Valerie Deslauriers, MD, Amélie Beauchamp, Fabio Garofalo, MD, Henri Atlas, MD, Pierre Garneau, MD, Ronald Denis, MD, Radu Pescarus, MD. Hôpital Sacre-Coeur
INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is a bariatric surgery aiming at reducing the stomach to 60-80% of its initial volume. A stricture or axis deviation post LSG occur in 0.7-3.5% of cases. Endoscopic and fluoroscopic investigations are essential in establishing the diagnosis. Although endoscopic and surgical treatment options are available, no clear treatment algorithm has been described. The objective of this study is to analyse the safety and efficacy of endoscopic treatment in gastric sleeve stenosis.
METHODS: A retrospective analysis of all patients that were diagnosed with a stricture or axis deviation of their gastric conduit post LSG between 01/2014 and 03/2016 was performed. Patients with a concomitant leak were excluded. All patients included underwent endoscopic treatment at our institution by one surgical endoscopist. Sequential therapy involving 20mm, 30mm and 40mm achalasia balloon dilatations as well as stent placement for dilatation failures was performed. Achalasia balloon dilatations were realized for 3 minutes up to 15 psi. Endoscopic treatment was performed under general anesthesia or intravenous sedation. Pre- and post-intervention (1 month and long-term follow-up) symptoms scores, demographic information and clinical outcomes were collected.
RESULTS: Overall, 17 patients underwent endoscopic treatment for sleeve stenosis. 16/17 patients were females. Mean age was 42.2 years old. The average BMI was 46 kg/m2 preoperatively. A bougie was used to calibrate all sleeves: 36F bougie for 9 patients and 40F bougie for 8 patients. Staple line suturing was performed in 6 patients (35%). 47% were revisional surgery post previous gastric banding. Median time between the LSG and the diagnosis of gastric sleeve stenosis was 8 months (range, 1-13). All 17 patients had a severe axis deviation at the incisura angularis and 4/17 had a second proximal stricture. In all 4 patients the proximal stricture resolved post dilatation, although 2/4 still required surgery for persistent incisura angulation. Overall, endoscopic treatment was successful in 9/17 patients (53%). One dilatation was necessary in 6/9 successful cases, while in 3/9 cases, 3 dilatations were performed. Two patients underwent stent placement. No perforations or adverse events were noted. Patients that failed endoscopic treatment (8/17) underwent successful revision to a laparoscopic gastric bypass.
CONCLUSIONS: Endoscopic balloon dilatation is safe and may avoid surgery in more than 50% of patients with post LSG stenosis. Surgical revision is indicated in patients that fail 3 endoscopic treatments. Axial deviation at the incisura angularis appears to be more difficult to correct endoscopically than actual strictures.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80608
Program Number: S076
Presentation Session: Flexible / Therapeutic Endoscopy and NOTES
Presentation Type: Podium