REVISIONAL TECHNIQUE FOR SLEEVE GASTRECTOMY INCISURAL STENOSIS AND ANGULATION: LAPAROSCOPIC SEROMYOTOMY
Yalini Vigneswaran*, Sergio A. Toledo Valdovinos, Victoria Lyo, Andrea Stroud, Farah Husain
Oregon Health and Science University, Portland, OR
Introduction:
Management of patients with gastric stenosis or angulation after sleeve gastrectomy can be challenging due to varying efficaciousness of revisional therapies. The purpose of this study is to demonstrate the use of and describe the clinical outcomes of seromyotomy in the algorithm of treating clinically relevant sleeve stenosis.
Methods:
This is a case series of four patients that underwent laparoscopic seromyotomy after previous sleeve gastrectomy. These patients had clinical symptoms of oral intolerance and/or severe heartburn with studies to support incisural stenosis and angulation correlating with clinical symptoms.
Results:
Four patients underwent laparoscopic seromyotomy at a median of 12.4 months after their initial sleeve gastrectomy. Three of the four patients had failed endoscopic dilation prior to seromyotomy. Length of seromyotomy measured 6 to 8cm along the previous staple line and the myotomy was always performed under endoscopic insufflation to evaluate resolution of angulation. There were no intraoperative or perioperative complications. At a median follow up of 10.4 months, all patients had resolution of their symptoms after seromyotomy. Additionally, all patients had continued weight loss after seromyotomy which was on average an additional 19.2% EWL.
Conclusions:
We believe laparoscopic seromyotomy of the incisural stenosis is a promising revisional technique to be included in the management algorithm of gastric sleeve stenosis prior to revision to gastric bypass. Our practice algorithm starts with objective evaluation with pH, motility and endoscopy studies and with evidence of stenosis or angulation, these patients will first undergo TTS balloon and/or pneumatic dilation. If these endoscopic therapies are unsuccessful, laparoscopic seromyotomy can be discussed as a surgical option prior to conversion to gastric bypass for severe persistent symptoms. As demonstrated here, this technique is a low risk procedure and can allow for further weight loss with sleeve gastrectomy despite initial failure. Relieving both the stenosis and the associated sleeve twisting that occurs during gastric filling may be the key in allowing for return of normal motility of the sleeve.
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