Overview
Definition:
A sleeve gastrectomy stricture refers to a narrowing of the gastric sleeve lumen, most commonly occurring along the staple line, which impedes the passage of food from the stomach into the duodenum
Stricturoplasty is a surgical technique employed to widen or reconstruct a stenotic segment of the gastrointestinal tract, often used to treat these strictures.
Epidemiology:
Strictures following sleeve gastrectomy are a significant complication, with reported incidences ranging from 0.3% to 5.9% in various studies
The majority of these strictures become symptomatic within the first few weeks to months post-operatively, though delayed presentations are possible.
Clinical Significance:
Sleeve gastrectomy strictures can lead to severe nutritional deficits, dehydration, persistent nausea and vomiting, and significantly impact patient quality of life
Prompt diagnosis and effective management are crucial to prevent long-term morbidity and ensure successful weight loss outcomes
Understanding these complications is vital for DNB and NEET SS surgical candidates.
Clinical Presentation
Symptoms:
Persistent nausea and vomiting, especially after solid food intake
Progressive dysphagia, initially with solids, then with liquids
Early satiety
Abdominal pain, often epigastric
Unintended weight loss or failure to lose weight
Dehydration and electrolyte imbalances.
Signs:
Vital sign abnormalities may reflect dehydration (e.g., tachycardia, hypotension)
Abdominal examination may reveal epigastric tenderness
Auscultation may reveal hyperactive bowel sounds if proximal obstruction is present
Percussion may reveal tympany due to retained gastric contents.
Diagnostic Criteria:
Diagnosis is typically based on a combination of suggestive symptoms, physical examination, and confirmatory imaging
There are no universally established formal diagnostic criteria, but a high index of suspicion in a post-sleeve gastrectomy patient with obstructive symptoms is key.
Diagnostic Approach
History Taking:
Detailed history of the bariatric surgery, including date, surgeon, and any immediate post-operative complications
Onset, duration, and character of symptoms (nausea, vomiting, dysphagia)
Dietary progression and tolerance
Previous endoscopic or radiological findings
Red flags include persistent intractable vomiting, signs of dehydration, or severe epigastric pain.
Physical Examination:
A thorough abdominal examination focusing on tenderness, masses, and signs of dehydration
A general assessment for nutritional status and signs of electrolyte imbalance is essential.
Investigations:
Upper gastrointestinal endoscopy (EGD) is the gold standard for direct visualization and biopsy if needed, allowing assessment of the stricture location, length, and severity
Barium swallow/meal is useful for initial assessment of the lumen patency and identifying the level of obstruction
CT scan of the abdomen may be used to rule out extraluminal causes or complications like abscesses
Contrast-enhanced CT or MRI may be indicated in complex cases.
Differential Diagnosis:
Other causes of upper GI obstruction in a post-bariatric surgery patient include marginal ulcers, extrinsic compression from lymphadenopathy or hematoma, internal hernias, and gastric remnant malignancy (though rare early on)
Functional gastric dysmotility can mimic some symptoms.
Management
Initial Management:
Immediate management focuses on hydration and nutritional support, often via nasogastric tube decompression or parenteral nutrition if oral intake is impossible
Broad-spectrum antibiotics may be initiated if there is suspicion of infection or perforation.
Medical Management:
Proton pump inhibitors (PPIs) are crucial for reducing gastric acid, aiding ulcer healing if present, and potentially minimizing further irritation
Antiemetics are used to manage nausea and vomiting.
Surgical Management:
Endoscopic management is often the first line of treatment for manageable strictures, involving dilation with balloons or Savary dilators
For refractory or severe strictures, surgical intervention is necessary
Options include revision of the sleeve gastrectomy, conversion to another bariatric procedure (e.g., gastric bypass), or stricturoplasty
Stricturoplasty involves incising the stenotic segment longitudinally and closing it transversely to widen the lumen, typically performed laparoscopically.
Supportive Care:
Close monitoring of fluid and electrolyte balance
Nutritional counseling and support, potentially involving a dietitian specializing in bariatric surgery
Regular follow-up with the surgical team is essential.
Complications
Early Complications:
Bleeding and perforation during endoscopic dilation or surgical revision
Leaks from staple lines or anastomoses
Infection.
Late Complications:
Recurrence of stricture despite treatment
Staple line dehiscence
Weight regain due to altered anatomy or inadequate intake
Reflux esophagitis.
Prevention Strategies:
Meticulous surgical technique during sleeve gastrectomy, ensuring adequate caliber of the bougie and proper staple line reinforcement
Careful attention to operative details like oversewing or applying hemostatic agents to the staple line
Avoiding excessive tension on the staple line
Judicious use of gastropexy to prevent twisting
Diligent post-operative care and patient education on diet.
Prognosis
Factors Affecting Prognosis:
The length and severity of the stricture
The presence of associated complications like ulcers or ischemia
The patient's nutritional status
The promptness of diagnosis and initiation of treatment
The skill of the managing surgeon.
Outcomes:
With effective management, including endoscopic dilation or surgical stricturoplasty/revision, most patients can achieve resolution of symptoms and restoration of adequate oral intake
Long-term outcomes depend on preventing recurrence and addressing any underlying contributing factors.
Follow Up:
Lifelong follow-up is generally recommended for bariatric surgery patients
For those who have undergone stricture management, closer surveillance may be required, including periodic endoscopic assessments, to monitor for recurrence and ensure optimal nutritional status.
Key Points
Exam Focus:
Strictures of the gastric sleeve typically occur along the staple line, often within 3 months post-op
Upper GI endoscopy is the primary diagnostic modality
Endoscopic balloon dilation is the first-line treatment for amenable strictures
Surgical stricturoplasty or revision is indicated for refractory cases
Prevention focuses on surgical technique and staple line integrity.
Clinical Pearls:
Always consider a staple line leak or stricture in a patient presenting with persistent nausea, vomiting, and dysphagia after sleeve gastrectomy
Consider graduated balloon dilations before resorting to surgery
Stricturoplasty offers a way to widen the lumen without significantly altering the length of the sleeve.
Common Mistakes:
Delaying diagnosis by attributing symptoms to normal post-operative discomfort
Aggressive dilation without adequate assessment of the stricture length and surrounding tissue
Failing to consider other causes of gastric outlet obstruction
Inadequate nutritional support during the management phase.