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 : • 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 incisuraangularis (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 incisuraangularisand 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