Dapri Giovanni, Cadière Guy Bernard, Himpens Jacques
Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium.
Obes Surg. 2009 Apr;19(4):495-9. doi: 10.1007/s11695-009-9803-0. Epub 2009 Jan 24.
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.
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.
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.
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.
袖状胃切除术（SG）可单独进行（ISG），也可与十二指肠转位的吸收不良手术联合进行（SG/DS）。在术后并发症中，SG狭窄相对少见，文献中提及甚少。我们报告了9例长段狭窄患者的治疗经验，这些患者不符合内镜球囊扩张的条件，接受了ISG或SG/DS术后的腹腔镜浆膜切开术治疗。
2006年3月至2008年1月，4例ISG术后患者（0.7%）和5例SG/DS术后患者（0.8%）因长段狭窄不符合内镜球囊扩张条件，连续接受了腹腔镜浆膜切开术。吞咽困难分别在平均9.2±2.6个月（ISG）和18.6±13.2个月（SG/DS）后出现。术前平均吞咽困难频率为4±0（ISG）和4±0（SG/DS）。两组均有2例患者新发胃食管反流病（GERD）症状。吞钡检查显示SG上部狭窄2例，角切迹水平狭窄7例。胃镜检查显示狭窄平均长度为4.7±0.9 cm（ISG）和5.2±1.3 cm（SG/DS）。主要观察指标为狭窄愈合率。次要观察指标包括手术时间、术中及术后并发症、吞钡检查结果以及GERD症状改善情况。
无转为开放手术者，无死亡病例。术中无胃穿孔，但1例患者（ISG）转为Roux-en-Y胃旁路术。平均手术时间为153.7±39.4分钟（ISG）和110±6.1分钟（SG/DS）。术后记录到1例胃漏（ISG）。平均住院时间为7.6±5.8天（ISG）和3.4±0.8天（SG/DS）。1个月后所有患者吞钡检查结果均满意，且能够耐受正常饮食。平均随访21±5.6个月（ISG）后，平均吞咽困难评分降至0.6±0.9，平均随访17.6±10.5个月（SG/DS）后降至0.8±0.8。两组均有2例患者新发GERD症状改善。
SG术后长段狭窄的腹腔镜浆膜切开术可行，对有症状的吞咽困难治疗有效。对新发GERD症状改善有有益影响。然而，存在术后漏的风险。
