Bariatric Times - January 2009 - (Page 8)

8 Surgical Perspective Bariatric Times • January 2009 Endoscopic Tr ea tment of Baria tric Sur g er y Complica tions by Jose M. Martinez, MD, FACS, and Atul K. Madan, MD, FACS Both from the Division of Laparoendoscopic and Bariatric Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida. . Continued from Page 1 STRICTURE One of the more commonly encountered complications after Roux-en-Y gastric bypass is a stricture at the gastrojejunostomy. Another possible but less likely site of a stricture is at the jejunojejunostomy. The most appropriate initial management of a gastrojejunal anastomotic stricture is to perform an endoscopic dilatation. While some have used bougie dilation successfully,4 we feel that balloon dilation with or without flouroscopic guidance offers the safest method. The balloon is passed through the working channel of the endoscope. The dilation may be monitored under fluoroscopic guidance (Figures 1 and 2). A key step is the ability to traverse the anastomosis to ensure the balloon is intraluminal on the distal side of the anastomosis to decrease the incidence of perforation. This is achieved by traversing the stricture with a guidewire. The wire is then followed with catheters that allow injection of contrast under fluoroscopy to demonstrate it has safely traversed the stricture and is in the small bowel. If the anastomosis can be traversed with an adult-sized endoscope, dilation may not be needed. Instead, dietary re-education is often the best course of action. We discourage dilation with wire- or non-wireguided bougie dilator because of the increased risk of injury to the often angulated small bowel just distal to the anastomosis. Dilating balloon catheters come in multiple diameters (Figure 3). The goal is to achieve an inner lumen similar to the original surgery. The most commonly used size is 13 to 15mm diameter, so the resulting anastomosis post-healing will be in range of 10 to 12mm. This technique is highly effective but may require repeat dilation, which still results in good success.5-7 The most common but still rare complications encountered from balloon dilation are bleeding and perforation.5-7 One concern about dilation of a stricture that is not often discussed is the possibility of increasing the diameter to the point of creating a gastrojejunostomy that is too large to keep food into the stomach. If the gastric pouch is not distended, there is worry that

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Bariatric Times - January 2009

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