Marginal or Stomal Ulcers

Marginal or stomal ulcers are ulcerations at the gastrojejunostomy that frequently occur on the jejunal side of the anastomosis (Fig. 52.1). Marginal ulcers may be seen in 16% of patients after Roux-en-Y gastric bypass (RYGB).² Many ulcers remain subclinical, and the true incidence is likely higher. Ulceration can occur at any time but patients usually present within 3 months of surgery with pain, nausea, bleeding, or perforation.^3,4 Several potential and controversial inciting factors are implicated, including gastrogastric fistula, large gastric pouch with inclusion of parietal cells and resultant acid exposure, ischemia, foreign body reaction to staples or nonabsorbable sutures at the anastomosis, Helicobacter pylori, nonsteroidal anti-inflammatory drugs (NSAIDs), and gastric pouch orientation.^5–7 The etiology is probably multifactorial with ischemia the likely culprit. Preoperative H. pylori testing and eradication is not routinely recommended because of conflicting data that this practice reduces the incidence of marginal ulceration.^8,9 During upper endoscopy, the gastric pouch should be closely inspected for a gastrogastric fistula, and biopsy specimens should be obtained for H. pylori. Patients usually respond to treatment with proton pump inhibitors, liquid sucralfate, and H. pylori eradication therapy when appropriate.^10,11 NSAIDs should be avoided, and smoking should be discontinued. Endoscopic removal of foreign material, such as nonabsorbable suture or staples, may help ulcer resolution. In cases of symptomatic refractory ulceration, surgical revision may be required.

Fig. 52.1 Marginal ulceration on the gastric side of the gastrojejunostomy.

Stomal Stenosis

Stomal stenosis is an important complication that occurs in approximately 3% to 12% of patients after open RYGB and in 11% to 27% of patients after laparoscopic RYGB.^2,4 Most strictures occur within the first year after surgery, with a mean time interval of 2 to 3 months to diagnosis.^12,13 Patients present with nausea, vomiting, pain, or dysphagia. The exact mechanism for stricture formation is unknown, but ischemia, ulceration, subclinical anastomotic leak, circular stapler size, and surgical expertise are potential contributing factors.^13,14 The gastrojejunostomy is intentionally created to be 11 to 15 mm in diameter. Although there is no clear definition for stomal stenosis, the latter is diagnosed when the luminal diameter is less than 10 mm or when passage of a standard upper endoscope through the anastomosis is met with resistance (Fig. 52.2).

Fig. 52.2 Stomal stenosis.

In cases of symptomatic strictures, serial dilation using a through the scope balloon dilation catheter is preferred with the goal of achieving a stomal diameter of 10 to 12 mm. Dilation should not exceed 15 mm. The initial balloon size is based on the estimated diameter of the anastomotic stricture. Three sequential sizes may be inflated during one session, in keeping with the recommended “rule of 3’s” for stricture dilation. An effective dilation results in partial disruption of the anastomotic wall. Caution is warranted in the setting of coexistent marginal ulceration because of increased risk of perforation. Overzealous dilation, which can result in perforation or an overstretched anastomosis with resultant dumping syndrome and regain of weight, should be avoided. When a tight stricture precludes traversal with the endoscope and impairs visualization of the postanastomotic jejunal limbs, wire-guided through the scope balloon dilation under fluoroscopy is recommended. The reported perforation rate after balloon dilation approximates 2% to 3%.^13,15 Small perforations can be managed conservatively.

Most (>90%) strictures are responsive to endoscopic balloon therapy.^12,16 Most strictures can be effectively dilated in one or two sessions, but tight strictures may require several sessions. The time interval between sessions ranges from 1 to 3 weeks.^15,16 The successful use of bougie dilators has been reported, but this technique requires guidewire placement within the jejunal Roux limb before dilation.¹⁷ Although temporary placement of a fully covered stent in selected patients with refractory strictures may be successful at achieving long-term stoma patency, a high rate of stent migration (>50%) has been observed in some studies (Fig. 52.3).¹⁸ If stent placement is contemplated, it is best to avoid dilating the stricture before stent placement to minimize the risk of migration. The duration of stent placement is typically 3 months. Other therapeutic techniques, including needle-knife electroincision of the anastomosis (which carries an increased risk of perforation) and intralesional steroid injection after balloon dilation, have been reported with some success.^19,20 In the rare case in which endoscopic therapy is ineffective, surgical revision may be necessary. Patients with a modified RYGB with a Silastic ring around the proximal pouch to prevent dilation of the gastrojejunostomy may require surgical removal or replacement of the band.

Fig. 52.3 A, Enteral stent across gastrojejunostomy stricture. B, Fluoroscopic image shows fully covered stent traversing the gastrojejunostomy stricture immediately after deployment; arrows indicate the waist of the stricture.

Gastrogastric Fistula

The reported incidence of staple line dehiscence with resultant gastrogastric fistula varies with the extent of division of the excluded stomach and is greater than 20% when the gastric pouch and bypassed stomach are undivided or partially divided to less than 5% when the segments are completely transected.^21,22 Gastrogastric fistula denotes an abnormal communication between the neogastric pouch and the bypassed stomach. There are several postulated reasons for the development of fistulas, including surgical technique without complete division of the gastric pouch, marginal ulceration, anastomotic leak, and foreign body erosion.^21,23 Even when the pouch is completely transected, a gastrogastric fistula can occur if the pouch is situated in close proximity to the bypassed stomach. Surgical interposition of omentum or a loop of jejunum between the segments may reduce this complication.²⁴ Patients usually present with regain of weight, abdominal pain, or reflux symptoms. When a gastrogastric fistula is suspected, diagnosis is confirmed by upper endoscopy, upper gastrointestinal (GI) series, or in some instances abdominal computed tomography scan with oral contrast agent.

Gastrogastric fistulas are frequently small and easily overlooked. Endoscopically, a small gastrogastric fistula can appear as a diverticulum in the gastric pouch; larger fistulas allow endoscope passage into the excluded stomach (Fig. 52.4). When gastrogastric fistulas are associated with marginal ulceration, gastric biopsy specimens for H. pylori should be obtained. Barium studies are helpful in diagnosing small dehiscences. Most symptomatic patients require surgical intervention. However, in patients with small gastrogastric fistulas and associated marginal ulcers, an initial conservative approach consisting of proton pump inhibitor therapy, liquid sucralfate, or H. pylori eradication, as appropriate, may be effective.^21,23 NSAID use and smoking should be strictly avoided. Patients are reevaluated after 4 to 8 weeks; if the fistula is healed, long-term use of a proton pump inhibitor is advised.^21,23 In patients with small gastrogastric fistulas (<5 mm) who are unresponsive to medical therapy, endoscopic therapy, in the form of endoscopic suturing, argon plasma coagulation, fibrin glue injection, hemoclip application, or a combination thereof, may be considered given the reported successful outcome in small case series.^23,25,26 Long-term follow-up data are awaited before any particular endoscopic therapy can be formally recommended for this select group of patients.

Fig. 52.4 A, Small diverticulumlike gastrogastric fistula (arrow). B, Large gastrogastric fistula (arrow).

Gastrointestinal Bleeding

Early bleeding is uncommon after open bariatric surgery (<1%) compared with laparoscopic RYGB (1% to 4%).^27–30 Bleeding is generally from the gastrojejunostomy. Endoscopic management of an early postoperative bleed is challenging because of the risk of perforation at the surgical anastomosis. In this setting, air insufflation should be minimized, and the use of nonthermal hemostatic devices, such as endoscopic clips, is preferred. Close collaboration with the surgeon is key for a successful outcome. Hematemesis is the most common clinical presentation in early bleeds.³¹ GI bleeding that occurs beyond the early postoperative period tends to occur from staple lines at the gastrojejunostomy (e.g., marginal ulcers), jejunojenunostomy, or bypassed stomach. Most patients are managed successfully with appropriate endoscopic therapy. Endoscopic therapy is achieved by standard hemostatic interventions such as injection, thermal, or mechanical modalities. Discontinuation of NSAIDs and testing for H. pylori serology are advised. Deep enteroscopy (e.g., balloon-assisted enteroscopy) is generally required to access the jejunojejunal anastomosis and enable retrograde examination of the bypassed stomach and duodenum. Patients presenting with obscure GI bleeding should be investigated for causes not related to the surgery, such as colonic pathology.

Food Impaction

Inadequate chewing and rapid ingestion of large food boluses, stomal stenosis, and motility disturbances result in food impaction.^32,33 Retrosternal or abdominal pain and dysphagia are presenting symptoms. Food disimpaction is usually achieved by cautious push of the impacted food with the tip of the scope into the jejunal limb. Otherwise, piecemeal extraction through an overtube becomes necessary using accessories such as snares, nets, and grasping forceps. Care must be exercised not to traumatize the gastric pouch, anastomosis, or jejunal limbs. Gastric bezoars are a rare complication.³⁴

Choledocholithiasis

Rapid weight loss predisposes bariatric patients to cholesterol gallstones. Within 6 months of surgery, 36% of patients develop new gallstones, and an additional 10% develop biliary sludge.^5,35–37 Several causative factors have been suggested, including altered bile composition, cholesterol supersaturation of bile, gallbladder dysmotility, and loss of duodenal induced stimulation of gallbladder emptying.^35–39 Although gallstones are prevalent in morbidly obese individuals, there is no consensus on the need for prophylactic cholecystectomy. Cholecystectomy is generally performed in open RYGB but is not standard practice in laparoscopic RYGB, unless gallstones are diagnosed preoperatively. Elective cholecystectomy during bariatric surgery may contribute further to the symptoms of diarrhea and intolerance to fatty foods, and the occurrence of postoperative bile leaks poses a considerable challenge in these patients, in whom endoscopic retrograde cholangiopancreatography (ERCP) is unsafe in the immediate postoperative period and a transhepatic approach is difficult in the absence of biliary dilation.^19,40

Although new gallstones may be common, symptomatic gallstones occur infrequently (7%), and subsequent cholecystectomy is usually well tolerated in these patients.^41,42 Choledocholithiasis after gastric bypass is uncommon. Diagnosis is usually based on abnormal liver tests, transabdominal ultrasound, or magnetic resonance cholangiopancreatography. Performing ERCP in these patients is a challenging and arduous task. The procedure may be attempted by using a pediatric colonoscope, a balloon-assisted enteroscope, or a duodenoscope back-loaded onto a guidewire. Alternatively, a duodenoscope may be passed through a surgical, radiologic, or endoscopically guided gastrostomy or through a gastrogastric fistula.^43,44 Laparoscopy-assisted transgastric ERCP allows quick access to the common bile duct with visualization of the papilla in the usual anatomic orientation.⁴⁵

Anastomotic Leaks

Reported rates of anastomotic leaks are 0 to 5.6%.^46,47 Endoscopy should be avoided in early anastomotic leaks, which can be life-threatening and may be associated with signs of toxicity such as tachycardia, fever, and leukocytosis. There is an increased risk of leak exacerbation or wound dehiscence with endoscopy. The mainstay of treatment is sepsis control and supportive care or surgical exploration in patients who are unstable.^19,48 If the leak develops late with no signs of toxicity, endoscopic approaches may be considered. Enteral stents are an alternative therapeutic option with reported success.⁴⁹ Data on the use of temporary enteral stent placement, fibrin glue, and hemoclips to seal leaks are limited.^50,51 Additional long-term outcomes data are required before firm recommendations can be made on the efficacy and safety of these procedures in this setting.

Band Erosion

Band erosion occurs in 1% to 11% of patients.^2,52 Patients can present with infection at the access port site, pain, vomiting, bleeding, abdominal abscess, fistula, or sudden weight gain. Endoscopic removal of a near-complete penetration of a gastric band has been described, but surgical removal is strongly recommended.⁵³ Caution must be exercised if endoscopic removal of a gastric band is considered, especially when the penetration through the gastric wall is incomplete because this carries a high risk of gastric perforation and peritonitis.

Pouch Dilation

The gastric pouch may dilate in approximately 12% of patients after laparoscopic adjustable gastric banding owing to proximal herniation of the stomach.^5,54 Deflation of the band resolves this problem in most cases. Endoscopy is of no therapeutic value in this setting.

Gastroesophageal Reflux Disease

Acid reflux is common with a reported increase in acid regurgitation from 13% to 69% after band placement.⁵⁵ The prevalence of postoperative esophagitis was 75% in one study.⁵⁵ Initial management consists of acid suppression therapy combined with sucralfate; surgical revision is considered in unresponsive patients.

Band Erosion

Approximately 1% to 2% of patients with vertical banded gastroplasty develop band erosion.^2,56 Patients tend to present with weight gain and to a lesser extent abdominal pain. Surgical consultation should be sought in these patients, who generally require reoperation or conversion to RYGB.

Staple Line Dehiscence

Staple line disruption in vertical banded gastroplasty results in failure to lose weight rather than ulceration. Staple line dehiscence has been described after blunt abdominal trauma.⁵⁷ Endoscopy is helpful in diagnosing and evaluating the disruption. Patients should be referred for surgical revision to RYGB.

Pouch Dilation

Pouch dilation can occur as a consequence of band erosion, stomal obstruction, or staple line dehiscence. Endoscopy is the modality of choice for diagnosis before surgical intervention.

Anastomotic Leaks

Data are limited on the endoscopic management of anastomotic leaks after sleeve gastrectomy alone or in combination with duodenal switch. Similar to leaks seen with other bariatric procedures, operative treatment is the mainstay for patients with signs of sepsis and hemodynamic instability unresponsive to conservative management. Successful treatment of gastric leaks at the gastroesophageal junction using temporary coated self-expanding stents in stable patients was reported in a small study.⁵⁸

Fistulas

A study using partially covered self-expanding metal stents to treat gastrocutaneous and duodenocutaneous fistulas reported a success rate in 66% of patients.⁵⁹ More than one stent was required in some cases to achieve fistula closure.

Gastric Sleeve Stricture

Endoscopic balloon dilation and temporary placement of covered self-expanding stents are options for therapy. However, experience is limited, and there is a paucity of data regarding the long-term success of these approaches.⁵⁸