What is the recommended approach for dilating post sleeve gastrectomy (bariatric surgery) stenosis?

Management of Post Sleeve Gastrectomy Stenosis

Endoscopic pneumatic balloon dilation is the first-line treatment for post sleeve gastrectomy stenosis, with a success rate of approximately 76% in providing long-term symptom relief. 1, 2

Types of Stenosis and Initial Assessment

• Post sleeve gastrectomy stenosis occurs in approximately 0.7-5% of cases, commonly located at the incisura angularis or in the proximal stomach 1, 3
• Stenosis can be classified as:
  • Organic: visible luminal narrowing
  • Functional: deformation without obvious narrowing
  • Combined: features of both 3
• Endoscopic assessment should be the first step in stable patients presenting with gastrointestinal symptoms suggestive of stenosis 1

Endoscopic Management Algorithm

First-Line Approach: Balloon Dilation

• Pneumatic balloon dilation is the preferred first-line treatment for most post-sleeve gastrectomy stenoses 1
• Technical specifications:
  • Use large pneumatic balloons (30-40 mm diameter, 8-10 cm long)
  • Position with endoscope side-by-side to the balloon
  • Inflate to 20 psi for 1-3 minutes
  • Use carbon dioxide for insufflation during the procedure 1
• Fluoroscopy is recommended (though not mandatory) to ensure proper balloon placement and avoid crossing the pylorus 1
• After dilation, inspect for tears; if tears involve the muscularis propria, consider endoscopic suturing to close the defect 1
• Dilations can begin as early as 2 weeks after surgery 1
• Serial dilations may be required, typically spaced 2-4 weeks apart 1, 4

For Refractory Stenosis

• If stenosis persists after 2-3 dilations to a maximum diameter of 35 mm, consider placement of a fully covered self-expanding metal stent (FCSEMS) 1
• The stent should:
  • Be up to 60 mm long
  • Not cross the gastroesophageal junction
  • Remain in place for approximately 2 months 1, 4
• The purpose of the stent is to improve pressure and flow dynamics 1

Surgical Options for Failed Endoscopic Management

• If endoscopic management fails after multiple attempts, conversion to Roux-en-Y gastric bypass should be considered 1, 4
• Approximately 17% of patients may ultimately require salvage surgery 2

Efficacy and Safety Considerations

• Overall success rate of endoscopic balloon dilation is approximately 76% (95% CI, 67%-86%) 2
• Success rates vary by location:
  • Proximal stenosis: 90% (95% CI, 63%-98%)
  • Distal stenosis: 70% (95% CI, 47%-86%) 2
• Perforation is a rare but serious complication, occurring in approximately 0.9-1.5% of cases 5, 2
• If perforation is suspected, inject contrast to assess for extravasation 1
• Consider performing the procedure in an operating room with a surgeon present (preferably the original surgeon) for critically ill patients or when the endoscopist has limited experience 1

Special Considerations

• Downstream stenosis may contribute to staple-line leaks by increasing intraluminal pressure 1
• Patients with stenosis often have higher depression and anxiety scores and lower quality of life, requiring a multidisciplinary approach 1, 6
• For patients with severe stenosis or helical stenosis that fails to respond to endoscopic therapy, revision to Roux-en-Y gastric bypass may be necessary 4
• Mild weight regain (approximately 3 kg or 4.2% of total body weight) may occur following successful endoscopic dilation 5

By following this algorithmic approach to managing post sleeve gastrectomy stenosis, clinicians can achieve high success rates while minimizing the need for more invasive surgical interventions.