UPPER GASTROINTESTINAL SERIES AFTER SLEEVE GASTRECTOMY IS UNNECESSARY TO EVALUATE FOR GASTRIC SLEEVE STENOSIS
Amar B. Mandalia*, Jessica X. Yu, Allison R. Schulman
Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
Background: There has been a rapid increase in the number of sleeve gastrectomy (SG) procedures performed worldwide, and a paralleled increase in the prevalence of gastric sleeve stenosis (GSS). Symptoms include dysphagia, reflux, and/or symptoms of obstruction. Upper gastrointestinal series (UGIS) is commonly performed as part of the diagnostic algorithm prior to referral for endoscopic dilation, however, little is known about the utility of this study in making a diagnosis.
Aims: The aim of this study was to evaluate the positive predictive value (PPV) and negative predictive value (NPV) of UGIS in detection of GSS.
Methods: We performed a retrospective analysis of a prospectively collected database at a single tertiary care center for patients referred with nausea/vomiting or obstructive symptoms following SG. All patients underwent upper endoscopy (EGD) for evaluation of GSS. A single bariatric endoscopist performed all procedures. If stenosis was demonstrated, patients were treated with balloon dilation using a hydrostatic balloon followed by successive pneumatic balloon dilation (PBD). Repeat PBD was performed every 2-4 weeks with increasing balloon size (30 mm, 35 mm, 40 mm) and/or filling pressure until symptoms resolved. Data collected included demographics, UGIS findings, procedural information, and response to treatment. Primary outcomes were PPV and NPV for UGIS in predicting GSS. Secondary outcomes included EGD findings and symptom response to dilation. Response was determined by a follow-up validated questionnaire from 1 (complete resolution) through 5 (no improvement). A response of 3 or less (i.e. symptoms occurring between 1x/week and 1x/month) was considered a positive response to dilation. Descriptive statistics were summarized as proportions, meanąSD.
Results: Between 5/2017 and 11/2018, 23 consecutive patients with SG underwent EGD for symptoms of nausea (65.2%), vomiting (60.9%), reflux (60.9%), dysphagia (17.4%), and/or abdominal pain (52.2%). Demographic characteristics are shown in Table 1. Mean (ąSD) age was 44.3ą12.2 and 84% were female. 18 (78.3%) patients underwent UGIS prior to EGD. Of these, 5 (27.8%) identified GSS. On diagnostic EGD, 20 (87%) patients were diagnosed with GSS. The sensitivity and NPV of UGIS to detect GSS was 31.3%, and 15.4%, respectively. All 5 patients with GSS demonstrated on UGIS also had GSS demonstrated on endoscopic evaluation (specificity = 100%, PPV = 100%). Mean dilations per patient was 2.04ą1.0. 13 patients (72.2%) had symptom improvement with successive dilations.
Conclusion: UGIS following SG has low NPV to evaluate for GSS. Independent of the UGIS findings, the majority of patients found to have GSS on EGD have symptom improvement with successive dilations. Thus, the utility of UGIS is limited for the diagnosis of GSS and patients should instead be referred directly for EGD.
Table 1. Baseline Patient Characteristics
| Age (years) (meanąSD) | 44.3ą12.2 |
| Females (n(%)) | 21 (84) |
| Laparoscopic Technique (n(%)) | 18 (95) |
| Open Technique (n(%)) | 1 (5) |
| Pre-surgery Body Mass Index (kg/m2) (meanąSD) | 48.1ą8.8 |
| Nadir Body Mass Index (kg/m2) (meanąSD) | 31.2ą5.6 |
| Current Body Mass Index (kg/m2) (meanąSD) | 32.6ą6.1 |
| Presenting Symptoms | |
| Reflux (n(%)) | 14 (60.9) |
| Nausea (n(%)) | 15 (65.2) |
| Vomiting (n(%)) | 14 (60.9) |
| Abdominal Pain (n(%)) | 12 (52.2) |
| Dysphagia (n(%)) | 4 (17.4) |
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