Presentation on theme: "Gastric Obstruction post “Sleeve gastrectomy”"— Presentation transcript:
1Gastric Obstruction post “Sleeve gastrectomy” Hussein Mcheimech, MD
226 yr old female patient underwent laparoscopic sleeve gastrectomy 9 month ago, complaining of post prandial vomiting for the last 7 month .Dysphagia only to solids , with no other symptoms.Total weight loss since surgery = 60 kg
3PSHx :laparoscopic sleeve gastrectomy 9 m agoLap. Cholecystectomy 8 m agoPMHx: noneNKDATo note a hiatal hernia is detected on follow up upper GI on day 2 post op.
4Physical exam: no Abnormal findings. Vitals signs within normal parameters.Abdomen : soft , bs + , non tender with no signs of organomegaly.
22Report Passage of contrast from the stomach to the jejunal loop. No passage of contrast thru the duodenum
23Gastric outlet obstruction following sleeve gastrectomy
24Complication rate of LSG : 0.7 – 4% Gastric outlet obstruction less frequent than leaks.Rarely discussed in the literature.
25Symptoms Dysphagia Nausea and vomiting Symptoms of obstruction when moving from fluids to solid foodSticking to fluids consumption, not progressing to solidsSaliva or food regurgitationImpaction of food (especially meat or bread)De novo gastroesophageal reflux disease symptoms
26Studies Upper GI will show : Endoscopy is the prefered modality thin stenotic ringKinkingtortuosity in the sleevelack of progression of the contrast columnEndoscopy is the prefered modalityAn unsurpassable stretch of lumen when using a 9.8mm endoscope should be considered a stricture
27Causes Early (Acute): gastric mucosal edema external compression (mainly hematoma)Kinking at the incisura angularis (acute angle created by oversewing )Late:Strictures (due to : pouch ischemia , retraction due to scarring)Adhesions.
28Avoiding strictures Faucher tube, endoscope: Allows a safe distance between the incisura angularis and the stapling edge.Prevents thru and thru stitching if oversweing is performed.Meticulous lesser curvature dissectionPrevent ischemiaTwisting of the gastric tube:Can be prevented by keepin a straight stappling line
29Treatment: Surgery as last resort EXCEPT in the early post op period. For early cases, surgery to :Manage a hematomaRelease over sewn stitches relieve pressure or ischemia.in case of kinking , fixating the incisura.
30Late cases Endoscopic balloon dilation: In cases of stenosis or adhesions.5 dilations as following:Last dilation + needle cautery cuts at 4 quadrants.78 % success rate (7/9 pts, 5 stenosis , 2 adhesions)
32Endoscopic stentingEubanks et al and Scott7-day period of stenting(success rate of 83% ( small sample n=6)Stents removed after 1 week due to pain.Dilation and stenting are contraindicated in cases of long segment stenosis.Final approach in case of failure:R en Y gastric bypass or total gastrectomy
33ConclusionGastric outlet obstruction following LSG is a rare complication.The condition presents as early or lateEarly obstruction is surgery dependantLate presentation is dependant on the patient’s attitude, inflammation, fibrosis as well as surgical technique.
34Treatment should be tailored to each patient. The most effective treatment is conversion toRoux en Y gastric bypassloop bypasswith or without gastrectomy