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Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis

Published:November 28, 2019DOI:https://doi.org/10.1016/j.gie.2019.11.034

      Background and Aims

      Gastric stenosis is a rare but potentially serious adverse event after sleeve gastrectomy. Despite current suboptimal treatments, endoscopic balloon dilatation (EBD) has emerged as a safe and efficacious approach. The purpose of this study is to assess the overall success of EBD for sleeve gastrectomy stenosis (SGS) as first-line therapy.

      Methods

      MEDLINE, Embase, Web of Science, Google Scholar, and Cochrane Database were searched from inception to July 2018. The primary outcome was defined as overall success rate of clinical resolution of SGS obstructive symptoms with EBD, expressed as pooled event rate and 95% confidence interval (CI). The secondary predefined outcomes include EBD success rates for SGS in the proximal (cardia) location or mid-distal location (antrum/incisura), in early SGS (up to 3 months after laparoscopic sleeve gastrectomy), and late SGS (3 months or longer after laparoscopic sleeve gastrectomy) and success rate of cases requiring stents or salvage surgery.

      Results

      Eighteen studies encompassing 426 patients were analyzed. The average age and body mass index were 41.7 years and 40.1 kg/m2, respectively, and the average number of dilations for all cases was 1.8 per person. Overall EBD success rate was 76% (95% CI, .67-.86). EBD success rate in the proximal SGS was 90% (95% CI, 63%-98%), distal SGS was 70% (95% CI, 47%-86%), early SGS within 3 months was 59% (95% CI, 34%-79%), and late SGS after 3 months was 61% (95% CI, 41%-78%). Seventeen percent of patients underwent secondary salvage surgery, with a success rate of 91% (95% CI, 80%-96%).

      Conclusions

      Endoscopic balloon dilation appears to be a safe and effective minimally invasive alternative to surgical revision and should be used as first-line therapy for SGS

      Abbreviations:

      CRE (controlled radial expansion), EBD (endoscopic balloon dilatation), LSG (laparoscopic sleeve gastrectomy), RYGB (Roux-en-Y gastric bypass), SEMS (self-expanding metal stent), SGS (sleeve gastrectomy stenosis)
      Obesity is an increasingly prevalent worldwide epidemic with significant morbidity and mortality. Among bariatric surgery procedures in the United States, sleeve gastrectomy has become the most popular weight loss surgery, recently surpassing gastric bypass.
      • Varela J.E.
      • Nguyen N.T.
      Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers.
      Laparoscopic sleeve gastrectomy (LSG) now accounts for over 50% of bariatric procedures in the United States, because it is not technically challenging and has low adverse event rates.
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      Five-year outcomes of laparoscopic sleeve gastrectomy as a primary procedure for morbid obesity: a prospective study.
      LSG may lead to as much as 70% of excess weight loss within 3 years
      • Ogra R.
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      Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.
      and has even been used in patients who failed to achieve weight loss after gastric banding or vertical banded gastroplasty.
      • Yazbek T.
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      Laparoscopic sleeve gastrectomy (LSG)—a good bariatric option for failed laparoscopic adjustable gastric banding (LAGB): a review of 90 patients.
      Other advantages of LSG include preserved GI continuity, minimal nutrient malabsorption, low risk of dumping syndrome, and lower mortality rates.
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      Laparoscopic sleeve gastrectomy (LSG)—a good bariatric option for failed laparoscopic adjustable gastric banding (LAGB): a review of 90 patients.
      • Khorgami Z.
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      • et al.
      Recent national trends in the surgical treatment of obesity: sleeve gastrectomy dominates.
      • Sabah S.A.
      • Haddad E.A.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      Although LSG is considered a safe and effective approach to morbid obesity, it is associated with a variety of adverse events that differ from those of other bariatric procedures like Roux-en-Y gastric bypass (RYGB). These include sleeve gastrectomy leaks, new-onset GERD, development of intra-abdominal abscess, and stenosis.
      • Zundel N.
      • Hernandez J.D.
      • Neto M.G.
      • et al.
      Strictures after laparoscopic sleeve gastrectomy.
      ,
      • Donatelli G.
      • Dumont J.L.
      • Pourcher G.
      • et al.
      Pneumatic dilation for functional helix stenosis after sleeve gastrectomy: long-term follow-up.
      Post-LSG stenosis often occurs weeks to months after surgery and may not be diagnosed right away. Unlike stenosis in RYGB, which can be treated with relative ease using hydrostatic controlled radial expansion (CRE) balloons,
      • Espinel J.
      • Pinedo E.
      Stenosis in gastric bypass: endoscopic management.
      ,
      • Go M.R.
      • Muscarella 2nd, P.
      • Needleman B.J.
      • et al.
      Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass.
      sleeve gastrectomy stenosis (SGS) usually develops from luminal narrowing or torsional scarring from improper alignment of the staple line along the greater curvature.
      • Rebibo L.
      • Hakim S.
      • Dhahri A.
      • et al.
      Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and management.
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      • Deslauriers V.
      • Beauchamp A.
      • Garofalo F.
      • et al.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      The most common sites of SGS occur at the incisura angularis or more proximally at the gastroesophageal junction.
      • Dapri G.
      • Cadière G.B.
      • Himpens J.
      Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch.
      Initial symptoms mimic an obstructive picture and may include persistent nausea, vomiting, dysphagia, and inability to tolerate oral intake.
      • Ogra R.
      • Kini G.P.
      Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.
      ,
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      ,
      • Burgos A.M.
      • Csendes A.
      • Braghetto I.
      Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients.
      An upper GI study, such as endoscopy or fluoroscopy, can confirm the diagnosis of SGS before any intervention is initiated. Given the excellent safety profile of endoscopy, an approach using pneumatic endoscopic balloon dilation (EBD) has emerged as a promising alternative treatment option for SGS.
      Because SGS is relatively rare (.1%-4%), there are currently no clear guidelines for the management of this adverse event.
      • Burgos A.M.
      • Csendes A.
      • Braghetto I.
      Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients.
      Current treatments range from conservative management, including observation and bowel rest, to surgical interventions such as revisional sleeve gastrectomy, seromyotomy, or conversion to RYGB.
      • Donatelli G.
      • Dumont J.L.
      • Pourcher G.
      • et al.
      Pneumatic dilation for functional helix stenosis after sleeve gastrectomy: long-term follow-up.
      ,
      • Burgos A.M.
      • Csendes A.
      • Braghetto I.
      Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients.
      Although many case reports and series on EBD demonstrate encouraging results, little effort has been made to examine which type of balloon or how many dilation attempts yields the highest success on SGS. Additionally, physicians have no algorithm that suggests when to abort 1 strategy or to try another, and the fallback option of surgical revision is invasive and can be technically challenging. The purpose of this meta-analysis study therefore is to assess the overall likelihood of success of EBD and to establish the safety and efficacy of EBD as first-line therapy for SGS.

      Methods

      Data sources

      The search strategy, inclusion and exclusion criteria, and primary and secondary outcomes were defined before the search. Five databases including MEDLINE, EMBASE, Cochrane, Web of Science, and Google Scholar were searched from inception to July 2018. A search strategy using a combination of subject headings and text words was constructed to identify studies that report EBD success rates for SGS. Both published studies and unpublished works including conference abstracts studies were included in the analysis. Specific Medical Subject Headings (MeSH) terms included “bariatric surgery,” “weight loss surgery,” “metabolic surgery,” “stenosis,” “strictures,” “endoscopic,” and “sleeve gastrectomy” (Appendix 1, available online at www.giejournal.org).

      Study design

      Observational retrospective studies, case series, and prospective studies were included for full review if they used balloon dilations as first-line therapy and reported outcomes of EBD dilation on post-LSG stenoses. Exclusion criteria included studies with fewer than 5 patients, patients with history of achalasia or concomitant leaks, bariatric procedures other than sleeve gastrectomy, and studies in which EBD was not the initial therapy attempt. Registration of this systematic review protocol was done in PROSPERO (International Prospective Register of Systematic Reviews).

      Intervention

      The study therapy was defined as EBD used as first-line therapy for SGS or strictures.

      Outcomes

      The primary outcome was overall EBD success rate, defined as clinical resolution of initial obstructive symptoms from SGS without additional interventions, expressed as pooled event rate and 95% confidence interval (95% CI). The predefined secondary outcomes included EBD success rates for SGS in proximal (cardia) location or mid-distal location (antrum/incisura), in early SGS (up to 3 months after LSG) and late SGS (3 months or longer after LSG), overall endoscopic therapy success rate of stents and EBD, and success rate of cases requiring subsequent stents or salvage surgery if endoscopic dilation failed. A time cut-off for early stenosis was set at 3 months based on a post–sleeve gastrectomy leak guideline.
      • Alazmi W.
      • Al-Sabah S.
      • Ali D.A.
      • et al.
      Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature.
      ,
      • Nguyen N.T.
      • Nguyen X.-M.T.
      • Dholakia C.
      The use of endoscopic stent in management of leaks after sleeve gastrectomy.

      Data extraction and quality assessment

      Data were extracted by 2 authors (S.C., V.P.) independently and then compared. Study authors were contacted to provide additional data if incomplete data were noted. Titles/abstracts considered potentially relevant by either reviewer (V.P., S.C.) were retrieved for review of the full manuscript. The lists of full manuscripts meeting inclusion criteria from the 2 reviewers (V.P., S.C.) were compared, and any disagreements were resolved by discussion and consensus, with the senior author (C.T.T.) serving as the final arbiter if consensus was not achieved.

      Data synthesis and analysis

      A random-effects model was used for most of the meta-analysis because of the initial assumption of heterogeneity among the individual studies. Heterogeneity was assessed by Cochrane’s Q test and the I2 statistic, classified as not important (0%-40%), moderate (30%-60%), substantial (50%-90%), and considerable (75%-100%).
      • Higgins J.P.T.
      • Green S.
      Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011].
      If substantial (I2 > 50%), sensitivity analyses excluding outliers, subgroup analysis, and meta-regression were performed using age, gender, baseline body mass index, type of balloons used, size of dilation/maximum dilation, country of origin (East vs West), time from surgery, and time to follow-up provided there were sufficient numbers of studies to conduct these analyses. A funnel plot was constructed to evaluate for publication bias for the main outcomes, and the Egger test was reported if there were at least 10 studies present. Quality of data was assessed according to GRADE criteria for all primary and secondary outcomes using the GRADE Pro software (http://gradepro.org/). All analyses were done using Comprehensive Meta-Analysis software, version 3.0 (Biostat, Englewood, NJ, USA) unless specified otherwise.

      Results

      Among the initial 205 citations identified, 18 studies were eligible for 1 or more analyses (Fig. 1). Four hundred twenty-six patients were obtained from the 18 studies (Table 1). Countries where the studies were conducted include the United States, France, New Zealand, Kuwait, Egypt, Brazil, Romania, Israel, and Taiwan. The average reported age of all participants was 41.7 years (range, 34.6-45.6), and the average body mass index at initial presentation for LSG was 40.1 kg/m2 (range, 32.9-46.5). Female patients encompassed 70.7% of the total group. The average number of dilations per person was 1.8.
      Table 1Study characteristics
      AuthorYearCountryType of studyFemale (%)Average age (y)Mean time LSG to EBD (days)Mean follow-up (days)Primary outcome
      Agnihotri
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      2017USARetrospective94.142.7531330Endoscopic management of SGS using achalasia balloons, followed by SEMS stent
      Baretta
      • Baretta G.
      • Campos J.
      • Correia S.
      • et al.
      Bariatric postoperative fistula: a life-saving endoscopic procedure.
      2015BrazilProspective30Gastric fistula after bariatric surgery with distal stenosis from LSG undergoing balloon dilation
      Boueyre

      Boueyre E, Touchais O, Foulatier O, et al. Efficacy of gastric hydrostatic dilation in the functional obstruction after sleeve gastrectomy [abstract]. UEG Journal 2013; 1(suppl):A135-A587.

      2013FranceProspective88.945.6429180Efficacy of hydrostatic balloon dilation in functional obstruction after sleeve gastrectomy
      Chang
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      2017TaiwanRetrospective55.637.8211743Surgical standardization of treating SGS after initial endoscopic dilation
      Deslauriers
      • Deslauriers V.
      • Beauchamp A.
      • Garofalo F.
      • et al.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      2018USARetrospective94.142.2330345Endoscopic treatment with balloon dilations of post-LSG stenosis
      Dhorepatil
      • Dhorepatil A.S.
      • Cottam D.
      • Surve A.
      • et al.
      Is pneumatic balloon dilation safe and effective primary modality of treatment for post-sleeve gastrectomy strictures? A retrospective study.
      2018Retrospective177360Pneumatic balloon as primary treatment modality for post–sleeve gastrectomy strictures
      Donatelli
      • Donatelli G.
      • Dumont J.L.
      • Pourcher G.
      • et al.
      Pneumatic dilation for functional helix stenosis after sleeve gastrectomy: long-term follow-up.
      2017FranceRetrospective78.443204465Pneumatic balloon dilation of late functional helix stenosis after LSG
      Ellatif
      • Ellatif M.E.A.
      • Alfalah H.
      • Asker W.A.
      • et al.
      Place of upper endoscopy before and after bariatric surgery: a multicenter experience with 3219 patients.
      2016EgyptRetrospective591080Diagnosis and treatment of postbariatric complications using upper endoscopy
      Hutopila

      Hutopila I, Priboi M, Smeu B, et al. Treatment of stenosis after laparoscopic sleeve gastrectomy [abstract]. Obes Surg 2015; 25(Suppl 1):S1-S364.

      2015RomaniaProspective100180Endoscopic or laparoscopic treatment solutions for stenosis after LGS
      Jirapinyo

      Jirapinyo P, Abidi WM, Thompson CC. Systematic treatment of sleeve gastrectomy stenosis with hydrostatic and pneumatic balloon dilation is safe and effective [abstract]. Gastroenterology 2018;154:S-1276.

      2017USARetrospective45150336Improvement or resolution of SGS symptoms after EBD without need for surgery
      Manos
      • Manos T.
      • Nedelcu M.
      • Cotirlet A.
      • et al.
      How to treat stenosis after sleeve gastrectomy?.
      2017FranceRetrospective72.237.228.2Endoscopic treatment of stenosis after LSG
      McGouran

      McGouran D, Sekra A, Ogra R. Endoscopic managmenet of symptomatic stenosis post-laparoscopic sleeve gastrectomy for obesity, experience at a large bariatric surgery center [abstract]. Indian J Gastroenterol 2017;36(Suppl 1):A1-A105.

      2017New ZealandProspectiveSuccess rates of CRE balloon, achalasia balloon, and SEMS stent for symptomatic SGS
      Nath
      • Nath A.
      • Yewale S.
      • Tran T.
      • et al.
      Dysphagia after vertical sleeve gastrectomy: evaluation of risk factors and assessment of endoscopic intervention.
      2016USARetrospectiveHydrostatic balloon dilatation to treat dysphagia after vertical sleeve gastrectomy
      Ogra
      • Ogra R.
      • Kini G.P.
      Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.
      2015New ZealandProspective5845.3150360Management options for symptomatic stenosis after LSG
      Parikh
      • Parikh A.
      • Alley J.B.
      • Peterson R.M.
      • et al.
      Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.
      2012USARetrospective83.34248.8261Management options for symptomatic stenosis after LSG
      Rebibo
      • Rebibo L.
      • Hakim S.
      • Dhahri A.
      • et al.
      Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and management.
      2016FranceRetrospective94.14547.2300Treatment of gastric stenosis after LSG with endoscopic or surgical management
      Sabah
      • Sabah S.A.
      • Haddad E.A.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      2016KuwaitProspective84.634.695156Treatment of stenosis post-LSG using endoscopic balloon dilatation
      Shnell
      • Shnell M.
      • Fishman S.
      • Eldar S.
      • et al.
      Balloon dilatation for symptomatic gastric sleeve stricture.
      2014IsraelRetrospective81.344.1183Efficacy and safety of balloon dilation in symptomatic sleeve stenosis
      LSG, Laparoscopic sleeve gastrectomy; EBD, endoscopic balloon dilation; SGS, sleeve gastrectomy stenosis; SEMS, self-expanding metal stent; CRE, controlled radial expansion; —, not available.
      Obstructive symptoms typically presented weeks to months after LSG. Based on calculated rates from the 5 studies that provided clinical information, the symptoms that patients experienced were nausea (70.8%), vomiting (39.7%), reflux (75.0%), abdominal pain (49.3%), or inability to tolerate oral intake (35.1%). All cases of SGS were confirmed via endoscopic examination and/or upper GI series. Patients with a history of achalasia were excluded. EBD was the first-line therapy for all patients.
      Among the 17 studies that reported the type of balloon used, 9 used the CRE balloon and 12 used the Rigiflex II balloon (Boston Scientific, Marlborough, Mass, USA), with some studies using both type of balloons (Table 2). CRE balloons come in wide variety of lengths and sizes and are designed to be passed through an endoscope while exerting radial forces during inflation. Rigiflex II, on the other hand, is a fixed large-diameter, wire-guided pneumatic balloon dilator that does not pass through an endoscope but provides a greater radial force with a larger balloon size. Balloons were chosen based on availability, experience of the physician, or accessibility of the stricture site. In cases of persistent obstructive symptoms, further dilatations of increasing balloon diameters were attempted in a step-wise approach as per the treating physician’s experience in most studies. Lack of response to EBD required subsequent stent placement or revisional surgery.
      Table 2Type of balloon used per study, with success of EBD per dilation attempt and event rates of stent placement and surgery
      StudyBalloon typeInitial

      size (mm)
      Max

      size (mm)
      No. of casesOverall

      success (%)
      1 dilation (%)2 dilations (%)3 dilations (%)>3 dilations (%)Need

      stent (%)
      Need

      surgery (%)
      Agnihotri 2017
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      Rigiflex II30351770.635.323.55.95.917.611.8
      Baretta 2015
      • Baretta G.
      • Campos J.
      • Correia S.
      • et al.
      Bariatric postoperative fistula: a life-saving endoscopic procedure.
      Rigiflex II30977.8
      Boueyre 2013

      Boueyre E, Touchais O, Foulatier O, et al. Efficacy of gastric hydrostatic dilation in the functional obstruction after sleeve gastrectomy [abstract]. UEG Journal 2013; 1(suppl):A135-A587.

      CRE20n/a9100.0
      Chang 2017
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      CRE1218911.1.0.011.1.088.9
      Deslauriers 2018
      • Deslauriers V.
      • Beauchamp A.
      • Garofalo F.
      • et al.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      CRE/Rigiflex II20402755.640.711.13.7.07.429.6
      Dhorepatil 2018
      • Dhorepatil A.S.
      • Cottam D.
      • Surve A.
      • et al.
      Is pneumatic balloon dilation safe and effective primary modality of treatment for post-sleeve gastrectomy strictures? A retrospective study.
      Rigiflex II30402495.862.529.24.2
      Donatelli 2017
      • Donatelli G.
      • Dumont J.L.
      • Pourcher G.
      • et al.
      Pneumatic dilation for functional helix stenosis after sleeve gastrectomy: long-term follow-up.
      Rigiflex II30403360.630.321.29.1.018.2
      Ellatif 2016
      • Ellatif M.E.A.
      • Alfalah H.
      • Asker W.A.
      • et al.
      Place of upper endoscopy before and after bariatric surgery: a multicenter experience with 3219 patients.
      CRE151554100.0.0
      Hutopila 2015

      Hutopila I, Priboi M, Smeu B, et al. Treatment of stenosis after laparoscopic sleeve gastrectomy [abstract]. Obes Surg 2015; 25(Suppl 1):S1-S364.

      1376.923.1
      Jirapinyo 2017

      Jirapinyo P, Abidi WM, Thompson CC. Systematic treatment of sleeve gastrectomy stenosis with hydrostatic and pneumatic balloon dilation is safe and effective [abstract]. Gastroenterology 2018;154:S-1276.

      Rigiflex II20404680.42.2
      Manos 2017
      • Manos T.
      • Nedelcu M.
      • Cotirlet A.
      • et al.
      How to treat stenosis after sleeve gastrectomy?.
      Rigiflex II30151894.45.6
      Mcgouran 2017

      McGouran D, Sekra A, Ogra R. Endoscopic managmenet of symptomatic stenosis post-laparoscopic sleeve gastrectomy for obesity, experience at a large bariatric surgery center [abstract]. Indian J Gastroenterol 2017;36(Suppl 1):A1-A105.

      CRE/Rigiflex II5959.323.716.9
      Nath 2016
      • Nath A.
      • Yewale S.
      • Tran T.
      • et al.
      Dysphagia after vertical sleeve gastrectomy: evaluation of risk factors and assessment of endoscopic intervention.
      CRE10183369.739.415.215.2.0
      Ogra 2015
      • Ogra R.
      • Kini G.P.
      Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.
      CRE/Rigiflex II352680.842.330.83.83.819.2.0
      Parikh 2012
      • Parikh A.
      • Alley J.B.
      • Peterson R.M.
      • et al.
      Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.
      CRE15181080.020.0
      Rebibo 2016
      • Rebibo L.
      • Hakim S.
      • Dhahri A.
      • et al.
      Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and management.
      Rigiflex II30401776.511.811.8
      Sabah 2016
      • Sabah S.A.
      • Haddad E.A.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      Rigiflex II30402688.511.5
      Shnell 2014
      • Shnell M.
      • Fishman S.
      • Eldar S.
      • et al.
      Balloon dilatation for symptomatic gastric sleeve stricture.
      CRE/Rigiflex II20301643.812.512.518.8.037.5
      EBD, Endoscopic balloon dilation; CRE, controlled radial expansion; —, not available.
      The overall EBD success rate among the 18 studies was 76% (95% CI, .67-.83; I2 = 61.7; P < .01; 426 patients) (Fig. 2). Patients who did not achieve clinical resolution with EBD underwent endoscopic stenting, revisional surgery, were managed conservatively after partial resolution, or were lost to follow-up. The study by Chang et al
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      was noted to affect heterogeneity. Their primary aim was to assess SGS resolution by means of surgical interventions rather than EBD, and EBD was not their primary outcome. They attributed their low success rate to failure of using larger balloon sizes and lack of more than 1 attempt after the initial failed CRE balloon attempt. Therefore, because this study was markedly different in both protocol design and primary outcome, it was determined to be an outlier. After excluding this study, the overall success rate was 77% (95% CI, .69-.83; I2 = 55.5; 17 studies, 417 patients; P < .01) (Fig. 3).
      Figure thumbnail gr2
      Figure 2Overall success rates for all endoscopic balloon dilations. CI, Confidence interval.
      Figure thumbnail gr3
      Figure 3Overall success rates for endoscopic balloon dilations without Chang et al. CI, Confidence interval.
      Meta-regression was done to determine if any independent covariates correlated with EBD success rates and if they could explain the heterogeneity in the primary outcome. Age, gender, country of origin, and baseline body mass index before surgery did not affect EBD therapy results (Supplementary Table 1, available online at www.giejournal.org). There was no significant association between the number of dilatations needed per patient and EBD success rate (P = .72). Both the type of balloon used and the initial and maximal balloon dilation sizes did not affect success rates. There was no evidence of publication bias based on visual inspection of the funnel plot and nonsignificant Egger test (Supplementary Fig. 1, available online at www.giejournal.org). The overall quality of data was “very low” based on the GRADE criteria, because the studies had unclear or serious risk of biases and some had imprecision in the estimate of effect (Appendix 2, available online at www.giejournal.org).
      Among studies that specified EBD success rates according to SGS location, only 3 studies with 13 patients reported cases of proximal SGS. EBD as first-line therapy for proximal SGS achieved a success rate of 90% (95% CI, 63%-98%; I2 = .0; 3 studies, 13 patients; P = .01) (Fig. 4). Seven studies reported mid to distal cases of SGS, defined as stenosis at the antrum/incisura or body of the stomach. In this group, EBD success rate was 70% (95% CI, 47%-86%; I2 = 74.9; 7 studies, 159 patients; P = .09) (Fig. 5A); this rate was 75% (95% CI, 55%-88%; I2 = 72.2; 6 studies, 151 patients; P = .02) without the study by Chang et al
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      (Fig. 5B).
      Figure thumbnail gr4
      Figure 4Endoscopic balloon dilations success rates in proximal stenosis. CI, Confidence interval.
      Figure thumbnail gr5
      Figure 5Endoscopic balloon dilations success rates in distal stenosis with (A) and without (B) the outlier of Chang et al. CI, Confidence interval.
      Four studies reported cases of early SGS, and first-line EBD success rate was 59% (95% CI, 34%-79%; I2 = 37.4; 4 studies, 36 patients; P = .49) (Fig. 6). In the 5 studies that specified SGS after 3 months, EBD success rate was 61% (95% CI, 41%-78%; I2 = 47.2; 5 studies, 77 patients; P = .28 (Fig. 7A); this rate was 69% (95% CI, 55%-80%; I2 = .0; 4 studies, 69 patients; P = .01) without the study by Chang et al
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      (Fig. 7B).
      Figure thumbnail gr6
      Figure 6Endoscopic balloon dilations success rates in early stenosis. CI, Confidence interval.
      Figure thumbnail gr7
      Figure 7Endoscopic balloon dilations success rates in late stenosis with (A) and without (B) the outlier of Chang et al. CI, Confidence interval.
      Fourteen studies reported the use of revisional surgery as a second-line therapy in the event of multiple failed EBD attempts. Seventeen percent of patients (51/323) underwent salvage surgery, with a success rate of 91% (95% CI, 80%-96%; I2 = .0; 10 studies) (Fig. 8). Most surgeries were conversion to RYGB.
      Figure thumbnail gr8
      Figure 8Success rates for salvage surgery; I2 = 0%. CI, Confidence interval.
      Six studies reported the use of endoscopic self-expanding metal stents (SEMSs) after unsuccessful trials of EBD. The 32 patients who underwent endoscopic SEMS placement had a success rate of 70% (95% CI, 41%-89%; I2 = 31.6; P = .18 (Fig. 9). When including both first-line EBD and second-line SEMS therapy (Table 3), the combined endoscopic success rate increased to 78% (95% CI, 69%-86%; I2 = 66.1; 18 studies, 426 patients; P < .01) (Fig. 10A), or to 80% (95% CI, 71%-86%; I2 = 61.4; 17 studies, 417 patients; P < .01) without the study by Chang et al
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      (Fig. 10B). The reported mortality rate for all patients with SGS was 0%. Serious adverse events noted in the patients undergoing EBD were 2 GI bleeds requiring blood transfusions and resolved with conservative management and 2 perforations that resolved with revisional surgery, with an overall serious adverse event rate of .9%.
      Figure thumbnail gr9
      Figure 9Success rates for endoscopic stents (SEMS); I2 = 31%. CI, Confidence interval.
      Table 3Success rates for endoscopic balloon dilatations and stents
      No. of studiesNo. of patientsSuccess rate (95% confidence interval) (%)I2
      Total overall SGS
      Statistical analysis done without the outlier of Chang et al.19
      1741777 (69-83)55.5
      Proximal SGS31390 (63-98).0
      Number of studies too low to calculate heterogeneity.
      Distal SGS
      Statistical analysis done without the outlier of Chang et al.19
      615170 (47-86)72.2
      Early SGS43659 (34-79)37.4
      Late SGS
      Statistical analysis done without the outlier of Chang et al.19
      46969 (55-80).0
      Number of studies too low to calculate heterogeneity.
      Stents (SEMS)63270 (41-89)31.6
      All endoscopic therapy
      Statistical analysis done without the outlier of Chang et al.19
      1741780 (71-86)61.4
      SGS, Sleeve gastrectomy stenosis; SEMS, self-expanding metal stent.
      Statistical analysis done without the outlier of Chang et al.
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      Number of studies too low to calculate heterogeneity.
      Figure thumbnail gr10
      Figure 10Combined success rates for all endoscopic therapies with (A) and without (B) the outlier of Chang et al. CI, Confidence interval.

      Discussion

      LSG has become an increasingly popular option because of its quick recovery time and lower morbidity compared with other weight loss surgical options. The overall adverse event rate for LSG has been reported as 2.9% to 15.3%, with an overall mortality of .1% to .4%.
      • 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.
      However, insufficient data remain regarding endoscopic management of stenotic adverse events of LSG, and there are no guidelines to suggest which balloon type or methodology best optimizes successful SGS dilations. This is the first meta-analysis to examine the efficacy of EBD for treatment of SGS and demonstrates an overall success rate of 76% (95% CI, .67-.83; I2 = 61.7; 18 studies, 426 patients).
      EBD showed a tendency to be more successful in proximal SGS than in distal SGS (90% vs 70%; odds ratio, 2.81; P = .28; 3 studies, 68 patients), although this did not reach significance (Supplementary Fig. 2, available online at www.giejournal.org). One explanation is easier accessibility of the proximal SGS site, which allows for ease of maneuverability and optimal balloon positioning compared with the distal SGS site. However, the difference in EBD success rates could also be attributed to the underlying pathophysiology that depends on the site of SGS. Deslauriers et al
      • Deslauriers V.
      • Beauchamp A.
      • Garofalo F.
      • et al.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      noted that on initial endoscopic evaluation, proximal SGS had a circular, more symmetric appearance that was likely the result of mechanical narrowing. On the other hand, distal SGS located in the incisura or stomach body included a significant degree of axial deviation with an added twisting component to the stricture. These often occur from a torsional scarring along the staple line at the time of LSG. This difference in stricture formation can change the way balloon dilatation affects the stenosis.
      When an endoscopic balloon expands, it exerts an equal and outward radial pressure that works perpendicularly against the linear narrowing of proximal SGS. This same outward pressure may not be evenly distributed against the torsional forces of twisted strictures found in distal SGS, thereby inadequately disrupting stenotic tissue and decreasing the chance of sustained dilation. Indeed, among patients in the Deslauriers et al study
      • Deslauriers V.
      • Beauchamp A.
      • Garofalo F.
      • et al.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      that exhibited both proximal and distal stenoses, there was greater endoscopic improvement in proximal SGS with simple mechanical narrowing than in distal SGS at the incisura with axial deviation. Donatelli et al
      • Donatelli G.
      • Dumont J.L.
      • Pourcher G.
      • et al.
      Pneumatic dilation for functional helix stenosis after sleeve gastrectomy: long-term follow-up.
      noted that twisted strictures often exhibit asymmetric traction and consequent misalignment, usually from inadvertent rotation while stapling. They similarly observed that these twisting SGS are correlated with a higher EBD failure rate when compared with a more linear stenosis. Therefore, the intrinsic differences between a linear narrowing of the proximal SGS and a torsional stricture of the distal SGS with axial deviation could explain why EBD was more successful in the former group.
      There was no significant difference in EBD success rates between early SGS and late SGS (59% vs 61%; odds ratio, .73; P = .51; 5 studies, 97 patients) (Supplementary Fig. 3, available online at www.giejournal.org). We initially had assumed that delayed detection and treatment of SGS would result in a lower EBD success rate. The reasoning was that retraction of gastric tissue from the staple line or ischemia of the surrounding region progressively worsens over time, leading to increased fibrosis around the stricture site the longer treatment is delayed.
      • Zundel N.
      • Hernandez J.D.
      • Neto M.G.
      • et al.
      Strictures after laparoscopic sleeve gastrectomy.
      ,
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      Deslauriers et al
      • Deslauriers V.
      • Beauchamp A.
      • Garofalo F.
      • et al.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      even suggested that a contributing factor to their below average success rate (53%) was that their study had a longer mean follow-up time of 11.5 months and was thereby likely to capture more unsuccessful cases of SGS.
      There are a few reasons why the early SGS success rate appeared much lower than anticipated, especially when compared with the overall success rate of 76%. Shnell et al
      • Shnell M.
      • Fishman S.
      • Eldar S.
      • et al.
      Balloon dilatation for symptomatic gastric sleeve stricture.
      achieved a low success rate of 33% in their 6 early SGS cases, using a CRE balloon. Agnihotri et al
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      (50%) only a had a sample size of 2 patients with early SGS. Finally, in Deslauriers et al,
      • Deslauriers V.
      • Beauchamp A.
      • Garofalo F.
      • et al.
      Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis.
      nearly all patients exhibited distal SGS with axial deviation at the incisura, which as mentioned previously is associated with an inherently lower success rate than a linear proximal stricture. Given that these are 3 of the 4 studies reporting early SGS, additional studies are required to more accurately assess whether the chronicity of SGS affects EBD efficacy. Nevertheless, our data suggest that EBD as first-line therapy has a similar degree of safety and efficacy regardless of time between LSG and SGS symptom onset.
      The decision to include analyses both with and without the outlier study from Chang et al
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      was because of a difference in the study’s primary objective at achieving SGS resolution. Although the initial treatment modality was EBD, they recognized that their approach to SGS was focused on using surgical management rather than EBD therapy,
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      leading to an exceedingly low EBD success rate of 11.1% (1/9 patients). They also attributed their low success rate to using too small of a balloon dilator (CRE balloon, maximum 18 mm) in the initial dilation attempt without attempting dilations with larger balloons. Therefore, the analysis both with and without these 9 patients yields a more accurate representation of the efficacy of first-line EBD therapy in treating SGS. Several factors may help decide what type of balloon to use: location, time after LSG, length of stenosed segment, stomach length, and presence of torsional component.
      Meta-regression had indicated that balloon type and initial balloon dilation size do not affect overall EBD success rates (Supplementary Table 1). For instance, both Manos et al
      • Manos T.
      • Nedelcu M.
      • Cotirlet A.
      • et al.
      How to treat stenosis after sleeve gastrectomy?.
      and Ellatif et al
      • Ellatif M.E.A.
      • Alfalah H.
      • Asker W.A.
      • et al.
      Place of upper endoscopy before and after bariatric surgery: a multicenter experience with 3219 patients.
      achieved nearly 100% success rates using the larger Rigiflex and smaller CRE balloons, respectively. Nath et al
      • Nath A.
      • Yewale S.
      • Tran T.
      • et al.
      Dysphagia after vertical sleeve gastrectomy: evaluation of risk factors and assessment of endoscopic intervention.
      and Agnihotri et al
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      both achieved nearly identical success rates (70%) using the Rigiflex and CRE balloons, respectively, as well (Supplementary Fig. 4, available online at www.giejournal.org). Thus, a significant contributing factor of the success of EBD for SGS may depend on the physician’s expertise with the type of balloon used.
      However, a closer examination of the few studies that used multiple balloon types suggests otherwise. Compared with the through-the-scope CRE balloon, the larger Rigiflex II achalasia balloon provides a more robust dilation.
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      Shnell et al
      • Shnell M.
      • Fishman S.
      • Eldar S.
      • et al.
      Balloon dilatation for symptomatic gastric sleeve stricture.
      initially experienced difficulty with the smaller CRE balloon, achieving a success rate of just 31% (4/13). Once they were able to use the bigger achalasia balloons, they were successful in 100% (3/3) of cases. Similarly, Ogra et al
      • Ogra R.
      • Kini G.P.
      Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.
      had a much higher EBD success rate after switching from the CRE balloon (11% success rate) to a 30-mm achalasia balloon (71.4% success rate). Because of the achalasia balloon’s rigidity, it is less likely to bend in a twisted stricture compared with the CRE balloon. Logically, a more rigid balloon with a larger diameter would be more likely to tear the stenotic tissue in the stricture zone, yielding a higher success rate.
      • Donatelli G.
      • Dumont J.L.
      • Pourcher G.
      • et al.
      Pneumatic dilation for functional helix stenosis after sleeve gastrectomy: long-term follow-up.
      ,
      • Joo M.K.
      Endoscopic approach for major complications of bariatric surgery.
      ,
      • Dhorepatil A.S.
      • Cottam D.
      • Surve A.
      • et al.
      Is pneumatic balloon dilation safe and effective primary modality of treatment for post-sleeve gastrectomy strictures? A retrospective study.
      Additionally, an increased duration time of 15 to 20 minutes per dilation using the larger balloon in the initial attempt could better overcome the elasticity of the fibrosis that occurs in these stricture sites, thus leading to higher success rates as in the case of Dhorepatil et al.
      • Dhorepatil A.S.
      • Cottam D.
      • Surve A.
      • et al.
      Is pneumatic balloon dilation safe and effective primary modality of treatment for post-sleeve gastrectomy strictures? A retrospective study.
      Although anecdotal evidence from various dual-balloon studies may suggest superiority of the achalasia balloon, the type of balloon used may ultimately depend on accessibility and length of stenosis of SGS. For instance, although Shnell et al
      • Shnell M.
      • Fishman S.
      • Eldar S.
      • et al.
      Balloon dilatation for symptomatic gastric sleeve stricture.
      reported higher success with the achalasia balloon, they were unable to position the larger balloon appropriately in the distal SGS cases because of limited access of the introducer in a twisted SGS.
      Balloon choice can also depend on length of stenosis. It is believed that repeated EBD is more effective in shorter-length SGS than in long segment SGS.
      • Parikh A.
      • Alley J.B.
      • Peterson R.M.
      • et al.
      Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.
      ,
      • Sarkhosh K.
      • Birch D.W.
      • Sharma A.
      • et al.
      Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide.
      The reasoning is that shorter SGS have fewer stretches of fibrosis with less resistance against the expanding balloon, thus allowing the stenotic lumen to remain patent after dilatation. Unfortunately, most studies fail to report the length of stenosis segment, thereby making it difficult to analyze in this study. Of note, Ogra et al
      • Ogra R.
      • Kini G.P.
      Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.
      was able to successfully treat 6 of 7 short strictures (<3 cm) at the incisura with a smaller CRE balloon. However, in the long-segment strictures at the incisura, the CRE balloon was successful in just 1 of 9 patients (11%), whereas the achalasia balloon was successful in 5 of 7 patients (71%). For these long, often twisting types of SGS in which multiple achalasia balloon attempts fail, using a cautery incision on 4 quadrants (including muscle layer) after EBD has been shown to achieve more durable results.
      • Zundel N.
      • Hernandez J.D.
      • Neto M.G.
      • et al.
      Strictures after laparoscopic sleeve gastrectomy.
      Does overall success rate increase with multiple balloon dilatations? Based on 8 studies that reported the number of attempts per balloon size (Table 2), the success rate of balloon dilatation was 37.4% with the first attempt, 21.0% after 2 attempts, 8.1% after 3 attempts, and less than 2% on greater than 3 attempts. In other words, of the 134 successful dilatations reported in these 9 studies (total of 198 dilatations), 131 of these occurred within the first 3 attempts. It follows therefore that the likelihood of success drastically decreases beyond the third dilatation of the same balloon size. However, switching to a larger balloon size after 3 failed attempts may increase success rates in subsequent dilations.
      A main concern regarding the use of a larger balloon, such as the 30-mm achalasia balloon, in the initial attempt is the risk of perforation or tear. Within this meta-analysis, this was a rare event. Agnihotri et al
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      mentioned a patient who experienced a deep tear during a 35-mm achalasia balloon dilation that exposed the muscularis propria but recovered completely without surgical intervention. To minimize these risks, it is imperative that a thorough endoscopic assessment is done before EBD treatment to not only characterize the SGS, but also to identify any structural defects prone to perforation or tears. Indeed, appropriate balloon placement both improves the chance of dilation success and greatly minimizes risk of perforation.
      • Schulman A.
      • Chiang A.L.
      • Skinner M.J.
      • et al.
      Endoscopic management of sleeve gastrectomy complications [abstract].
      In cases of unresolved SGS despite multiple EBD attempts, stents and revisional surgeries have been used. Endoscopic SEMSs achieved a success rate of 70% in cases refractory to EBD, and the inclusion of stents as second-line therapy does increase our study’s overall endoscopic success rate from 76% to 78%, or from 77% to 80% without including Chang et al.
      • Chang P.C.
      • Tai C.M.
      • Hsin M.C.
      • et al.
      Surgical standardization to prevent gastric stenosis after laparoscopic sleeve gastrectomy: a case series.
      However, adverse event rates are not insignificant in SEMSs, with reported rates of stent migration varying from 5% to 62%.
      • Joo M.K.
      Endoscopic approach for major complications of bariatric surgery.
      Additionally, the safety and efficacy of stent insertion for treatment of SGS remains understudied. Although stent migration is worrisome, suturing the pliable stent to the gastric wall has been shown to lessen this concern.
      • Agnihotri A.
      • Barola S.
      • Hill C.
      • et al.
      An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy.
      For patients who require recurrent large-diameter (eg, 40 mm) achalasia balloon dilation or stent placement, surgery may be the next step in management (Fig. 11). This option, used after multiple failed endoscopic attempts, confers a high efficacy rate among the included studies, thereby providing clinicians a safe and effective fallback option for persistent SGS. Of the studies that reported surgical intervention after failed EBD therapy, conversion to RYGB was preferred over laparoscopic seromyotomy. Although a study using coding and billing data showed higher mortality with revisional bariatric surgery than what has been previously reported from the surgical registry,

      Popov V, Castaneda D, Georgi M, et al. Mortality and inpatient costs of revisional bariatric surgery: a nationwide analysis. Gastroenterology 2018;154:S80-1.

      it may be the best option for patients after failure of EBD.
      Figure thumbnail gr11
      Figure 11Proposed algorithm for endoscopic management of sleeve stenosis. CRE, Controlled radial expansion.
      Limitations of our analyses include the lack of randomized or case-controlled studies comparing EBD with other treatment modalities such as stents or surgical intervention as primary treatments or comparing various balloon types and stenosis location. Also, most studies include a small number of subjects, with short duration of follow-up. A well-designed clinical trial observing the long-term effects of EBD therapy on SGS would be helpful to elucidate adverse events of EBD and their persistence.
      In conclusion, EBS appears to be a safe and effective minimally invasive alternative to surgical revision and should be used as first-line therapy for SGS, with 76% overall success rate, .9% adverse event rate, and 17% requiring salvage surgery. Proximal or shorter distal SGS can initially be treated with the smaller CRE balloon, with use of the larger achalasia balloon as next step in management if necessary. Distal, longer SGS with a degree of axial torsion would benefit from a larger 30-mm achalasia balloon in the initial attempt, provided the duration of recovery is appropriate after the initial bariatric surgery. For patients with long-term symptomatic stenosis in the setting of multiple failed EBD attempts, endoscopic stents or surgical revision remain a viable second-line therapy.

      Appendix 1: Description of Boolean operators used during the initial search strategy for studies meeting inclusion criteria

      1 bariatric surgery.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      2 bariatric surgeries.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      3 bariatric surgical procedure.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      4 bariatric surgical procedures.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      5 metabolic surgery.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      6 metabolic surgeries.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      7 stomach stapling.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      8 weight reduction surgery.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      9 weight reduction surgeries.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      10 weight loss surgery.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      11 weight loss surgeries.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11
      13 sleeve gastrectomy.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      14 sleeve gastrectomies.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      15 13 or 14
      16 endoscopy.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      17 endoscopies.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      18 16 or 17
      19 stricture.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      20 strictures.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      21 stenosis.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      22 stenoses.mp. [mp=ti, ab, ot, nm, hw, kf, px, rx, ui, an, eu, pm, sy, tn, dm, mf, dv, kw, fs]
      23 19 or 20 or 21 or 22
      24 12 and 15 and 18 and 23
      25 remove duplicates from 24

      Appendix 2: GRADE summary of findings table for all primary and secondary outcomes. SGS refers to sleeve gastrectomy stenosis

      Figure thumbnail fx5
      Figure thumbnail fx2
      Supplementary Figure 2CI, Confidence interval.
      Figure thumbnail fx3
      Supplementary Figure 3CI, Confidence interval.
      Figure thumbnail fx4
      Supplementary Figure 4CI, Confidence interval.
      Supplementary Table 1Meta-regression of secondary analyses in variables examined with regard to endoscopic balloon dilation success rates on sleeve gastrectomy stenosis
      No. of studiesR2
      Coefficient of determination, analyzed based on the fitted regression line.
      Event rate coefficient95% Confidence intervalP valueI2
      Percent heterogeneity that unexplained variance is zero for each variable.
      Age12.00–.024–.203 to .155.7968.4
      Gender12.00.015–.030 to .061.5166.1
      Country of origin (East vs West)17.00.405–.735 to 1.545.4961.3
      Body mass index10.00.049–.100 to .198.5271.4
      Follow-up time12.00.002–.002 to .005.3261.2
      Days from LSG15.00–.001–.005 to .003.5360.6
      Balloon type (CRE vs Rigiflex)17.00.162–.861 to 1.186.7665.5
      Initial dilation size13.00.048–.036 to .132.2772.0
      Maximum dilation size15.00.003–.057 to .064.9269.0
      Average no. of dilations per person13.00.213–.960 to 1.385.7270.4
      LSG, Laparoscopic sleeve gastrectomy; CRE, controlled radial expansion.
      Coefficient of determination, analyzed based on the fitted regression line.
      Percent heterogeneity that unexplained variance is zero for each variable.

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      Linked Article

      • Balloon dilation in sleeve gastrectomy stenosis: a simple solution to an occasionally tricky problem
        Gastrointestinal EndoscopyVol. 91Issue 5
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          The global obesity epidemic over the past decade has led to the development of several surgical therapeutic options for severe obesity, defined as a body mass index (BMI) of 40 kg/m2.1 Patients with BMI of 35 to 39.9 kg/m2 with an obesity-related comorbidity such as diabetes or hypertension and patients with a BMI of >30 kg/m2 and metabolic syndrome, or difficult-to-control diabetes, are also suitable for bariatric surgical procedures.1 Bariatric surgical procedures can be classified into restrictive procedures such as sleeve gastrectomy, malabsorptive procedures such as jejunoileal bypass and biliopancreatic diversion, and a combination of restriction and malabsorption, as with Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch.
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