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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1116_Библиотеки_им_академика_М_И_Перельмана.pdf
T. R. McCarty and C. C. Thompson478
common complication associated with laparoscopic sleeve gastrectomy. Sleeve
stenosis may occur early in the post-operative course (even days after the surgery)
or years post-sleeve gastrectomy [8, 11]. Broadly speaking, laparoscopic sleeve
gastrectomy associated stenosis may be classically classified into two categories:
acute and chronic [12]. Acute stenoses may be a result by mucosal edema and
acute angulation of the sleeve while chronic stenoses are considered to be related
to ischemia of the pouch and angulation or retraction due to fibrosis or scarring.
Current literature estimates that sleeve gastrectomy associated strictures occur in
0.2–4.0% of laparoscopic sleeve operations [8, 13–15]. Despite this number being
as high as 4%, typically less than 1% of stenoses require endoscopic revision or
surgical reintervention [16].
3 Mechanisms, Location, and Classification of Stricture
Sleeve stenosis typically develops as a result of luminal narrowing or torsional
scarring—Fig. 1 [12]. Although multiple etiologies and mechanisms exist to
potentially explain stricture formation, risk factors for stricture formation are
Fig. 1 a and b Endoscopic images of sleeve stenosis at the level of the incisuria angularis c
Upper gastrointestinal series image demonstrating a stricture after laparoscopic sleeve gastrectomy. Permission obtained from de Moura DTH, Jirapinyo P, Aihara H, Thompson CC.
Endoscopic tunneled stricturotomy in the treatment of stenosis after sleeve gastrectomy.
VideoGIE. 2019;4(2):68–71
How to Manage Sleeve Complications Through Endoscopy …
mainly related to the surgical technique—most commonly improper alignment
of the staple line along the greater curvature is believed to be the main driver
of sleeve stenosis [17, 18]. Alternative mechanisms to explain sleeve stenosis
include narrowing of the gastric sleeve as a result of using thin, small bougies,
over-aggressive imbrication of the staple-line, stapling too close to the bougie, or
unintentional progressive rotation of the staple-line in an anterior to posterior fashion, potentially causing a functional helix-like stenosis of the sleeve [10, 18–20].
Although these mechanisms are mostly structural in nature, functional sleeve
stenosis as a result of axis deviation has also been demonstrated. These type of
functional sleeve stenoses develop as a result of edema or hematomas at the staple line, and typically do not require treatment and resolve spontaneously—unlike
mechanical etiologies. The most common location for stricture formation includes
the incisura angularis or more proximally at the gastroesophageal junction [20,
21]. Previous data by Deslauriers and others has shown that proximal strictures
may have a more symmetric appearance, potentially due to mechanical narrowing
[22]. Distal stenoses, which are classically located at the incisura angularis, are
typically due to axial deviation with a twisting-like stricture formation and may be
more difficult to treat endoscopically.
479
4 Signs and Symptoms
It is important to first underscore that there are two types of stenosis following
sleeve gastrectomy: a clinical (symptomatic) and subclinical (asymptomatic) stenosis [23]. Clinical or symptomatic stenosis is by far the most relevant to clinicians as it warrants timely investigation and treatment. Classic symptoms of sleeve
stenosis include nausea, vomiting, abdominal pain, and typically dysphagia. These
manifestations present with obstructive symptoms and inability to tolerate oral
intake though severity of symptoms largely depends upon the degree of sleeve narrowing. Given these non-specific symptoms, it is also critical to evaluate for potential motility disorders as well as other causes.
5 Diagnosis and Management
Although an upper gastrointestinal series with fluoroscopy may be used to confirm the diagnosis of sleeve stenosis, endoscopic management provides an
ideal first diagnostic and therapeutic approach for short-segment sleeve stenoses. Additionally, while upper gastrointestinal series may be selected for some
patients, it remains vital to underscore these tests may miss leaks and to consider
cross-sectional imaging if a high clinical suspicion remains. While current sleeve
stenosis treatments range from endoscopic treatment and revisional surgical interventions, seromyotomy, or conversion to Roux-en-Y gastric bypass, endoscopic
management remains a first-line strategy when conservative management fails.
This is mostly due to high initial success rates with balloon or pneumatic dilation
T. R. McCarty and C. C. Thompson480
as well as providing the least minimally invasive approach [24]. Given the excellent safety profile of endoscopy, an approach using balloon dilation has emerged
as a promising initial treatment option and alternative to revisional surgery with
laparoscopic seromyotomy [19, 25]. A summary table for sleeve stenosis is highlighted in Table 1.
6 Bougie Dilation
At present, there is limited evidence to recommend endoscopic bougienage as a
first-line strategy for the treatment of short-segment sleeve stenosis. Published
data is largely limited to a small case series by Burgos et al., where the authors
describe successful dilation with various sized Savary bougies [24]. In this series,
a single endoscopic dilation with a Savary 48F bougie was successful at improving a sleeve-related stricture at the incisura angularis that developed 7 months
post-operatively. While this patient with a late occurring stenosis remained
asymptomatic at follow-up 11 months post-dilation, another patient included
in this study developed a sleeve leak and distal stenosis 2 weeks post-surgery
and required progressive bougienage (using Savary dilators 45F, 51F, and 54F).
Another patient in this study developed stenosis at the middle-third portion of the
sleeve within the first month following the surgery and required Savary dilation
with a 36F bougie. The final patient included in this case series developed an early
stricture at the incisura angularis within 2 weeks of the surgery; however, did not
respond to multiple endoscopic dilations with the Savary bougie. Based on this
one series, it is impossible to draw strong conclusions regarding a role for Savary
dilation of sleeve stenosis. Additionally, concerns have been raised regarding the
blind dilation of early sleeve stenosis with a Savary dilator, especially within the
first 2 weeks of post-operation, as the wound is still healing and the risk of perforation is high [23]. Given the paradigm shift towards controlled radial expansion
(CRE) balloons for the treatment of esophageal stenosis, it is likely balloon dilation will be a much more common first-line treatment for sleeve stenosis.
7 Controlled Radial Expansion (CRE) Balloon
and Pneumatic Dilation
In a recent systematic review by Brunaldi and colleagues, 9 studies have evaluated
the role of CRE balloon dilation in the management of sleeve stenosis [17].
Among these 9 studies, including 129 cases, CRE balloon dilation was successful
for 108 cases (non-pooled success rate of 83.7%). Of note, most of these studies
were small in number and case series, potentially allowing for selection bias. A
representative image of CRE balloon dilation of sleeve stenosis is shown in Fig. 2.
In this same systematic review, the success rate for studies evaluating pneumatic
dilation was reported to be 88.7%—including 7 studies with 115 patients [17].
In another recent meta-analysis by Chang et al. data was combined for multiple
How to Manage Sleeve Complications Through Endoscopy …
Treatment strategy
Endoscopic balloon or
pneumatic dilation; consider
SEMS placement or surgical
intervention if failure
Fluoroscopy, endoscopy, or
cross-sectional imaging
481
Classic symptom presentation Time course to develop Diagnosis
Complication of sleeve
gastrectomy
Table 1 Summary table for endoscopic management of stenosis following sleeve gastrectomy
Anytime (early and late
development)
abdominal pain
Stenosis Dysphagia; nausea/vomiting;
Adapted from: Schulman AR, Thompson CC. Complications of Bariatric Surgery: What You Can Expect to See in Your GI Practice. Am J Gastroenterol
2017;112:1640–55
T. R. McCarty and C. C. Thompson482
Fig. 2 Successful dilation of
sleeve gastrectomy stricture
using a through-the-scope
(TTS) using a controlled
radial expansion (CRE)
balloon
types of balloon dilators (including CRE and Rigiflex II pneumatic dilation balloons) [19]. This study provided key data including an overall pooled success rate
of 76%. More importantly, these authors also stratified success rates for sleeve
stenosis by stricture location. Proximal strictures were successfully dilated with
endoscopic balloon dilators in 90% of cases while dilation was only effective
in 70% of cases for distal stenoses. Furthermore, stratification by early and late
stenosis was also performed for studies reporting these characteristics and demonstrated success rates of 59% and 61%, respectively. Additionally, on metaregression analyses, balloon type (CRE versus pneumatic) as well as balloon size,
did not affect rates of clinical success [19]. Step-by-step instructions for use of
balloon dilation is highlighted in Fig. 3. Overall, for severe stenoses, we recom-
mend a graded or step-up approach, involving first treatment with CRE balloon
dilation, and then consideration for pneumatic dilation for refractory strictures.
8 Self-Expanding Metal Stent (SEMS) Placement
For patients that fail to respond to endoscopic balloon dilation, placement of a
self-expanding metal stent (SEMS) may also be a viable option for many. This
may be especially helpful in the setting of concomitant sleeve leak and offers a
safe and effective alternative, obviating the need for repeat surgical intervention. While an effective treatment for leaks, these stents should be removed after
6–8 weeks as stent migration has been noted to occur in up to 15% of cases [26].
Importantly, use of a dumbbell shaped, lumen apposing metal stent (LAMS)
with a bi-flanged design may reduce the migration rate [10, 27]. Although limited literature exists from cases series, the non-pooled success rate of SEMS as
a first-line strategy for the management of sleeve stenosis is 95.5% [17]. When
used after balloon dilation for refractory strictures, SEMS placement has a success
rate of approximately 78% to 83%, though a significant risk of migration has been
reported [17, 19]. Reported adverse events and stent migration with SEMS placement have ranged widely from 5% to >50% in some studies [17, 19, 28]. Although
suturing of the stent in place has been described, similar to what is performed for
How to Manage Sleeve Complications Through Endoscopy …
Fig. 3 In this case, a sleeve stenosis was noted at the incisura angularis. Next, a Savary guide-
wire was placed deep in the second portion of the duodenum, then the scope was exchanged
over the wire. b and c The pneumatic balloon was advanced over the wire and the endoscope
was advanced adjacent to the balloon. d Dilation with a 40 mm pneumatic balloon was then performed under fluoroscopic and endoscopic guidance. The balloon was inflated to 18 PSI with
complete effacement of the balloon waist. e Pressure was held for 5 minutes before balloon deflation and withdrawal. f Final appearance of incisura angularis post-sleeve dilation
483
some esophageal stents, the location of stenosis as well as the limited maneuverability within the sleeve may make this challenging for the endoscopist [29].
Figure 4 demonstrates successful placement of a SEMS on endoscopic and fluoroscopic imaging [30]. We advocate SEMS placement only in the setting of a severe
stricture refractory to first-line balloon dilation or in the setting of a distal stenosis
with length > 3 cm. Most importantly, this should ideally be performed in centers with significant expertise and after consultation with the patient and surgical
colleagues.
9 Alternative Endoscopic Treatments for Sleeve
Stenosis
Several other novel or alternative endoscopic treatments have been described in
the literature to date. It should be noted, however, that these are limited to case
reports and small case series and likely only possible at centers with significant
expertise. As such, we will highlight a few of these novel strategies but do not feel
they should be rapidly adopted in clinical practice at this time. One such treatment
that our group has previously described includes use of a novel endoscopic tunneled stricturotomy technique [12]. The steps involved for this technique include
submucosal injection proximal to the area of the stricture followed by submucosal
T. R. McCarty and C. C. Thompson484
Fig. 4 Placement of a fully covered self-expandable metal stent (SEMS) for sleeve stenosis.
a Endoscopic image. b Fluoroscopic image. Images and permission obtained from Costa MN,
Capela T, Seves I, Ribeiro R, Rio-Tinto R. Endoscopic Treatment of Early Gastric Obstruction
After Sleeve Gastrectomy: Report of Two Cases. GE Port J Gastroenterol. 2016;23(1):46–9
tunneling to disrupt the muscle layer and perform stricturotomy, and then closure—Fig. 5 [12]. In another case report by the Hopkins group, led by Vivek
Kumbhari, these authors described successful gastric peroral endoscopic myotomy (G-POEM) for the treatment of sleeve stenosis [31]. While more recently
developed as a treatment for delayed gastric emptying, G-POEM was performed
after the patient had previously not responded to endoscopic balloon dilation—
Fig. 6 [31]. The procedure was highly successful with with resolution of the tortuosity. While these case reports of novel techniques and treatments demonstrate
these methods to be feasible and may provide an alternative for patients unable
to undergo or refractory to balloon dilation and not amenable to surgical revision,
additional studies are needed to measure their efficacy and safety.
10 Strategies for Endoscopic Success
Currently, there are no data driven or consensus guidelines to suggest which balloon type or methodology offers the best outcomes for the endoscopic management of sleeve stenosis. Additionally, there are a lack of randomized trials or
well-designed case-controlled studies to compare balloon versus pneumatic dilation as well as to other treatment modalities such as seromyotomy. Ultimately,
these types of studies, along with cost-effectiveness analyses, are needed to guide
future therapy and identify optimal algorithms to ensure the best patient care.
Despite the current lack of evidence, the meta-analysis by Chang and colleagues perhaps provides the best current estimate or strategy for adoption to clinical practice [19]. Endoscopic balloon dilation was more successful for proximal
How to Manage Sleeve Complications Through Endoscopy …
485
Fig. 5 With this endoscopic tunneled stricturotomy technique, first submucosal injection is performed approximately 3 to 5 cm proximal the area of stenosis. a Next, submucosal tunneling
dissection is performed, b with careful attention to identify muscle fibers during submucosal tunneling. c Demonstrates submucosal tunneled stricturotomy with d final appearance after endoscopic suturing to close the defect. e and f Endoscopic and g and h fluoroscopic images are
shown to illustrate the area of stenosis pre- and post-intervention. Permission obtained from de
Moura DTH, Jirapinyo P, Aihara H, Thompson CC. Endoscopic tunneled stricturotomy in the
treatment of stenosis after sleeve gastrectomy. VideoGIE. 2019;4(2):68–71
T. R. McCarty and C. C. Thompson486
Fig. 6 a Balloon dilation image demonstrating sleeve stenosis—entire stomach becomes
ischemic as opposed to simply seeing a single ring-like ischemic area (high risk of perforation).
b Fluoroscopic image highlights sleeve stricture. c Upper gastrointestinal series demonstrating stenosis at the incisura angularis. d Upper gastrointestinal series demonstrating improved
stricture after gastric peroral endoscopic myotomy (G-POEM) has been performed. Permission
obtained from Farha J, Fayad L, Kadhim A, Simsek C, Badurdeen DS, Ichkhanian Y, et al.
Gastric Per-Oral Endoscopic Myotomy (G-POEM) for the Treatment of Gastric Stenosis PostLaparoscopic Sleeve Gastrectomy (LSG). Obes Surg. 2019;29(7):2350–4
stenoses when compared to more distal strictures; however, this was not statistically significant (90% versus 70%; P = 0.28). Due to limited study reporting (only
3 studies including a total of 68 patients), this may be underpowered to detect a
true or significant difference. Proximal strictures anecdotally are considered easier
to treat given improved visibility, ease of maneuverability, and potential underlying pathophysiology of stricture formation.
Based upon these results, Chang and colleagues (including an author of
this review) have proposed an algorithm for endoscopic management of sleeve
How to Manage Sleeve Complications Through Endoscopy …
487
stenosis—Fig. 7. This strategy recommends CRE balloon dilation as a firstline strategy for all proximal strictures as well as short (defined as < 3 cm) distal stenoses. For long strictures in the distal sleeve, we recommend starting with
pneumatic dilation at 30 mm. From there, the pneumatic dilation balloon may
be progressively increased and reattempted at a maximum 40 mm for a total of
3 times prior to consideration of SEMS placement or surgical reintervention. It
should be emphasized that these recommendations do not relate to the immediate
post-operative period where fresh staple lines may have a high risk of perforation.
11 Conclusions
In summary, we have reviewed the pathophysiology and characteristics of sleeve
stenosis as well as discussed how to endoscopically manage stricture complications from laparoscopic sleeve gastrectomy. It remains critical for the endoscopist
to be in close communication with the patient and surgical colleagues, understand
bariatric surgery anatomy, and evaluate for alternative complications such as leaks
or GERD during the endoscopic examination. While balloon dilation, either via
Fig. 7 Proposed algorithm for endoscopic management of sleeve stenosis Permission obtained
from Chang SH, Popov VB, Thompson CC. Endoscopic balloon dilation for treatment of
sleeve gastrectomy stenosis: a systematic review and meta-analysis. Gastrointest Endosc.
2020;91(5):989–1002 e4