Management of Strictures Following Sleeve Gastrectomy

Educational Objectives

The goal of this program is to improve the management of strictures following sleeve gastrectomy. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose the presence of stricture after sleeve gastrectomy.

2. Perform endoscopic or surgical management of a stricture, depending on its clinical presentation.

Summary

Chances of stricture after a sleeve gastrectomy: in various reports, an overall 0.4% to 1% chance has been reported (it was ≈4% when the procedure was newly adopted); 90% of strictures occur at the incisura angularis (angular notch) and are symptomatic almost immediately, or within the first few weeks (≤6 wk); importantly, distal strictures are associated with a proximal leak of the gastric sleeve; these leaks are very difficult to manage and have high morbidity

Pathophysiology: intrinsic causes — may be related to gastric wall edema secondary to the surgery or to technical errors such as using too small a bougie to calibrate the sleeve or stapling too close to bougie; there can be twisting or corkscrewing of the staple line, causing a kink; reinforcing or oversewing the staple line can lead to stenosis; excessive scarring or chronic inflammation at the site of the surgery, tissue retraction from an infection or leak, and intramural hematoma are other potential intrinsic causes; extrinsic causes — typically related to imbrications of the staple line

Diagnosis: largely clinical, based on the symptoms, which include poor oral tolerance along with diarrhea, regurgitation, vomiting, frothing, and gastroesophageal reflux disease; these could occur almost immediately following surgery or weeks later; when symptoms are chronic, varying degrees of dysphagia are seen, including regurgitation, choking sensation, food impaction, and poor progression of liquids or solids, which lead to maladaptive eating behaviors; these could either prevent weight loss or cause weight regain; radiography and endoscopy are also used; typical diagnosis is via an upper gastrointestinal (GI) series; computed tomography is occasionally used; endoscopy most accurately defines the anatomy; retained fluid and stenosis are seen; if significant fluid is suspected abode the stricture, airway protection is paramount

Management: varies with clinical presentation; acute obstructions must be managed aggressively with hydration and control of symptoms, especially vomiting (to prevent aspiration); decrease secretions by administering proton pump inhibitors intravenously while keeping the patient in an upright position; consider placing a nasogastric tube (under fluoroscopy so as not to move past the stenosis); the symptoms of a functional stricture should resolve within 24 to 48 hr; if symptoms worsen, endoscopic or surgical intervention is needed

Endoscopic approach: involves balloon dilatation or stent placement; rates of success with endoscopic dilatation vary; short-segment stenosis and functional stenosis due to edema respond well; care must be taken to avoid sleeve perforations and other complications; pneumatic balloon should be used, and dilatation of 15 to 25 mm diameter is the goal; sleeves with spiral twist at the incisura are difficult to be managed with pneumatic dilatation; stenting has been utilized in cases of sleeves with spiral twist and other stenosis with varying results; if stents are used for a longer period of time, may cause pressure, ulcers, and erosions into the aorta, which could cause a fatal esophageal fistula

Surgical approaches: if an imbrication was used previously, releasing or removing the imbricating sutures is effective if done early; it is less successful once scars have formed; seromyotomy might be used for later stenosis (similar to the procedure performed for achalasia); however, the procedure has ≤11% leakage rate and is rarely used today; another option is a wedge resection at the stricture site; if stricture is at the incisura area, this is essentially gastrectomy of the stricture segment and reanastomosis of the stomach; strictureplasty is an approach for short strictures, wherein the stricture is opened longitudinally and then sutured transversally; the last option is to convert the gastrectomy to a Roux-en-Y gastric bypass; conversion is the most effective option, but also the most invasive

Prevention of stenosis: the incisura angularis is the area most prone to stenosis, so maintain a safe distance between the bougie and the stapler at this level; apply symmetric lateral retraction of the sleeve with the same amount of anterior and posterior stomach so that the staple line does not twist; avoid using too narrow a bougie and pulling of the stomach too aggressively very close to the bougie with the stapler; leave the bougie in place during the oversewing of the staple line; during oversewing, do not involve too much tissue in the suture, especially in a Lembert-type of oversewing

Readings

Brunaldi VO et al. Isolated sleeve gastrectomy stricture: a systematic review on reporting, workup, and treatment. Surg Obes Relat Dis. 2020;16:955-966; doi:10.1016/j.soard.2020.03.006; Deslauriers V et al. Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis. Surg Endosc. 2018;32:601-609; doi:10.1007/s00464-017-5709-4; Sarkhosh K et al. Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide. Can J Surg. 2013;56:347-352; doi:10.1503/cjs.033511; Seeras K et al. Sleeve gastrectomy. StatPearls Publishing. 2020 Jun 28; Available from: https://www.ncbi.nlm.nih.gov/books/NBK519035/.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Lo Menzo was recorded exclusively for Audio Digest using virtual teleconference software, in compliance with social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks Dr. Lo Menzo for his cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS681302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.