For many obese people, gastric bypass surgery is a life-saving procedure. However, it is not without its risks and complications.
One of the more frequent post-operative complications of gastric bypass is a narrowing of the opening made between the surgically created gastric pouch and the small intestine — a condition known as gastrojejunal anastomotic strictures.
Fortunately, there is a safe and effective method of treating the complication, according to new research from the Washington University School of Medicine (St. Louis) on endoscopic balloon dilation.
The study, published in the August issue of Gastrointestinal Endoscopy, the monthly peer-reviewed journal of the American Society for Gastrointestinal Endoscopy (ASGE; Oakbrook, Illinois), reports that dilation (stretching of the anastomosis or opening) to at least 15 mm is safe, decreases the need for further endoscopic dilation and improves the patient’s symptoms. It did not adversely affect weight loss at one year compared to those without strictures or dilation, according to the study.
Michael Kochman, MD, a gastroenterologist and a professor of medicine with the University of Pennsylvania (Philadelphia) told Diagnostics & Imaging Week that about 4% to 5% of gastric bypass patients will develop a stricture at the outlet of the gastric pouch where the small bowl is sewn or stapled to it, resulting in profound rapid weight loss that exceeds that which one would expect, making it difficult for the patient to digest solid foods. To fix the problem, he said endoscopic balloon dilation is a relatively safe and effective procedure during which the patient is sedated and the endoscopist uses an endoscope to see the patient’s gastrointestinal system, and passes a dilating balloon catheter through the stricture and inflates it to dilate the stricture up to an acceptable size so that the patient can comfortable digest food. Depending on the patient, it’s usually a 10-20 minute procedure, he said.
“The result is usually a durable and pretty dramatic improvement,” Kochman said.
ASGE notes that obesity is a major health problem in the U.S. and other westernized countries. The organization said that large prospective studies have demonstrated increased mortality for moderately and severely obese individuals. According to guidelines from the American College of Physicians (ASP; Philadelphia) surgery should be considered as a treatment option for morbidly obese individuals who instituted, but failed an exercise and diet program (with or without drug therapy). A 2005 study in the Archives of Surgery found that weight loss surgeries in the U.S. rose from 12,775 in 1998 to 70, 256 in 2002, an increase of 450%. According to the American Society for Bariatric Surgery (ASBS; Gainesville, Florida) in 2006, an estimated 177,600 people with morbid obesity had bariatric surgery in the U.S.
Bariatric surgery, or weight loss surgery, limits the amount of food the stomach can hold by surgically reducing the stomach’s capacity to a few ounces. Some surgeries also alter the digestion process, curbing the amount of calories and nutrients absorbed.
“This study shows that the majority of these strictures can be managed safely and effectively. Endoscopy remains the cornerstone of diagnosis and therapy for this complication, and surgical revision is rarely necessary,” said the study’s lead author Kevin Peifer, MD, clinical assistant professor, University of Illinois, College of Medicine (Rockford, Illinois) and formerly an advanced endoscopic fellow at the Washington University School of Medicine. “As the number of gastric bypass procedures grows, it will become increasingly important for surgeons and gastroenterologists to recognize and treat the complications that may arise.”
Stricture of the gastrojejunal anastomosis is a common complication of both open and laparoscopic Roux-en-Y gastric bypass surgeries (the most frequently performed bariatric surgery for morbid obesity). In a single-center retrospective study of 801 morbidly obese patients who underwent Roux-en-Y gastric bypass surgery between 1997 and 2005 at the Washington University School of Medicine, 43 patients developed anastomotic stricture.
Upper endoscopy was performed in patients who were vomiting, which raised concern for anastomotic narrowing, by using the standard gastroscope, with an outer diameter of 8.6 mm. A gastrojejunal anastomotic stricture was identified as a narrowing at the anastomosis that prevented passage of the gastroscope in these symptomatic patients.
According to the study, 79% of patients were successfully managed with a single balloon dilation and 93% were successfully dilated with one or two endoscopic sessions, all without perforation or significant bleeding. Only one patient in the study required surgery for revision of an anastomosis that was not responsive to endoscopic therapy.
At the Washington University School of Medicine, the anastomotic strictures are routinely dilated to at least 15 mm during the initial endoscopy. Other groups have raised the concern that overly aggressive dilation of the stricture may allow patients to increase caloric intake, and weight loss may slow or even reverse. In the current study, researchers found that weight loss at six and 12 months was not affected by dilation of the strictures to at least 15 mm.
According to ASGE, endoscopy is performed by specially-trained physicians called endoscopists using the most current technology to diagnose and treat diseases of the gastrointestinal tract. Using flexible, thin tubes called endoscopes, endoscopists are able to access the human digestive tract without incisions via natural orifices. Endoscopes are designed with high-intensity lighting and fitted with precision devices that allow viewing and treatment of the gastrointestinal system. In many cases, screening or treatment of conditions can be delivered via the endoscope without the need for further sedation, treatment or hospital stay, the organization noted.