ANASTOMOTIC STRICTURES FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY-MANAGEMENT & GUIDELINES

Purpose: Anastomotic stricture following LRYGBP presents with dysphagia, nausea and vomiting. Diagnosis is made by endoscopy and/or radio-graphic studies. Therapeutic options include endoscopic dilation and surgical revision. We propose clinical guidelines for managing gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: Of 369 consecutive LRYGBP performed, 19 patients developed anastomotic stricture (5.1%). One additional patient was referred from another facility. Pneumatic balloons were used for initial dilation for all patients. Savary-Gilliard bougies were used for some of the subsequent dilations. Results: Flexible endoscopy was diagnostic in all 20 patients allowing dilation in 18 (90%). Two patients did not undergo endoscopic dilation due to anastomotic obstruction and ulcer. The median time to stricture development was 32 days (range: 17–85). Most patients (78%) required >2 dilations. The complication rate was 1.6% (one case of microperforation). At a mean follow-up of 13.4 months, all patients were symptom-free. Post-LRYGBP gastrojejunostomy strictures can be endoscopically graded as follows: Grade I (Mild: allowing passage of a 10.5mm endoscope): usually managed by a single pneumatic dilation up to 18mm; Grade II (Moderate: allowing passage of an 8.5mm pediatric endoscope): managed by pneumatic dilation up to 15mm and subsequent dilations; Grade III (Severe: allowing passage of a guidewire): managed by initial dilation with pneumatic balloon dilators up to 10mm and subsequent dilations; Grade IV (Total/near-total obstruction): managed by surgical revision. Conclusions: Gastrojejunostomy stricture following LRYGBP is associated with substantial morbidity and patient dissatisfaction. We propose guidelines for grading and managing these strictures.