STENOSIS AFTER BARIATRIC SURGERY Riccardo BRACHET CONTUL MD

STENOSIS AFTER BARIATRIC SURGERY Riccardo BRACHET CONTUL MD, Adjunct Professor at Turin University Master of Laparoscopic Surgery, Unit of Bariatric Surgery P. MILLO, MD, Unit of Bariatric Surgery - Chief M. FABOZZI, MD Unit of Bariatric Surgery DEPARTMENT OF LAPAROSCOPIC, BARIATRIC E COLORECTAL SURGERY – CHIEF DR. R. ALLIETA AOSTA “U. PARINI” REGIONAL HOSPITAL - ITALY

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS: DEFINITION An abnormal narrowing or constriction of the diameter of a bodily passage or orifice (as from inflammation, cancer, or the formation of scar tissue). STENOSIS: SYMPTOMS • Dysphagia (first with solids and progressing to intolerance even with liquids) • Vomiting (sometimes with nausea) • Symptoms of obstruction when moving from fluids to solid food • Sticking to fluid comsumption, not progressing to solids • Saliva or food regurgitation • Impaction of food (especially meat or bread) • De novo gastroesophageal reflux disease symptoms • At times pain in the epigastric to retrosternal area.

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS: DIAGNOSIS • Symptoms • UGI-radiograms • Endoscopy (narrowing of the anastomosis or suture or outlet that did not allow passage or afforded significant resistance to passage of the 9 -mm endoscope in the symptomatic patients)

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AND TYPE OF OPERATION • SAGB • LAPAROSCOPIC VERTICAL BANDED GASTROPLASTY • LAPAROSCOPIC GASTRIC GREAT CURVATURE PLICATION • LAPAROSCOPIC SLEEVE GASTRECTOMY • LAPAROSCOPIC GASTRIC BYPASS • LAPAROSCOPIC BILIO-PANCREATIC DIVERSION

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AND TYPE OF OPERATION SAGB FUNCTIONAL STENOSIS RELATED TO COMPLICATIONS (GASTRIC POUCH DILATATION, SLIPPAGE, GASTRIC WALL EROSION/BAND MIGRATION, TOO MUCH INFLATION OF THE BAND, …) THERAPY TREATMENT OF THESE COMPLICATION

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AND TYPE OF OPERATION LAPAROSCOPIC VBG (actually abandoned technique) STENOSIS RELATED TO NARROW OUTLET, EROSION, GASTRIC POUCH DILATION… THERAPY TREATMENT OF THESE COMPLICATION

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LSG Due to the long staple line and altered intragastric pressures. STENOSIS is reported in 0. 26 -4% of operations This rate is underestimated: -Because early published series of LSG tended to use larger bougies with the intention of two-stage weight loss. Additionally, little literature exists regarding patient characteristics, operative techniques, and other variables that may contribute to the development of a sleeve stenosis - Few reports have described the subsequent management of these patients -

STENOSIS AFTER LSG - CAUSES ACUTE • Gastric mucosal edema Kinking (specially when a very narrow sleeve makes an acute turn in the middle, usually in relation to incisura angularis • • Narrowing to oversewing of the staple line • Irregular staple line CRONIC Ischemia of the pouch Retraction due to scarring Fistula Inclusion of the gastroesophageal junction in the staple line Conversion of Gastric Banding in Sleeve (or LRYGBP)

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica LSG FUNCTIONAL STENOSIS AFTER LSG Twisting of the sleeve

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LSG – HOW TO AVOID 1. Keep a safe distance between the incisura angularis and edge where staples are applied (with boogie in place while stapling) - to avoid stricture and kinking 2. When cutting the adesions between stomach and posterior peritoneum over the pancreas, preserve the branches of the left gastric artery - to avoid ischemic lesions 3. Keeping the staple line straight, by resecting simmetrically anterior and posterior gastric walls (trick: pull the gastroepiploic margin of section) - to avoid kinking and twisting of the tube. 4. Also the reinforcement oversewing has to respect point 3. Zundel N, et al. SURG LAPAROENDOSC PERCUTAN TECH 2010, 20(3): 154 -8

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LSG - TREATMENT 1. EDEMA: NIL PER OS, HIDRATION, PPI + Escina ev, CLINICAL OBSERVATION 2. OTHER STENOSIS - ENDOSCOPY with pneumatic balloon dilation (1 - several sessions) or X-ray guided dilation - STENTS (covered or partially covered): usually remain in place only a week (have to be removed for migration or pain) - SURGERY (laparoscopy with cutting of a narrowing stitch, seromyotomy, stricturoplasty, conversion to RYGBP, total gastrectomy) Zundel N, et al. SURG LAPAROENDOSC PERCUTAN TECH 2010, 20(3): 154 -8

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LSG - TREATMENT 230 LSG • Caution should be taken in performing LSG to avoid the creation of sleeve stenosis. • Clinically significant short-segment stenoses may be treated successfully with endoscopic balloon dilation. • Long-segment stenoses are less likely to respond to endoscopic techniques and may ultimately require conversion to Roux-en-Y gastric bypass.

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LGCP 1. 2. Frequent but transitory (1 -2 weeks) nausea and vomiting and/or sialorrea due to edema and congestion – about 30% Only sometimes persisting symptoms (range 2 -5%) linked to stricture due to stomach kinking or invaginated gastric fold or gastro-gastric hernia or serous fluid collection within the cavity formed by gastric plication ENDOSCOPIC AND/OR RADIOLOGIC DIAGNOSIS SURGICAL TREATMENT (reversal of plication, revision to sleeve gastrectomy, for ex. ) Abdelbaki TN, et al. GASTRIC PLICATION FOR MORBID OBESITY: A SYSTEMATIC REVIEW; OB SURG 2012, 22: 1633 -9 Friede M, et al. LGCP FOR TREATMENT OF MORBID OBESITY – 244 PAT. S; OB SURG 2012, 22: 1298 -307

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LRYGBP One of the most common complications. The presentation is readily recognizable with symptoms of : • Dysphagia (first with solids and progressing to intolerance even with liquids) • Emesis • At times pain in the epigastric to retrosternal area. Diagnosis with: • UGI • Endoscopy (narrowing of the anastomosis or suture that did not allow passage or afforded significant resistance to passage of the 9 -mm endoscope in the symptomatic patients)

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LRYGBP - CAUSES Historically, rates of GJ strictures have varied considerably in the literature with some studies citing stricture rates of greater than 20 %. This discrepancy may be due to factors such as different surgical techniques for creating the GJ anastomosis (end-toend, end-to-side, and side-to-side) • • size of the gastric pouch • tension • path of the Roux limb • medications • smoking • how the strictures are defined and diagnosed.

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LRYGBP – ? ? 1. There is considerable variability in stricture rates between different techniques utilizing different size staplers. 2. Within one stapler category, however, there is still significant variability in GJ stricture rates. 3. This variation in rates may be partly explained by the difference in how some clinicians defined a stricture and how patients with clinical symptoms are worked up. 4. For ex. the variation in determining when a patient is appropriate for endoscopic evaluation is also accompanied with a variation of the overall date of presentation of strictures.

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LRYGBP Pathogenesis Csendes A et al, Ob Surg 2008 Early stenosis < 4 p. o. weeks Presence of fibrin Presence of inflammatory material Presence of submucosal hematoma Fibrin + soft inflammatory tissue Late stenosis Fibrotic tissue MORE DIFFICULT TO BE DILATED BY ENDOSCOPE

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LRYGBP Results Csendes A et al, Ob Surg 2008

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica This is the largest series (835 pat. s) which report stratification and analysis of LRYGBP according to GJA technique. No significant differences in the rates of anastomotic stricture were found between the techniques, and rates are comparable to those previously reported in the literature. This report suggests that the type of GJA technique does not affect the incidence of early anastomotic complications.

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica (mean 5. 5%)

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica BARIATRIC SURGERY – U. PARINI HOSPITAL AOSTA STENOSIS • LSG 3/101 (3%) • LRYGBP 18/503 (3. 6%)

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER Robotic RYGBP 1093 LRYGBP vs 593 RRYGBP INCIDENCE AFTER Robotic RYGBP: 0 -4. 4% Markar SR et al; ROBOTIC VS LAP RYGBP IN MORBIDLY OBESE PATIENTS; INT J ROB COM ASS SURG 2011, 7: 393 -400 Matthew M, et al. ROBOTIC BARIATRIC SURGERY: A SYSTEMATIC REVIEW; SURG OB REL DIS 2012, 8: 483 -8

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LRYGBP ENDOSCOPIC TREATMENT 105/1330 PAT. S (7. 8%) TREATED PREDICTORS for need of repeated dilations • Age • Gender • Basal BMI • Time interval between surgery and synmptoms • Previous anastomotic leak • Diameter of the stenosis • Presence of ulcerations in the anastomosis • Diameter achieved in the first dilation

STENOSIS AFTER LRYGBP ENDOSCOPIC TREATMENT Relation found between time elapsed from surgery and recurrence of the stricture: • The earlier the stricture develops, the more difficult is its treatment, and more sessions are needed to obtain a sustained response • Perhaps because the fibrous scarring of the anastomosis is not complete until the second to third month of the procedure, and it keeps its tendency towards the stricture formation after the dilation. • Only 24% of cases with a stricture diagnosed after the fourth month needed a second dilation; meanwhile, 75% of those that presented symptoms in the first month after surgery needed two or more dilations.

STENOSIS AFTER LRYGBP ENDOSCOPIC TREATMENT Relation between achieving a 15 -mm diameter ballon dilation in the first procedure and the need of repeated dilations: • The group of pat. s dilated ONCE had been dilated wider than the group of TWO to FOUR dilation. • The desidered diameter of the GJA is at least TWO AND HALF TIMES the initial diameter • Dilate careful (it is not safe to dilate until the final desidered diameter with only one procedure specially in cases with very narrow initial diameter).

STENOSIS AFTER LRYGBP ENDOSCOPIC TREATMENT DA COSTA M, et al OBES SURG (2011) 21: 36 -41 105/1330 (7. 8%) 3± 1. 8 months Hand-sewn sutures 1 (57%), 2 (27. 6%), 3 (12. 3%) 1. 6 (1 -4) (1. 8%)

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LRYGBP Suggested Prevention 1. Intraoperative EGD 2. Modified GJ anastomosis 3. Drugs administrations (ex. Stheroids during endoscopic dilation? High dose IPP? other? ) 4. High-quality f. u. care ensures that the few pat. s that do develop aa stricutres are expeditiously and effectively diagnosed and treated when the complication does occurr

XXI CONGRESSO NAZIONALE SICOB Attualità e nuove prospettive in chirurgia bariatrica e metabolica STENOSIS AFTER LBPD±DS 1. INCIDENCE 9 -20% (GI or DI anastomosis with stapler, higher during Laparoscopy and with Circular Stapler anastomosis) 2. INCIDENCE 0 -4% (handsewn GI anastomosis in standard BPD) 3. Associated sometimes with gastroparesis in standard LBPD 4. DIAGNOSIS with UGI radiograms, Endoscopy 5. TREATMENT - Endoscopic dilation - GJ anastomosis revision (if failed endoscopic treatment) - Partial/total gastrectomy ± conversion to RYGBP or full restoration of bowel anatomy (if failed conservative treatments) Samin KA, et al Ob Surg 2006; Scopinaro N et al, Ob Surg 2002; Silecchia G et al, Surg End 2009 ; Serra C et al, Ob Surg 2006

COMPLICATIONS AFTER GASTRO-JEJUNAL BYPASS CONCLUSION Usually Endoscopic dilation is the treatment of choice of sleeve or anastomotic stenosis. § After several sessions (with persisting symptoms and/or narrow gastric lumen), stent positioning may be a good alternative. § Surgical treatment is the last resource (and should not be spared in case of need) §

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