Agnihotri Abhishek, Barola Sindhu, Hill Christine, Neto Manoel Galvao, Campos Josemberg, Singh Vikesh K, Schweitzer Michael, Khashab Mouen A, Kumbhari Vivek
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Medicine and Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Obes Surg. 2017 Oct;27(10):2628-2636. doi: 10.1007/s11695-017-2689-3.
Gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. This study aims to describe the safety and efficacy of a predefined step-wise algorithm for endoscopic management of GS post-LSG.
Consecutive patients with symptomatic GS post-LSG, presenting between July 2015 and August 2016, were subjected to a predefined treatment algorithm of serial dilations using achalasia balloons, followed by a fully covered self-expanding metal stent (FCSEMS) if dilations were inadequate. Patients who did not respond or opted out of ongoing endoscopic therapy were offered revision Roux-en-Y gastric bypass (RYGB).
Total of 17 patients underwent a median of 2 (range 1-4) balloon dilations. Twelve patients (70.6%) reported clinical improvement with balloon dilation alone, while 3 (17.6%) required subsequent FCSEMS placement. One patient suffered a tear to the muscularis propria with balloon dilation, which was managed conservatively. Overall, 15 (88.2%) reported clinical improvement with endoscopic management. PAGI-SYM scores revealed that the strongest response to therapy, based on mean reduction of score ± SD, was in the following items: nausea (3 ± 1.9, P < 0.001), heartburn during day (2.8 ± 1.5, P = 0.003), heartburn on lying down (3.4 ± 1.4, P < 0.001), reflux during day (2.8 ± 1.9, P < 0.001), and reflux on lying down (3.0 ± 1.9, P < 0.001). Two (11.8%) patients failed endoscopic therapy and underwent RYGB.
Endoscopic management of GS using the described algorithmic approach is safe and effective post-LSG. Patients with severe stenosis or helical stenosis are likely to require revision RYGB.
胃狭窄（GS）是腹腔镜袖状胃切除术（LSG）后一种潜在的不良事件。内镜治疗是首选；然而，治疗策略存在显著差异，且没有明确的算法。本研究旨在描述一种预定义的逐步算法用于LSG术后GS内镜治疗的安全性和有效性。
2015年7月至2016年8月期间连续出现症状性LSG术后GS的患者，接受了一种预定义的治疗算法，即先用贲门失弛缓症球囊进行系列扩张，若扩张不足则置入全覆膜自膨式金属支架（FCSEMS）。对无反应或选择退出正在进行的内镜治疗的患者提供翻修Roux-en-Y胃旁路术（RYGB）。
共有17例患者接受了中位2次（范围1 - 4次）球囊扩张。12例患者（70.6%）报告仅球囊扩张后临床症状改善，而3例（17.6%）患者随后需要置入FCSEMS。1例患者在球囊扩张时固有肌层撕裂，经保守治疗。总体而言，15例（88.2%）患者报告内镜治疗后临床症状改善。PAGI-SYM评分显示，基于评分均值±标准差的治疗反应最强的项目如下：恶心（3±1.9，P<0.001）、白天烧心（2.8±1.5，P = 0.003）、躺下时烧心（3.4±1.4，P<0.001）、白天反流（2.8±1.9，P<0.001）以及躺下时反流（3.0±1.9，P<0.001）。2例（11.8%）患者内镜治疗失败并接受了RYGB。
使用所述算法方法对LSG术后GS进行内镜治疗是安全有效的。严重狭窄或螺旋状狭窄的患者可能需要翻修RYGB。
