BACKGROUBD: A circular stapled proximal anastomosis for bariatric surgery creates a consistent, restricted outlet but can be associated with stricture. The purpose of our study was to analyze the incidence and predictive features of stricture requiring endoscopic dilatation after a circular, stapled anastomosis for bariatric surgery.
METHODS: We analyzed 370 consecutive patients undergoing two laparoscopic bariatric operations over a 3.5 year period: Roux-en-Y gastric bypass (RGB, n=290) and biliopancreatic diversion with duodenal switch (BPD/DS, n=80). The proximal anastomosis for these procedures is a gastro-jejunostomy (GJ) and duodeno-ileostomy (DI), respectively. Forty-one patients presented for revision of a previous bariatric surgery. Patients who developed postoperative dysphagia and vomiting and required endoscopic evaluation were identified.
RESULTS: Forty-six patients underwent postoperative endoscopy. Forty-three required dilation. Fifty-five percent (24/43) required only one dilation at an average of 5.5 weeks postoperatively (range, 3 to 9 weeks); 33% (14/42) underwent 2 dilations, and 12% (5/42) required > 2 dilations (range, 6 -28 weeks) postoperatively. The stricture rate was 11.6% overall: RGB (GJ) 42/290 (14.4%) vs. BPD/DS (DI) 1/80 (1%). Twenty six percent (11/43) of patients with stenosis had undergone previous bariatric surgery. Other features associated with stenosis were intraoperative leak 4/43 (9%) and postoperative therapeutic endoscopy (injection/bicap) for anastomotic bleeding 2/43 (5%). Twelve percent (5/43) of patients with stenosis had been treated for H. pylori preoperatively. We detected a marginal ulcer in one patient with a stricture and in three others without evidence of a stricture (4/370, 1.1%). Dilation was complicated by perforation in 3/43 (7%) with two patients requiring operative repair (5%). One patient failed dilation and required operative revision.
CONCLUSIONS: Gastro-jejunostomy stricture in the Roux-en-Y gastric bypass accounts for nearly all the stenoses in this series, presents early in the postoperative period and is amenable to endoscopic treatment with acceptable morbidity and no mortality. The stenosis rarely requires operative intervention. Previous bariatric operation markedly increases the risk of anastomotic stricture.