Management Options for Symptomatic Stenosis Following Sleeve Gastrectomy in the Morbidly Obese

Amit Parikh, DO, Joshua B Alley, MD, Richard M Peterson, MD MPH, Michael C Harnisch, MD, Jason M Pfluke, MD, Donovan N Tapper, MD, Stephen J Fenton, MD. San Antonio Military Medical Center, University of Texas Health Sciences Center at San Antonio

Objective: The laparoscopic vertical sleeve gastrectomy (LSG) is increasingly being used as a weight loss procedure. Little published data exist regarding the management of patients who develop a symptomatic stenosis. The purpose of this study was to determine the incidence of clinically symptomatic stenosis at our institution, identify factors that contribute to their formation, and present our management algorithm.

Methods: A retrospective review was performed of patients who underwent a LSG for morbid obesity between October 2008 – September 2010. All patients diagnosed with a clinically significant stenosis were included as well as patients transferred to our facility for specific treatment of sleeve stenosis.

Results: During this period, 186 patients underwent a LSG: 82% were female with a mean age of 49 years and mean pre-operative BMI of 43.1 kg/m². Six (3%) patients were diagnosed with a clinically symptomatic stenosis requiring intervention. All patients were female with a mean age of 40 years (28 – 54) and mean pre-operative BMI of 41 kg/m². All six patients underwent LSG over a 36 Fr. bougie using tissue reinforced staplers. Three patients had a portion of the staple line imbricated with a running 3-0 PDS suture. Upon suspicion of stenosis, all six patients underwent a contrast study with four (67%) demonstrating a focal narrowing of the sleeve. Endoscopy confirmed a short-segment stenosis in the mid-body of the sleeve of all six patients. The mean time from surgery to the initial endoscopic intervention was 47 days (26 – 150) and the mean time after the first intervention to tolerate a solid diet was 45 days (27 – 66). The mean number of endoscopic dilatations required was 2 (1 – 3) with a median balloon size of 18 mm. Endoscopic management was successful in all six patients. Two additional patients were referred to our institution for management of sleeve stenosis after undergoing LSG at another facility. The mean time to transfer was 28.5 days (21 – 36). The mean age was 35 years (33 – 37) with a mean pre-operative BMI of 40 kg/m². One surgery was complicated by a large staple line hematoma, and another by a staple line leak on POD 1 requiring an open exploration with oversew of the leak using permanent braided suture. Upon transfer, both underwent a contrast study that demonstrated minimal passage of contrast through a long segment of stenosis. Both underwent multiple endoscopic dilation procedures, followed by endoluminal stenting and ultimately required laparoscopic conversion to Roux-en-Y gastric bypass. The mean time from the initial surgery to the surgical revision was 77 days (65 – 89) and the mean time after the first intervention to tolerate a solid diet was 82.5 days (73 – 92).

Conclusion: Clinically significant short-segment stenoses following sleeve gastrectomy may be successfully treated with endoscopic balloon dilatation. Long-segment stenoses are less likely to respond to endoscopic techniques, and may ultimately require conversion to Roux-en-Y gastric bypass.

Session: SS09
Program Number: S043

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