OBES SURG DOI 10.1007/s11695-014-1210-5
LETTER TO THE EDITOR
Gastric Stenosis After Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients Abdulzahra Hussain & Shamsi El-Hasani
# Springer Science+Business Media New York 2014
We read this interesting article by Burgos et al. , and we congratulate the authors for their high quality results and the fact that they have successfully tackled a recognised problem following sleeve gastrectomy. We feel that we are obliged to share our views with the authors to enhance the scientific value of the paper. 1. In their article, it seems that all patients had a barium study followed by gastroscopy similar to the study of Parikh et al. in Surg Endosc . The gastroscopy and dilatation were done on an inpatient basis, and the patients spent several days in hospital. It was not clear if the gastroscopy was performed under conscious sedation or general anaesthetic, and we are unsure as to whether fluoroscopy was used with gastroscopy. 2. For patients who had a sleeve gastrectomy and presented with symptoms suggestive of a stenosis, a barium swallow, and to proceed with radiological balloon dilatation at the same session if required, is another option which saves both time and resources whilst also decreasing the cost. We believe barium study is superior to gastroscopy for diagnosing a stricture and assessing the length, alongside possible proximal dilatation of the sleeve. Also, at the same session, the patient can have balloon dilatation of the stricture (under conscious sedation) as a day case. In addition, radiological rather than endoscopic balloon dilatation of the stricture has the advantage of evaluating the dilatation of the waist of the stricture, especially if it is a short one. Needless to say, at the end of radiological dilatation, repeat administration of the dye will show if the stricture has been sufficiently dilated and that the sleeve is draining adequately. A. Hussain (*) : S. El-Hasani Princess Royal University Hospital, Orpington, UK e-mail: [email protected]
We agree with the authors that there may be a need for more than one dilatation to achieve a final good result, and this depends on the severity of the case. We do not endoscopically assess every patient before bariatric surgery, as the significant clinical yield is negligible. The majority of the conditions diagnosed using (prebariatric surgery) endoscopy are cured by bariatric procedures such as gastric bypass and sleeve gastrectomy . In an immediate postoperative barium study (3rd day), we have been using this test in our initial series; however, we stopped 6 years ago, as there are no genuine clinical benefits. A barium study cannot completely exclude a leak, and it cannot give any real assessment of a stricture because there will be oedema and inflammatory changes following recent surgery. Furthermore, it cannot add any information about the size of gastric sleeve because this is usually assessed during the procedure and by the use of calibration tube. Additionally, 3rd day postoperative barium study cannot provide significant data about gastric emptying unless there is a complete obstruction or a very narrow sleeve has been made. There are two types of stenosis following sleeve gastrectomy: a clinical (symptomatic) and subclinical (asymptomatic) stenosis. Clinical stenosis is the most important and warrants timely investigation and treatment. Current data from different studies did not show optimum calibre, and bariatric surgeons are using different sizes of bougies [4, 5]. Based on barium study, the current paper should provide a standard definition of strictures and stenosis that need management following sleeve gastrectomy if early barium study is of any significance. This has not been provided in the article. We believe that it is too early to dilate the stricture in the 13th post-operative, as the wound is still healing and the risk of perforation is high.
OBES SURG Conflict of Interest Mr. A Hussain and Mr. S El-Hasani have no conflict of interest of any kind in relation to this paper.
References 1. Burgos AM, Csendes A, Braghetto I. Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg. 2013;23:1481–6.2. 2. Parikh A, Alley JB, Peterson RM, et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve
gastrectomy in the morbidly obese. Surg Endosc. 2012;26: 738–46. 3. Daes J, Jimenez ME, Said N, et al. Laparoscopic sleeve gastrectomy: symptoms of gastroesophageal reflux can be reduced by changes in surgical technique. Obes Surg. 2012;22:1874–9. 4. Sarela AI, Dexter SP, O’Kane M, et al. Long-term follow-up after laparoscopic sleeve gastrectomy: 8-9-year results. Surg Obes Relat Dis. 2012;8:679–84. 5. Ruiz-Tovar J, Oller I, Tomas A, et al. Midterm impact of sleeve gastrectomy, calibrated with a 50-Fr bougie, on weight loss, glucose homeostasis, lipid profiles, and comorbidities in morbidly obese patients. Am Surg. 2012;78:969–74.