How to manage gastroesophageal (GE) junction tightness after bariatric surgery?

From the Guidelines

Endoscopic pneumatic dilation is the recommended first-line treatment for managing gastroesophageal (GE) junction tightness after bariatric surgery. This approach is supported by the most recent and highest quality study, which found that endoscopic pneumatic dilation is a safe and effective treatment for gastric stenosis after sleeve gastrectomy (SG) and gastro-jejunostomy strictures after Roux-en-Y gastric bypass (RYGB) 1.

When managing GE junction tightness, it is essential to consider the potential complications of treatment, including perforation, which may necessitate surgical intervention 1. The treatment plan should be individualized, taking into account the patient's specific needs and the severity of the stricture.

Key considerations in the management of GE junction tightness include:

• Initial assessment and diagnosis to determine the severity of the stricture
• Endoscopic pneumatic dilation as the primary interventional treatment
• Potential need for temporary stent placement or steroid injection for persistent strictures
• Surgical revision as a last resort for cases that fail conservative and endoscopic management
• Close monitoring and follow-up to prevent malnutrition and dehydration complications.

It is crucial to prioritize a stepwise approach, starting with less invasive treatments and progressing to more invasive options only as needed, to minimize the risk of complications and optimize patient outcomes.

From the Research

Management of GE Junction Tightness after Bariatric Surgery

• The management of gastroesophageal (GE) junction tightness after bariatric surgery can be achieved through various endoscopic techniques, including the use of coated self-expanding stents (CSES) 2 and endoscopic balloon dilation 3, 4, 5.
• CSES have been proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery, with good results in terms of morbidity and survival 2.
• Endoscopic balloon dilation is an effective treatment for gastrojejunal (GJ) strictures after Roux-en-Y gastric bypass (RYGB), with a higher success rate for "early" strictures (occurring within 90 days postoperatively) compared to "late" strictures 3.
• The optimal technique for dilation of stomal strictures remains to be determined, but many authors prefer the use of through-the-scope (TTS) balloon catheters 4.
• Predictors of initial failure of endoscopic dilation include the time from surgery to stricture formation and the diameter achieved at the first dilation 5.
• Endoscopic stents can also be used to manage gastric perforations, strictures, and fistulas after bariatric surgery, with a high success rate and minimal complications 6.

Endoscopic Techniques

• Endoscopic balloon dilation is a safe and effective method for treating GJ strictures after RYGB, with most patients requiring only one or two dilations 3, 5.
• Endoscopically placed stents can be used to manage gastric perforations, strictures, and fistulas after bariatric surgery, and can be used in conjunction with operative intervention to decrease the risk of complications 6.
• The use of fully covered endoscopic stents has been shown to be effective in managing bariatric complications, with a high success rate and minimal complications 6.

Complications and Outcomes

• The most common complications after bariatric surgery include leaks, strictures, fistulas, and erosion of transgastric and adjustable gastric bands 6.
• Endoscopic stents can be used to manage these complications, with a high success rate and minimal complications 6.
• The outcomes of endoscopic management of GE junction tightness after bariatric surgery are generally good, with a high success rate and minimal complications 2, 3, 4, 5, 6.