulcerations in the anastomosis• Diameter achieved in the first dilation
STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
Relation found between time elapsed from surgery and recurrence of the stricture:
•The earlier the stricture develops, the more difficult is its treatment, and more sessions are needed to obtain a sustained response•Perhaps because the fibrous scarring of the anastomosis is not complete until the second to third month of the procedure, and it keeps its tendency towards the stricture formation after the dilation. •Only 24% of cases with a stricture diagnosed after the fourth month needed a second dilation; meanwhile, 75% of those that presented symptoms in the first month after surgery needed two or more dilations.
STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
Relation between achieving a 15-mm diameter ballon dilation in the first procedure and the need of
repeated dilations:
•The group of pat.s dilated ONCE had been dilated wider than the group of TWO to FOUR dilation.
• The desidered diameter of the GJA is at least TWO AND HALF TIMES the initial diameter
• Dilate careful (it is not safe to dilate until the final desidered diameter with only one procedure specially in cases with very narrow initial diameter).
STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
STENOSIS AFTER LRYGBP
ENDOSCOPIC TREATMENT
DA COSTA M, et al OBES SURG (2011) 21:36-41105/1330 (7.8%) 3±1.8 months Hand-sewn sutures 1 (57%), 2 (27.6%), 3 (12.3%) 1.6 (1-4) (1.8%)
1. Intraoperative EGD
2. Modified GJ anastomosis
3. Drugs administrations (ex. Stheroids during endoscopic dilation? High dose IPP? other?)
4. High-quality f.u. care ensures that the few pat.s that do develop aa stricutres are expeditiously and effectively diagnosed and treated when the complication does occurr
STENOSIS AFTER LRYGBP
Suggested Prevention
XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica
1. INCIDENCE 9-20% (GI or DI anastomosis with stapler, higher during Laparoscopy and with Circular Stapler anastomosis)
2. INCIDENCE 0-4% (handsewn GI anastomosis in standard BPD)
3. Associated sometimes with gastroparesis in standard LBPD
4. DIAGNOSIS with UGI radiograms, Endoscopy
5. TREATMENT
- Endoscopic dilation
- GJ anastomosis revision (if failed endoscopic treatment)
- Partial/total gastrectomy ± conversion to RYGBP or full restoration of bowel anatomy (if failed conservative treatments)
STENOSIS AFTER LBPD±DS
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Samin KA, et al Ob Surg 2006; Scopinaro N et al, Ob Surg 2002; Silecchia G et al, Surg End 2009 ; Serra C et al, Ob Surg 2006
Usually Endoscopic dilation is the treatment of
choice of sleeve or anastomotic stenosis.
After several sessions (with persisting
symptoms and/or narrow gastric lumen), stent
positioning may be a good alternative.
Surgical treatment is the last resource (and
should not be spared in case of need)
CONCLUSION
COMPLICATIONS AFTER GASTRO-JEJUNAL BYPASS
Baia Chia (CA)
GRAZIE!!