Abbreviations:
BMI (body mass index), EBD (endoscopic balloon dilation), FCSEMS (fully covered self-expanding metal stent), LSG (laparoscopic sleeve gastrectomy), RYGB (Roux-en-Y gastric bypass)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.- Mechanick J.I.
- Youdim A.
- Jones D.B.
- et al.
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.
Surg Obes Relat Dis. 2013; 9: 159-191
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. Of those procedures, laparoscopic sleeve gastrectomy (LSG) and RYGB are the most commonly performed bariatric surgical procedures. In recent years, LSG has overtaken RYGB as the most commonly performed bariatric surgical procedure.- Mechanick J.I.
- Youdim A.
- Jones D.B.
- et al.
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.
Surg Obes Relat Dis. 2013; 9: 159-191
2
LSG is technically easier to perform than RYGB. It creates a gastric sleeve around a 32F to 40F bougie after transection of the stomach along the greater curvature, approximately 2 to 6 cm proximal to the pylorus. Inasmuch as the fundus of the stomach is excluded, the resultant tubular stomach is volume restricted and resistant to stretching, making it a high-pressure organ with a sphincter at both ends. This is thought to be the reason for a higher incidence of leaks and gastroesophageal reflux with LSG than with RYGB. Strictures in LSG may be due to the mechanical effects of twisting of the staple line, creating a spiral sleeve.
3
Stapling too close to the bougie, particularly at the incisura, and the use of small bougies can additionally predispose to stricture formation.3
Edema/hematoma at the staple line can additionally cause early post-LSG stenosis.Endoscopic management of post-LSG stenosis involves balloon dilation of strictures. However, the optimal size and type of balloon used, the frequency of dilations, and decision making about when to switch from endoscopic therapy to surgery are unclear. Chang et al
4
have sought to answer these questions by reviewing the literature on the management of post-LSG stenosis in a meta-analysis. They reviewed 18 studies from 2013 to 2018 and found a 76% efficacy rate for endoscopic balloon dilation (EBD) for treating post-LSG stenosis, with an average of 1.8 dilations per patient. Seventeen out of 18 studies reported on the type of balloon used. In 9 studies, controlled radial expansion balloons were used through the endoscope, whereas larger Rigiflex II balloons, which cannot be inserted through the endoscope and are used primarily for pneumatic balloon dilation for achalasia, were used in 12 studies; 4 studies used a combination of both balloons. Chang et al4
found that proximal LSG stenosis, reported in 3 studies, responded very well to EBD, with 90% efficacy. By contrast, in mid or distal stenosis, reported in 7 studies, the efficacy of EBD was reduced to 70%. The authors explain this difference in efficacy to proximal strictures being short (<3 cm) and symmetric, and distal strictures being long (>3 cm) and additionally possessing an axial or torsional component, which may negate the radial expansile force delivered by balloons. This observation would explain the relative inefficacy of the controlled radial expansion balloon for long distal strictures (31% efficacy), whereas the larger achalasia (Rigiflex II) balloons were more effective (71% efficacy). Short distal strictures, however, behaved like proximal strictures and had 86% efficacy with EBD. The authors also found a decremental response to multiple balloon dilations, with efficacy dropping to <2% with more than 3 dilations. They therefore suggest a maximum of 3 dilation attempts, each with controlled radial expansion and achalasia balloons, before switching to an alternative strategy. Chang et al4
additionally determined that endoscopic fully covered self-expanding metal stents (FCSEMSs) were effective in 70% of EBD failures, and revisional surgery (mainly conversion to RYGB) was effective in 91%.4
Questions, however, remain about balloon type, balloon size, and the number of dilations required. Given the limited nature and heterogeneity of the data, it is difficult to comment on superiority of the type or length of a balloon, but it is plausible that “bigger is better.” Additionally, it appears unlikely that more than 3 sessions with the same balloon will provide an incremental yield. The sample size is small, so with some caution it appears that the timing of the stricture did not affect the outcome.
Post-LSG stenosis can be treated alternatively by the use of FCSEMSs, seromyotomy, and surgical revision, although FCSEMSs have a migration risk of 58% in the postbariatric stricture setting.
5
,6
Suturing the stent to the gastric wall has been suggested as a feasible solution, but this increases the complexity of the procedure.7
Laparoscopic seromyotomy has been used in treating long strictures, but it requires a second surgery along with an added risk of GERD and leaks.8
There are exciting endoscopic options in the horizon, such as endoscopic myotomy for proximal LSG stenosis and gastric peroral endoscopic myotomy for distal strictures.
9
,10
The technique of bariatric surgery is also evolving, with sleeve gastrectomy being performed on a robotic platform.11
,12
Sleeve gastrectomy can now also be performed endoscopically with shorter procedure times but with a caveat of lower weight reduction.13
Given the global burden of obesity, surgical interventions for its management are likely to increase. The article by Chang et al
4
provides insight into the use of EBD as adequate first-line therapy for post-LSG stenosis. Surgery as salvage for failed EBD seems a good next step, but given the rapid changes in the field, that may change in the future. This article is another step in the evolving field of troubleshooting bariatric surgery–associated adverse events and opens more questions that will need to be answered by future studies.Disclosure
All authors disclosed no financial relationships.
References
- Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.Surg Obes Relat Dis. 2013; 9: 159-191
- Bariatric surgery worldwide: baseline demographic description and one-year outcomes from the fourth IFSO global registry report 2018.Obes Surg. 2019; 29: 782-795
- International Sleeve Gastrectomy Expert Panel consensus statement: best practice guidelines based on experience of >12,000 cases.Surg Obes Relat Dis. 2012; 8: 8-19
- Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis..Gastrointest Endosc. 2020; 91: 989-1002
- Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients.Obes Surg. 2013; 23: 1481-1486
- Use of endoscopic stents to treat anastomotic complications after bariatric surgery.J Am Coll Surg. 2008; 206 (discussion 938-9): 935-938
- Safety and efficacy of endoscopically secured fully covered self-expandable metallic stents (FCSEMS) for post-bariatric complex stenosis.Obes Surg. 2019; 29: 3484-3492
- Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch.Obes Surg. 2009; 19: 495-499
- Endoscopic tunneled stricturotomy with full-thickness dissection in the management of a sleeve gastrectomy stenosis.Obes Surg. 2019; 29: 2711-2712
- Gastric per-oral endoscopic myotomy (G-POEM) for the treatment of gastric stenosis post-laparoscopic sleeve gastrectomy (LSG).Obes Surg. 2019; 29: 2350-2354
- Cost analysis of robotic sleeve gastrectomy (R-SG) compared with laparoscopic sleeve gastrectomy (L-SG) in a single academic center: debunking a myth!.Surg Obes Relat Dis. 2019; 15: 675-679
- Robot-assisted sleeve gastrectomy and Roux-en-Y gastric bypass: results from the metabolic and bariatric surgery accreditation and quality improvement program data registry.Surg Obes Relat Dis. 2019; 15: 1281-1290
- Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study.Gastrointest Endosc. 2019; 89: 782-788
Article info
Identification
Copyright
© 2020 by the American Society for Gastrointestinal Endoscopy
ScienceDirect
Access this article on ScienceDirectLinked Article
- Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysisGastrointestinal EndoscopyVol. 91Issue 5
- PreviewGastric 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.
- Full-Text
- Preview
