Successful management of gastrojejunal strictures after gastric bypass: is timing important?

BACKGROUND: Endoscopic balloon dilation is an effective treatment of gastrojejunal (GJ) strictures after Roux-en-Y gastric bypass (RYGB), although its success might depend on the point at which they occur postoperatively. We hypothesized that "late" strictures (≥90 d after RYGB) might be less amenable to balloon dilations than "early" strictures occurring within 90 days postoperatively. METHODS: A review of a prospectively maintained database at a bariatric center was conducted to identify all patients who underwent upper endoscopy (UE) for investigation of gastrointestinal symptoms after RYGB. Those who were diagnosed with a GJ anastomotic stricture at endoscopy were selected for additional evaluation. The patients were classified into 1 of 3 groups, according to the point at which they presented with stricture symptoms (group 1, 0-90 d after RYGB; group 2, 91-365 d after RYGB; and group 3, >1 yr after RYGB). All strictures were dilated using through-the-scope controlled radial expansion balloons. RESULTS: From July 2006 to July 2009, 929 RYGB procedures were performed in our bariatric unit. Our surgical endoscopy team performs approximately 1500 UE investigations annually. Most investigations were for preoperative assessment of bariatric patients; however, a proportion is indicated for the investigation of postoperative weight regain and complications of foregut surgery, as well as endoluminal surgery. In the present study period, 591 gastric bypass patients underwent UE for investigation of gastrointestinal symptoms postoperatively. In total, 72 patients were diagnosed with a symptomatic GJ anastomotic stricture and underwent balloon dilation. Almost two thirds (63.9%) of the dilations were performed within 90 days after RYGB; 98% of these "early" strictures resolved with dilation. In comparison, of the "late" strictures, only 61% (16 of 26 patients) resolved and 38.5% (n = 10) required revisional surgery for additional management. CONCLUSION: Endoscopic balloon dilation is effective in treating early GJ strictures after RYGB. Late strictures are less amenable to endoscopic dilation and often require revisional surgery. Patients presenting with upper gastrointestinal symptoms after RYGB warrant early investigation with UE to investigate for a GJ stricture, which if present, should be promptly dilated.

Influence of pouch and stoma size on weight loss after gastric bypass.

BACKGROUND: Enlargement of the gastric pouch and/or gastrojejunostomy after Roux-en-Y gastric bypass (RYGB) is postulated to be the antecedent to suboptimal weight loss or weight regain. The present study evaluated the gastric pouch and stoma dimensions in RYGB patients and correlated them with the weight loss outcomes. METHODS: Patients who underwent upper endoscopy for investigation of gastrointestinal symptoms or weight regain after RYGB were identified. The stoma was considered enlarged if >2 cm in diameter and the pouch was considered enlarged if >6 cm long or >5 cm wide. Successful weight loss was defined as excess weight loss >50% or a body mass index decrease to ≤ 30 kg/m(2). RESULTS: A total of 380 patients had nondiagnostic upper endoscopy findings at a mean post-RYGB interval of 5.9 ± 4.0 years. Among these were 175 patients (group A; 87% women) who had successful weight loss and 205 patients (group B; 86% women) who were referred for investigation of weight regain. The pouch and stoma size were normal in most of the patients in group A (63.4%) compared with 28.8% of the patients in group B (P <.001). The most common abnormality was an enlarged stoma. The pouch length, pouch volume, and stoma diameter correlated inversely with excess weight loss. Multivariate analysis identified that the stoma diameter was independently associated with weight regain after RYGB. CONCLUSION: The current definition of a "normal" size pouch/stoma is associated with optimal weight loss after RYGB, although this might need to be reviewed. Patients who regain weight are likely to have abnormal anatomy, in particular, stoma enlargement. The surgical RYGB technique and methods of evaluating the gastric anatomy in RYGB patients need to be standardized, intraoperatively and postoperatively.

Endoscopic stent management of leaks and anastomotic strictures after foregut surgery.

BACKGROUND: Anastomotic complications after upper gastrointestinal surgery present an arduous therapeutic challenge. Avoiding revisional surgery is desirable and might be possible with the advent of endoscopically placed stents. We reviewed our experience with endoscopic stent management of anastomotic complications after esophagogastric surgery. METHODS: A prospectively maintained database at our surgical endoscopy unit was reviewed to identify patients who had undergone endoscopic stent placement after various foregut procedures. Data were obtained on patient demographics, primary surgical and endoscopic procedures, and outcome. RESULTS: From January 2007 to August 2010, 18 patients (12 women, mean age 51 ± 15 yr) underwent endoscopic stent placement for anastomotic complications; 14 were bariatric patients. A total of 31 stents (21 covered metal, 5 salivary, and 5 silicone-coated polyester) were used to treat anastomotic leaks (n = 13), strictures (n = 3), and fistulas (n = 2). Symptomatic improvement occurred in all but 2 patients (89%), and early oral intake was initiated in 11 (61%). Stent treatment was successful in definitively managing the anastomotic complication in 13 (72%) of the 18 patients. Five patients required additional surgical or endoscopic intervention. Stent migration occurred in 4 cases and was amenable to endoscopic management. Two patients died, with both deaths unrelated to stent placement. CONCLUSION: Endoscopic stent management of anastomotic complications after foregut surgery is effective in resolving symptoms, expediting enteral nutrition, and particularly successful for treating anastomotic leaks. In the absence of stents specifically designed for surgically altered gastrointestinal anatomy, some factors that might reduce the risk of stent migration include appropriate stent selection, anchoring the stent proximally, and regular surveillance after placement.

Endoscopic findings and outcomes of revisional procedures for patients with weight recidivism after gastric bypass.

BACKGROUND: Significant weight regain occurs for 10% to 20% of patients after Roux-en-Y gastric bypass (RYGB). Potential causative factors include anatomic abnormalities such as enlargement of the gastric pouch and gastrojejunostomy (GJ). This report describes endoscopic findings for patients referred for investigation of weight regain and presents the outcomes of revisional therapy for patients with abnormal anatomy. METHODS: To evaluate gastric pouch and stoma size, RYGB patients referred for weight regain underwent upper endoscopy. A GJ was defined as enlarged if it had a diameter greater than 2 cm in any dimension, and a pouch was defined as enlarged if its length exceeded 6 cm long or its width exceeded 5 cm. Patients with abnormal anatomy who subsequently underwent revisional procedures were arbitrarily categorized into three groups based on the interval from RYGB to endoscopic evaluation: less than 5 years (group 1), 5 to 10 years (group 2), longer than 10 years (group 3). The percentage of regained weight lost (%RWL) after revision was compared between the groups. RESULTS: In this study, 205 RYGB patients (176 women with a mean age of 47 ± 10 years and a current body mass index [BMI] of 43.4 ± 8.4 kg/m(2)) were evaluated. The mean time from primary RYGB was 6.9 ± 3.7 years, and the increase in BMI from its nadir was 9.78 ± 5.80 kg/m(2). Abnormal endoscopic findings (n = 146, 71.2%) included large GJ (n = 86, 58.9%), large pouch (n = 42, 28.8%), or both (n = 18, 12.3%). Of the 205 patients, 51 (24.9%) underwent a revisional surgical or endoluminal procedure. At a mean follow-up assessment 13 months after revision, group 1 (n = 12) had a mean %RWL of 103% ± 89.3%, and 62% of these patients lost all their regained weight. The mean %RWL was 45% ± 12.6% in group 2 (n = 30) and 40% ± 13.6% in group 3 (n = 9). CONCLUSION: Endoscopy is a valuable tool for evaluating weight regain after bariatric surgery that can identify abnormal post-RYGB anatomy in a majority of patients. Revisional procedures to restore normal RYGB anatomy appear to be most successful if performed within 5 years after the primary procedure.

Droperidol, when used for sedation during ERCP, may prolong the QT interval.

BACKGROUND: Droperidol is a known effective adjunctive agent for sedation/analgesia during endoscopic procedures, particularly in patients who are difficult to sedate with narcotics and benzodiazepines alone. However, the Food and Drug Administration (FDA) warning about potential droperidol-related fatal cardiac arrhythmias, issued in December 2001, led to concern about its safety in current clinical practice. OBJECTIVE: In this study, we evaluated the effects of droperidol on the Bazett's corrected QT interval (QTcB) administered to patients undergoing ERCP and frequency of cardiac arrhythmias. DESIGN: We retrospectively reviewed the medical records of patients who, at our institute, underwent ERCP while under sedation/analgesia and who received droperidol. Our protocol for patients who are considered to be candidates for droperidol use includes obtaining an ECG before and 1 to 3 hours after the procedure. RESULTS: From April 2002 to October 2004, 6292 ERCPs were performed, of which 3113 patients with normal baseline QTcB (2001 women, 1112 men) received droperidol. Mean dosages were 4.3 mg (range, 1.25-10 mg) in women and 4.5 mg (range, 1.25-13.75 mg) in men. A total of 233 patients (7.48%; 133 women, 100 men) developed QTcB prolongation. Mean increases of the QTcB above the upper limit of normal were 16 milliseconds in women (range, 1-194 milliseconds) and 22 milliseconds in men (range, 1-310 milliseconds). Of these, 15 patients (0.48%; 8 women, 7 men) had marked prolongation of the QTcB (defined QTcB, >500 milliseconds). No serious dysrhythmias occurred. CONCLUSIONS: Droperidol at usual doses during sedation/analgesia may precipitate QTcB prolongation above the normal range. However, no QT-related arrhythmias were noted in this study. Clinically significant cardiac events are probably rare with droperidol, despite documented QTcB effects. Baseline electrocardiogram for excluding patients with prolonged baseline QTcB and 1 to 3 hours afterward monitoring appears adequate when using droperidol. The study is still too small to detect very infrequent arrhythmia events.

[State-art: diagnosis and management in pancreas divisum]. / Ultimos adelantos: diagnóstico y tratamiento del pancreas divisum.

Pancreas divisum (PD), the most common congenital variant of pancreatic duct anatomy, occurs when the ductal systems of the ventral and dorsal pancreatic ducts fail to fuse during the second month of gestation. With non-union of the ducts, the major portion of the pancreatic exocrine secretion enters the duodenum by way of the dorsal duct and minor papilla. It has been generally accepted that a relative obstruction to pancreatic exocrine secretory flow through the minor duct and minor papilla could result in pancreatitis in small numbers of patients with PD. The debate whether PD causes pancreatitis continues, although most authorities agree that PD is a definite cause in a subgroup of patients. Most patients with PD and well-documented acute recurrent pancreatitis have responded favorably to surgical sphincteroplasty of the minor papilla. Endoscopic retrograde cholangiopancreatography (ERCP) is the most common procedure for diagnosis PD in patients who have pancreatobiliary symptoms. MRCP is being increasingly used to establish the diagnosis and secretin stimulation can improve ductal images greatly. Endoscopic management of symptomatic patients with PD is evolving. Only a limited number of series are available, using endoscopic pancreatic stent placement, minor papilla endoscopic papillotomy, or both to decompress the dorsal duct in an effort to restore pancreatic exocrine secretory flow. Even with relatively small numbers of patients and a near absence of controlled, randomized trials, it appears that the patients most likely to benefit, as with surgery, are those with well-documented ARP rather than pain alone or chronic pancreatitis. Overall we recommend that pancreatic stenting and pancreatic sphincterotomy should be done only in large centers with experience in therapeutic ERCP. Further randomized trials would be of interest.