Skip to main content
SpringerLink
Log in

Gastrojejunal Stricture After Gastric Bypass and Efficacy of Endoscopic Intervention

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

The Roux-en-Y gastric bypass procedure (RYGBP) is an effective treatment for morbid obesity. Anastomotic strictures are a common complication after RYGBP. This study examines the frequency of post-RYGBP gastrojejunal strictures (GJS), methods of evaluation, and the outcome of endoscopic intervention. Medical records of patients who had RYGBP for morbid obesity at our institution during four consecutive years were reviewed for patient demographics, medical comorbidities, surgical technique, and outcomes. Radiographic and endoscopic findings of those patients suspected to have GJS were noted. The impact of patient-related variables and surgical technique on risk of GJS, time to diagnosis of GJS, and treatment outcomes for GJS was determined. Of 888 patients, 503 had open RYGBP (57%) and 385 laparoscopic RYGBP (43%). Ninety-four patients (10.6%) underwent esophagogastroduodenoscopy (EGD) for possible GJS and 58 (6.5%) were found to have anastomotic stricture. Laparoscopic RYGBP was associated with increased incidence of GJS (43/385, 11.1%) compared with open RYGBP (15/503 or 2.9%, P = 0.0003). A total of 125 dilations were performed with an average of 2.2 dilations per patient. None of the strictures needed surgical revision. There were four perforations (3.2%) related to EGD. Mean time to diagnosis of GJS was 66.2 days. Eighty-seven of 94 patients underwent radiologic upper gastrointestinal (UGI) evaluation prior to EGD. UGI evaluation demonstrated a positive predictive value (PPV) of only 66% [95% confidence interval (CI) 52–77], and negative predictive value (NPV) of 83% (95% CI 65–93). Laparoscopic GBP is associated with increased risk of GJS. Endoscopic dilation of GJS is an effective treatment with minimal risk. Radiographic studies appear to have poor specificity for diagnosis of GJS and have a low positive predictive value. EGD should be performed in all suspected cases of GJS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350:1075–1079. doi:10.1056/NEJMp048029.

    Article  PubMed  CAS  Google Scholar 

  2. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47:1345–1351.

    PubMed  CAS  Google Scholar 

  3. Cummings DE, Overduin J, Foster-Schubert KE. Gastric bypass for obesity: mechanisms of weight loss and diabetes resolution. J Clin Endocrinol Metab. 2004;89:2608–2615. doi:10.1210/jc.2004-0433.

    Article  PubMed  CAS  Google Scholar 

  4. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4:353–357. doi:10.1381/096089294765558331.

    Article  PubMed  Google Scholar 

  5. DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg. 2002;235:640–5. Discussion 645–647. doi:10.1097/00000658-200205000-00005.

  6. Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1, 040 patients––what have we learned? Obes Surg. 2000;10:509–513. doi:10.1381/096089200321593706.

    Article  PubMed  CAS  Google Scholar 

  7. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515–529. doi:10.1097/00000658-200010000-00007.

    Article  PubMed  CAS  Google Scholar 

  8. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3–60 month follow-up. Obes Surg. 2000;10:233–239. doi:10.1381/096089200321643511.

    Article  PubMed  CAS  Google Scholar 

  9. Lujan JA, Frutos MD, Hernandez Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. Ann Surg. 2004;29:433–437. doi:10.1097/01.sla.0000120071.75691.1f.

    Article  Google Scholar 

  10. Nguyen NT, Ho HS, Palmer LS, Wolfe BM (2000) A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J Am Coll Surg. 191:149–55. Discussion 155–147. doi:10.1016/S1072-7515(00)00276-3.

    Google Scholar 

  11. Paxton JH, Matthews JB. The cost effectiveness of laparoscopic versus open gastric bypass surgery. Obes Surg. 2005;15:24–34. doi:10.1381/0960892052993477.

    Article  PubMed  Google Scholar 

  12. Sekhar N, Torquati A, Youssef Y, Wright JK, Richards WO. A comparison of 399 open and 568 laparoscopic gastric bypasses performed during a 4-year period. Surg Endosc. 2007;21:665–668. doi:10.1007/s00464-006-9151-2.

    Article  PubMed  CAS  Google Scholar 

  13. Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg. 2003;138:957–961. doi:10.1001/archsurg.138.9.957.

    Article  PubMed  Google Scholar 

  14. Shope TR, Cooney RN, McLeod J, Miller CA, Haluck RS. Early results after laparoscopic gastric bypass: EEA vs. GIA stapled gastrojejunal anastomosis. Obes Surg. 2003;13:355–359. doi:10.1381/096089203765887651.

    Article  PubMed  Google Scholar 

  15. Cooney RN, Bryant P, Haluck R, Rodgers M, Lowery M. The impact of a clinical pathway for gastric bypass surgery on resource utilization. J Surg Res. 2001;98:97–101. doi:10.1006/jsre.2001.6167.

    Article  PubMed  CAS  Google Scholar 

  16. Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg. 2004;188:105–110. doi:10.1016/j.amjsurg.2004.03.001.

    Article  PubMed  Google Scholar 

  17. Puzziferri N, Austrheim-Smith IT, Wolfe BM, Wilson SE, Nguyen NT. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann Surg. 2006;243:181–188. doi:10.1097/01.sla.0000197381.01214.76.

    Article  PubMed  Google Scholar 

  18. Nguyen NT, Stevens CM, Wolfe BM. Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass. J Gastrointest Surg. 2003;7:997–1003. Discussion 1003. doi:10.1016/j.gassur.2003.09.016.

    Google Scholar 

  19. Goitein D, Papasavas PK, Gagne D, Ahmad S, Caushaj PF. Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2005;19:628–632. doi:10.1007/s00464-004-9135-z.

    Article  PubMed  CAS  Google Scholar 

  20. Carrodeguas L, Szomstein S, Zundel N, Lo Menzo E, Rosenthal R. Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery: analysis of 1291 patients. Surg Obes Relat Dis. 2006;2:92–97. doi:10.1016/j.soard.2005.10.014.

    Article  PubMed  Google Scholar 

  21. Spaulding L. Treatment of dilated gastrojejunostomy with sclerotherapy. Obes Surg. 2003;13:254–257. doi:10.1381/096089203764467162.

    Article  PubMed  Google Scholar 

  22. Talieh J, Kirgan D, Fisher BL. Gastric bypass for morbid obesity: a standard surgical technique by consensus. Obes Surg. 1997;7:198–202. doi:10.1381/096089297765555728.

    Article  PubMed  CAS  Google Scholar 

  23. Barba CA, Butensky MS, Lorenzo M, Newman R. Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass. Surg Endosc. 2003;17:416–420.

    Article  PubMed  CAS  Google Scholar 

  24. Nguyen NT. Open vs. laparoscopic procedures in bariatric surgery. J Gastrointest Surg. 2004;8:393–395.

    Article  PubMed  Google Scholar 

  25. Rossi TR, Dynda DI, Estes NC, Marshall JS. Stricture dilation after laparoscopic Roux-en-Y gastric bypass. Am J Surg. 2005;189:357–360.

    Article  PubMed  Google Scholar 

  26. Swartz DE, Gonzalez V, Felix EL. Anastomotic stenosis after Roux-en-Y gastric bypass: a rational approach to treatment. Surg Obes Relat Dis. 2006;2:632–636. Discussion 637.

    Article  PubMed  Google Scholar 

  27. Szomstein S, Kaidar-Person O, Naberezny K, Cruz-Correa M, Rosenthal R. Correlation of radiographic and endoscopic evaluation of gastrojejunal anastomosis after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006;2:617–621.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The study was conceived by M.V. and was designed by A.M. Data was collected by M.V., F.D., and R.C., and were analyzed by A.M. The manuscript was first drafted by M.V. and R.C. Critical revision of the manuscript was done by A.M. and R.C.

Author information

Authors and Affiliations

  1. Division of Gastroenterology, Department of Medicine, C6600, Pennsylvania State University College of Medicine & The Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA

    Abraham Mathew, Michael A. Veliuona & Fedele J. DePalma

  2. Department of Surgery, Pennsylvania State University College of Medicine & The Milton S. Hershey Medical Center, Hershey, PA, 17033, USA

    Robert N. Cooney

Authors
  1. Abraham Mathew
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael A. Veliuona
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Fedele J. DePalma
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Robert N. Cooney
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Abraham Mathew.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mathew, A., Veliuona, M.A., DePalma, F.J. et al. Gastrojejunal Stricture After Gastric Bypass and Efficacy of Endoscopic Intervention. Dig Dis Sci 54, 1971–1978 (2009). https://doi.org/10.1007/s10620-008-0581-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-008-0581-7

Keywords

Search

Navigation