1. Gastric Obstruction post “Sleeve gastrectomy”
Hussein Mcheimech, MD

2. 26 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

3. PSHx :
laparoscopic sleeve gastrectomy 9 m ago
Lap. Cholecystectomy 8 m ago
PMHx: none
NKDA
To note a hiatal hernia is detected on follow up upper GI on day 2 post op.

4. Physical exam: no Abnormal findings.
Vitals signs within normal parameters.
Abdomen : soft , bs + , non tender with no signs of organomegaly.

5. Upper GI at 2m post op

11. Gastroscopy

12. abdominal CT 8/2/13 Good esophageal passage of contrast
Presence of a 25mm stenotic not obstructive segment at the level of the stomach body
To note food debris in the fundus after 6h of fasting.

18. Post op Upper GI

22. Report Passage of contrast from the stomach to the jejunal loop.
No passage of contrast thru the duodenum

23. Gastric outlet obstruction following sleeve gastrectomy

24. Complication rate of LSG : 0.7 – 4%
Gastric outlet obstruction less frequent than leaks.
Rarely discussed in the literature.

25. Symptoms Dysphagia Nausea and vomiting
Symptoms of obstruction when moving from fluids to solid food
Sticking to fluids consumption, not progressing to solids
Saliva or food regurgitation
Impaction of food (especially meat or bread)
De novo gastroesophageal reflux disease symptoms

26. Studies Upper GI will show : Endoscopy is the prefered modality
thin stenotic ring
Kinking
tortuosity in the sleeve
lack of progression of the contrast column
Endoscopy is the prefered modality
An unsurpassable stretch of lumen when using a 9.8mm endoscope should be considered a stricture

27. Causes 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.

28. Avoiding 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 dissection
Prevent ischemia
Twisting of the gastric tube:
Can be prevented by keepin a straight stappling line

29. Treatment: Surgery as last resort EXCEPT in the early post op period.
For early cases, surgery to :
Manage a hematoma
Release over sewn stitches relieve pressure or ischemia.
in case of kinking , fixating the incisura.

30. Late 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)

32. Endoscopic stenting
Eubanks et al and Scott
7-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

33. Conclusion
Gastric outlet obstruction following LSG is a rare complication.
The condition presents as early or late
Early obstruction is surgery dependant
Late presentation is dependant on the patient’s attitude, inflammation, fibrosis as well as surgical technique.

34. Treatment should be tailored to each patient.
The most effective treatment is conversion to
Roux en Y gastric bypass
loop bypass
with or without gastrectomy