What causes gastroesophageal (GE) junction tightness after bariatric surgery?

From the Guidelines

Gastroesophageal (GE) junction tightness after bariatric surgery is primarily caused by mechanical narrowing, usually located at the incisura angularis or an axial obstruction due to rotation phenomenon secondary to incongruence between the anterior and posterior gastric wall 1.

Causes of GE Junction Tightness

The causes of GE junction tightness can be attributed to several factors, including:

• Mechanical narrowing, usually located at the incisura angularis
• Axial obstruction due to rotation phenomenon secondary to incongruence between the anterior and posterior gastric wall
• Predisposing factors for gastric strictures after sleeve gastrectomy, such as calibrating the stomach with smaller bougie diameter, stapling too close to the incisura angularis, postoperative edema, or hematoma 1

Management of GE Junction Tightness

Management of GE junction tightness usually involves endoscopic balloon dilation, which may need to be repeated several times for complete resolution 1. In severe cases that don't respond to dilation, surgical revision may be necessary.

Prevention of GE Junction Tightness

To prevent this complication, surgeons often take precautions such as avoiding excessive tissue manipulation at the GE junction, proper staple selection, and sometimes prescribing proton pump inhibitors postoperatively to reduce acid-induced inflammation during healing.

Key Considerations

It is essential to note that the incidence of GE junction tightness can vary depending on the type of bariatric surgery performed, with sleeve gastrectomy being a common procedure associated with this complication 1. Additionally, early detection and management of GE junction tightness are crucial to prevent long-term complications and improve patient outcomes.

From the Research

Causes of Gastroesophageal (GE) Junction Tightness after Bariatric Surgery

• The exact cause of GE junction tightness after bariatric surgery is not explicitly stated in the provided studies, but several factors can contribute to this condition, including:
  • Stenosis of the esophago-jejuno anastomosis, which can occur after gastric surgery 2
  • Gastrojejunal strictures, which can develop after Roux-en-Y gastric bypass (RYGB) 3
  • Gastric leaks at the GE junction, which can occur after sleeve gastrectomy (SG) or duodenal switch (DS) 4
• These complications can lead to dysphagia, gastroesophageal reflux disease (GERD), and other symptoms, and can be treated with endoscopic balloon dilation, stent placement, or revisional surgery 3, 4, 5, 2
• Intra-operative physiologic measurements of the lower esophageal sphincter (LES) at the GEJ during robotic sleeve gastrectomy can help identify predictors of post-sleeve GERD symptoms, such as higher distensibility index (DI) and lower LES pressure 6

Risk Factors for GE Junction Tightness

• Female gender, proximal gastrectomy, use of a narrow-sized stapler, and the choice of stapling device can increase the risk of developing anastomotic stenosis after gastric surgery 2
• The timing of stricture symptoms after RYGB can also affect the success of endoscopic balloon dilation, with "late" strictures being less amenable to dilation than "early" strictures 3

Treatment Options for GE Junction Tightness

• Endoscopic balloon dilation is an effective treatment for early gastrojejunal strictures after RYGB, but late strictures may require revisional surgery 3
• Coated self-expanding stents can be used to treat gastric leaks at the GE junction after SG or DS, with good results in terms of morbidity and survival 4
• Endoscopic stents can also be used to manage other bariatric complications, such as staple line leaks, anastomotic leaks, and marginal ulcer perforations 5