Endoscopic Treatment Of Recurrent Gastro-Gastric Stricture Following Revision Of A Divided Roux-En-Y Gastric Bypass

摘要

Balloon dilation as a treatment for post-surgical anastomotic strictures is minimally invasive and relatively safe. The benefit of “through-the-scope” endoscopic balloon dilation has a reported long-term improvement for patient symptoms. This is a case report of a patient who developed severe dysphagia following revision of a divided Roux-en-Y gastric bypass with formation of a gastro-gastric anastomosis. The patient developed a gastro-gastric anastomotic stricture that rapidly recurred following multiple endoscopic dilations with balloon dilators. Following repeat endoscopic dilations, the anastomotic stricture was treated by submucosal injections of triamcinolone into the stricture, using a protocol described for esophageal strictures. Because this treatment prevented recurrent symptoms, she did not require repeat dilation for 3 months, prior to small intestinal transplantation. Repeat upper endoscopy prior to transplantation surgery revealed a patent gastro-gastric anastomosis. This case report demonstrates that injection of corticosteroid directly into a surgical anastomotic stricture improves the long-term efficacy of dilation. Introduction The National Longitudinal Study of Adolescent Health and the National Health and Nutrition Examination Survey (NHANES) studies have shown that over 40% of the population is overweight, and the prevalence in 18 to 29 year olds has almost doubled to 19% between 1991 and 1999 (1). Roux-en-Y gastric bypass surgery has become an increasingly popular treatment option for morbid obesity (2, 3). Anastomotic strictures causing recurrent obstructive symptoms are commonly seen following upper gastrointestinal surgeries (4). When oral intake becomes severely impaired owing to significant stricture, a rapid diagnosis and treatment is important. In recent years, balloon dilation has become the therapeutic option of choice since it is minimally invasive and relatively safe. However, the therapeutic efficacy of this procedure can be limited and often multiple dilations are required to makes the patient symptom free (5-7). Multiple dilations increase the risk of the catastrophic complication of perforation (8). Corticosteroids are known to inhibit fibrosis by preventing the migration and activation of inflammatory cells and fibroblasts. Various investigators have examined the role of corticosteroid injection for treating recurrent esophageal strictures requiring multiple dilations (9, 10). Gastro-gastrostomy is classically used as an anastomotic method during the reconstruction of pylorus preserving laparoscopic gastrectomy and during segmental gastrectomy for early gastric cancer and gastric ulcer. This case presents an unusual use of a gastro-gastrotomy complicated by a recurrent indolent stricture at the anastomotic site. Case This is a 40 year-old female who is status-post laparoscopic divided Roux-en-Y gastric bypass six years ago, followed by subsequent revision 2 years later for inadequate weight loss. She presented to an outside hospital with severe abdominal pain of one day duration associated with nausea and vomiting. An emergency exploratory laparotomy revealed a small intestinal volvulus with extensive necrosis of the jejunum. Infarcted small bowel was resected and the abdomen was packed without closure. The following day, due to both increasing serum lactate level and continued requirement for intravenous vasopressor drug, the patient had a repeat exploratory laparotomy. She was found to have further extensive necrosis of the ileum and ascending colon. Following resection of the infarcted bowel, she began to improve and was extubated successfully on post operative day 8. The patient was transferred to our hospital for further management of her complicated condition. It was determined that the patient’s gastrointestinal tract consisted of three separate segments: the esophagus with the blind gastric pouch; the excluded stomach and duodenum; and the colon from mid transverse colon to the anu