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Obesity is a major health problem in the United States and otherwesternized countries. Large prospective studies have demonstrated increasedmortality for moderately and severely obese individuals. According toguidelines from the American College of Physicians, surgery should beconsidered as a treatment option for morbidly obese individuals whoinstituted, but failed an exercise and diet program (with or without drugtherapy). A 2005 study in the Archives of Surgery found that weight losssurgeries in the U.S. rose from 12,775 in 1998 to 70, 256 in 2002, an increaseof 450 percent. According to the American Society for Bariatric Surgery, in2006, an estimated 177,600 people with morbid obesity had bariatric surgery inthe U.S.
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Bariatric surgery, or weight loss surgery, limits the amount of food thestomach can hold by surgically reducing the stomach's capacity to a fewounces. Some surgeries also alter the digestion process, curbing the amount ofcalories and nutrients absorbed.
"This study shows that the majority of these strictures can be managedsafely and effectively. Endoscopy remains the cornerstone of diagnosis andtherapy for this complication, and surgical revision is rarely necessary,"said the study's lead author Kevin J. Peifer, MD, clinical assistantprofessor, University of Illinois, College of Medicine at Rockford, Ill., andformerly an advanced endoscopic fellow at the Washington University School ofMedicine. "As the number of gastric bypass procedures grows, it will becomeincreasingly important for surgeons and gastroenterologists to recognize andtreat the complications that may arise."
Patients and Methods
Stricture of the gastrojejunal anastomosis is a common complication ofboth open and laparoscopic Roux-en-Y gastric bypass surgeries (the mostfrequently performed bariatric surgery for morbid obesity). In a single-center retrospective study of 801 morbidly obese patients who underwent Roux-en-Y gastric bypass surgery between 1997 and 2005 at the Washington UniversitySchool of Medicine, 43 patients developed anastomotic stricture.
Upper endoscopy was performed in patients who were vomiting, which raisedconcern for anastomotic narrowing, by using the standard gastroscope, with anouter diameter of 8.6 mm. A gastrojejunal anastomotic stricture was identifiedas a narrowing at the anastomosis that prevented passage of the gastroscope inthese symptomatic patients.
Results
Seventy-nine percent of patients were successfully managed with a singleballoon dilation. Ninety-three percent of patients were successfully dilatedwith one or two endoscopic sessions, all without perforation or significantbleeding. Only one patient in the study required surgery for revision of ananastomosis that was not responsive to endoscopic therapy.
At the Washington University School of Medicine, the anastomoticstrictures are routinely dilated to at least 15 mm during the initialendoscopy. Other groups have raised the concern that overly aggressivedilation of the stricture may all
