Giovanni Dapri1, Guy Bernard Cadière, Jacques Himpens. 1. Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium. giovanni@dapri.net
Abstract
BACKGROUND: Sleeve gastrectomy (SG) can be performed either as isolated (ISG), or with the malabsorptive procedure of duodenal switch (SG/DS). Among the postoperative complications, stenosis of the SG is relatively rare and only scarcely mentioned in literature. We report our experience in nine patients presenting a long stenosis, not eligible for endoscopic balloon dilation, and treated by laparoscopic seromyotomy after ISG or SG/DS. METHODS: From March 2006 to January 2008, four patients after ISG (0.7%) and five patients after SG/DS (0.8%) were consecutively submitted to laparoscopic seromyotomy for long stenosis, not eligible for endoscopic balloon dilation. Dysphagia appeared after a mean time of 9.2 +/- 2.6 months (ISG) and of 18.6 +/- 13.2 months (SG/DS). Preoperative mean dysphagia frequency was 4 +/- 0 (ISG) and 4 +/- 0 (SG/DS). Gastroesophageal reflux disease (GERD) symptoms appeared as de novo in two patients of both groups. Barium swallow showed a stenosis at the upper part of the SG (2) and at the level of the incisura angularis (7). Gastroscopy evidenced a mean length of the stricture of 4.7 +/- 0.9 cm (ISG) and of 5.2 +/- 1.3 cm (SG/DS). The primary outcomes measure was stricture healing rate. Secondary outcomes measures included procedure time, peroperative, and postoperative complications, performance of barium swallow check, and GERD symptoms improvement. RESULTS: There were no conversions to open surgery and no mortality. There was no peroperative gastric perforation, but one patient was converted into Roux-en-Y gastric bypass (ISG). Mean operative time was 153.7 +/- 39.4 min (ISG) and 110 +/- 6.1 min (SG/DS). One gastric leak was recorded postoperatively (ISG). Mean hospital stay was 7.6 +/- 5.8 days (ISG) and 3.4 +/- 0.8 days (SG/DS). Barium swallow check after 1 month was satisfied in all patients, and they were able to tolerate a regular diet. After a mean follow-up of 21 +/- 5.6 months (ISG), the mean dysphagia score was reduced to 0.6 +/- 0.9, and after a mean follow-up of 17.6 +/- 10.5 months (SG/DS) to 0.8 +/- 0.8. De novo GERD symptoms improved in two patients of both groups. CONCLUSION: Laparoscopic seromyotomy after SG for long stenosis is feasible, and efficient for the treatment of symptomatic dysphagia. It has a beneficiary influence on de novo GERD symptoms improvement. There is, however, the risk of postoperative leak.
BACKGROUND: Sleeve gastrectomy (SG) can be performed either as isolated (ISG), or with the malabsorptive procedure of duodenal switch (SG/DS). Among the postoperative complications, stenosis of the SG is relatively rare and only scarcely mentioned in literature. We report our experience in nine patients presenting a long stenosis, not eligible for endoscopic balloon dilation, and treated by laparoscopic seromyotomy after ISG or SG/DS. METHODS: From March 2006 to January 2008, four patients after ISG (0.7%) and five patients after SG/DS (0.8%) were consecutively submitted to laparoscopic seromyotomy for long stenosis, not eligible for endoscopic balloon dilation. Dysphagia appeared after a mean time of 9.2 +/- 2.6 months (ISG) and of 18.6 +/- 13.2 months (SG/DS). Preoperative mean dysphagia frequency was 4 +/- 0 (ISG) and 4 +/- 0 (SG/DS). Gastroesophageal reflux disease (GERD) symptoms appeared as de novo in two patients of both groups. Barium swallow showed a stenosis at the upper part of the SG (2) and at the level of the incisura angularis (7). Gastroscopy evidenced a mean length of the stricture of 4.7 +/- 0.9 cm (ISG) and of 5.2 +/- 1.3 cm (SG/DS). The primary outcomes measure was stricture healing rate. Secondary outcomes measures included procedure time, peroperative, and postoperative complications, performance of barium swallow check, and GERD symptoms improvement. RESULTS: There were no conversions to open surgery and no mortality. There was no peroperative gastric perforation, but one patient was converted into Roux-en-Y gastric bypass (ISG). Mean operative time was 153.7 +/- 39.4 min (ISG) and 110 +/- 6.1 min (SG/DS). One gastric leak was recorded postoperatively (ISG). Mean hospital stay was 7.6 +/- 5.8 days (ISG) and 3.4 +/- 0.8 days (SG/DS). Barium swallow check after 1 month was satisfied in all patients, and they were able to tolerate a regular diet. After a mean follow-up of 21 +/- 5.6 months (ISG), the mean dysphagia score was reduced to 0.6 +/- 0.9, and after a mean follow-up of 17.6 +/- 10.5 months (SG/DS) to 0.8 +/- 0.8. De novo GERD symptoms improved in two patients of both groups. CONCLUSION: Laparoscopic seromyotomy after SG for long stenosis is feasible, and efficient for the treatment of symptomatic dysphagia. It has a beneficiary influence on de novo GERD symptoms improvement. There is, however, the risk of postoperative leak.
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