What is the recommended use of a bougie (bougie dilator) in patients with gastric sleeve strictures?

Use of Bougie in Gastric Sleeve Surgery

For gastric sleeve strictures following bariatric surgery, use wire-guided bougie dilators or through-the-scope balloon dilators under endoscopic control, never unguided weighted bougies, to minimize perforation risk while achieving safe and effective stricture resolution. 1

Recommended Dilation Technique

Choice of Dilator

• Use either wire-guided bougie dilators or balloon dilators—both are equally effective and safe for post-sleeve gastrectomy strictures. 1
• Wire-guided techniques provide greater assurance that the dilator follows the gastric lumen, significantly reducing perforation risk compared to blind passage 1
• Through-the-scope balloon dilation allows direct endoscopic visualization throughout the procedure 1

Critical Safety Principles

• Never use weighted (Maloney) bougies with blind insertion—safer alternatives are available and mandatory. 1
• Unguided weighted bougies should be restricted only to simple reflux strictures, rings, or webs—they are contraindicated for complex or tight strictures where perforation risk is substantially higher 1
• Post-bariatric strictures are considered complex and require guided techniques 1

Dilation Protocol

Initial Approach

• For very narrow strictures not passable by adult gastroscope, limit initial dilation to 10-12 mm diameter (30-36F). 1
• Target diameter for filiform (extremely narrow) strictures should be even lower at ≤9 mm 1
• The goal for benign strictures is typically 13-15 mm to achieve symptom resolution 1

Incremental Dilation Strategy

• Consider using no more than three successively larger diameter increments in a single session (the traditional "rule of three"), though this is not strictly evidence-based 1
• For very tight or complex post-sleeve strictures, limit initial dilation to 1-2 size increments for enhanced safety 1
• Multiple sessions are typically required—patients should be counseled about this expectation before the first procedure 1

Wire-Guided Technique Details

• Place the guidewire at least 20-30 cm below the stricture, typically in the gastric antrum or remaining stomach pouch 1
• Fix the guidewire externally to minimize risk of internal displacement 1
• Use liberal lubrication to facilitate passage of both wire and dilator 1
• Apply slight counter-tension during dilator passage 1

Role of Fluoroscopy

• Perform dilation without fluoroscopy for simple, straightforward strictures—safety and efficacy are well-established. 1
• Use fluoroscopic guidance for high-risk strictures including those that are long, angulated, multiple, or cannot be passed endoscopically 1
• Fluoroscopy is particularly valuable when the guidewire meets resistance or adequate wire length cannot be passed distally 1

Critical Complications and Prevention

Perforation Risk

• Esophageal/gastric perforation occurs in 0-7% of dilations (typically 3-4%) with mortality <1%—this is the most serious complication requiring immediate recognition 2
• The risk of cervical esophageal perforation during bougie placement in sleeve gastrectomy, though rare, is life-threatening and has been reported 3
• Inadequate technique or excessive force increases perforation risk substantially 2, 4

Intraoperative Bougie Complications

• Bougie stapling during sleeve gastrectomy is a serious complication requiring immediate correction—extreme caution during bougie insertion is mandatory 5
• Endoscopic calibration during sleeve creation may reduce major complications compared to bougie-only calibration (though this addresses prevention rather than stricture treatment) 6

Post-Procedure Monitoring

• Monitor patients for at least 2 hours in recovery with regular vital signs assessment. 1
• Ensure patients tolerate water before discharge 1
• Do not perform routine imaging post-procedure unless patients develop persistent chest pain, fever, breathlessness, or tachycardia during recovery. 1
• If perforation is suspected based on persistent pain or systemic signs, perform CT scan with oral contrast immediately 1
• Consider immediate treatment with fully covered self-expanding metal stent if perforation is confirmed 1

Additional Technical Considerations

• Use carbon dioxide insufflation instead of air during endoscopy to minimize luminal distension and post-procedural pain 1
• Provide clear written discharge instructions emphasizing the need to return immediately if pain, breathlessness, or fever develop 2
• The procedure should only be performed by experienced operators in fully equipped endoscopy rooms with access to fluoroscopy and surgical support 1

Common Pitfalls to Avoid

• Never rush dilation—treatments may be repeated over months to achieve and maintain symptom relief 7
• Avoid using bougies <10 mm diameter without fluoroscopic guidance as they are floppy and difficult to control 1
• Do not attempt aggressive single-session dilation of tight, complex post-bariatric strictures—staged approach is safer 1
• Ensure proper antibiotic prophylaxis for patients at risk of endocarditis 7