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Post-op sleeve strictures

Endoscopic pneumatic balloon dilation for post-op sleeve strictures

The authors believe that with early recognition and treatment, the presence of a stricture does not alter the pattern and degree of excess body weight loss achieved by sleeve gastrectomy

Endoscopic treatment for post-operative strictures with pneumatic balloon dilation is effective and safe as the first line of management following sleeve gastrectomy, according to researchers from the Bariatric Medicine Institute, Salt Lake City, UT. The study, ‘Is pneumatic balloon dilation safe and effective primary modality of treatment for post-sleeve gastrectomy strictures? A retrospective study’, which included 33 patients who underwent either a sleeve gastrectomy or the first step of a laparoscopic Duodenal Switch (LDS) and were subsequently found to have a post-sleeve gastrectomy stricture, was published in BMC Surgery.

The researchers began using pneumatic balloon dilation to help resolve these types of obstructions in 2010 and the paper is the outcome from their prospectively kept database for patients who developed a laparoscopic sleeve gastrectomy stricture within 90 days of surgery.

During the procedure, the authors explain that the endoscope is passed distally to the stricture and into the distal small bowel. A MAXXWIRE (MeritMedica Endotek) metallic guide-wire is passed through the scope and using fluoroscopic guidance placed in the distal small bowel and the EGD scope is removed keeping the guide-wire in place. Using the guidewire and fluoroscopic guidance, they slide the Rigiflex II Balloon (Boston Scientific) into position using the previously placed paper clip as a reference.

The balloon is then inflated under fluoroscopic and endoscopic visualisation to 30mm at 10 PSI for an average of 14.5min per patient. Depending on clinical improvement and the patients’ decision, repeat dilations were performed up to a maximum of 40 mm, with a minimum interval of two weeks between two dilations.

Outcomes

From 1,756 patients in the database, 33 patients (1.8% - 24 sleeve gastrectomy and nine LDS) developed a stricture as a complication and were considered eligible for pneumatic dilation. Twenty-seven patients were female, the average age of the patients was 46.4 (±9.6) years and the average BMI was 43.7 (±6.4). Sixty-five percent of the patients followed up at one year and the excess body weight loss (EBWL%) at one year was 66.1% (62.6–69.7%). Of 33 patients, 15 patients (45.4%), five patients (15.1%) and nine patients (27.2%) had diabetes mellitus (DM), positive smoking history and hiatal hernia repair, respectively.

In 54.5% (18/33) of patients the stricture was localised to the mid-Body, 30.2% (10/33) were at the incisura and 15.2% (5/33) had it in the upper 1/3 of the sleeve. The average time from surgery to diagnosis was 5.6 months (±6.8 months), average duration of primary surgery to the first pneumatic dilation was 5.9 months (+/− 6.6) and the average duration from primary surgery to the second dilation was 8.6 months (+/− 7.1). Two patients were dilated three times and the average duration of primary surgery to the third dilation was 19 months (+/− 19.7). The average balloon size used for the first dilation was 32.1mm (+/− 6.8); for the second dilation it was 35mm (+/− 5.2) and for the third dilation it was 40mm.

In the 21 patients who required a single dilation for symptom resolution, the mean duration was 15.6min (+/− 6.6). Eight patients required a second dilation for symptom resolution and the mean duration of dilation in the first dilation was 14.6min (+/− 8.3) and in their second dilation was 20min (+/− 8min). The two patients who required three dilations for symptom resolution were dilated for 10min during the first dilation; 22.5min (+/− 10.6min) during their second dilation and 30 min during their third dilation. A total of 93.9% (31/33) patients had complete resolution of symptoms after pneumatic balloon dilation. Of the remaining 6.1% (2/33) patients, one patient required surgical intervention for symptom resolution and one patient required a fully covered self-expanding metal stent.

“We believe with early recognition and treatment, the presence of a stricture does not alter the pattern and degree of excess body weight loss achieved by LSG,” the authors stated. “This can be seen in the EBWL% achieved by the patients in this study, which was 66.1%.”

They also noted that the pneumatic balloon achieves the high radial force of expansion and their use of a higher initial balloon size and increasing the duration time ensures the initial few minutes of dilation help tear the muscular fibres, while the longer duration overcomes the elasticity of the fibrosis which invariably occurs at the site of the stricture.

“In our series, the duration of dilation is as important as balloon size in achieving early resolution of symptoms and avoiding revision surgeries,” the authors conclude. “However, both the timing and size of the balloon should not be considered settled, and we look for other authors to corroborate our findings or further define what can be done when strictures appear in the sleeve patient. Surgical intervention should be considered only after multiple failed attempts at dilation.”

To access this paper, please click here

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