Version May 2024
INTRODUCTION — The performance of bariatric weight loss surgery is escalating in response to the obesity epidemic. Among the available bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are commonly performed procedures. (See "Bariatric procedures for the management of severe obesity: Descriptions".)
In the past, many of the adverse events that occurred following bariatric surgery were managed with repeat surgery, which was often associated with morbidity. Therapeutic gastrointestinal endoscopy offers a less invasive approach for treating postsurgical conditions such as stomal (anastomotic) stenosis. As a result, gastrointestinal endoscopists are often involved in the care of bariatric surgery patients.
This topic will review endoscopic evaluation for patients who have undergone bariatric surgery, highlighting endoscopy-guided interventions for complications related to bariatric surgery. The indications, preoperative evaluation, postoperative management, imaging, adverse events, and outcomes of bariatric surgery are discussed separately:
●(See "Bariatric surgery for management of obesity: Indications and preoperative preparation".)
●(See "Imaging studies after bariatric surgery".)
●(See "Bariatric surgery: Postoperative and long-term management".)
●(See "Bariatric operations: Early (fewer than 30 days) morbidity and mortality".)
●(See "Bariatric operations: Late complications with subacute presentations".)
An overview of upper gastrointestinal endoscopy including patient preparation is presented separately. (See "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)".)
Anesthesia and sedation for gastrointestinal endoscopy is presented separately. (See "Gastrointestinal endoscopy in adults: Procedural sedation administered by endoscopists" and "Anesthesia for gastrointestinal endoscopy in adults".)
INDICATIONS — Endoscopy plays an important role in the evaluation and management of postoperative upper gastrointestinal symptoms and adverse events following bariatric surgery [1-3]. Commonly encountered symptoms include abdominal pain, nausea, vomiting, and dysphagia [4-7]. The etiology of these symptoms can be multifactorial and may involve noncompliance with prescribed food choices and eating behaviors. An evaluation with endoscopy and/or radiographic imaging is warranted to identify the etiology of symptoms that persist despite behavior modification and to provide therapeutic intervention if needed. Evaluation is particularly important in patients who present within the first three to six postoperative months, since this is when most adverse events occur [4,6,8].
Other symptoms that are evaluated with endoscopy include weight regain, upper gastrointestinal bleeding, and reflux. The evaluation and management for patients with suspected adverse events related to bariatric surgery are discussed in more detail separately:
●(See "Bariatric operations: Early (fewer than 30 days) morbidity and mortality".)
●(See "Bariatric operations: Late complications with subacute presentations".)
ROUX-EN-Y GASTRIC BYPASS
Post-surgical anatomy — The expected endoscopic findings after Roux-en-Y gastric bypass (RYGB) (figure 1) include a normal esophagus and gastroesophageal junction (GEJ). (See "Bariatric procedures for the management of severe obesity: Descriptions", section on 'Roux-en-Y gastric bypass'.)
Examination of the stomach is limited to the gastric pouch, which varies in size, but is typically short (approximately 3 to 5 cm in length) and has a small volume (30 to 50 mL). The gastrojejunal anastomosis, or stoma, is generally 10 to 12 mm in diameter and should easily permit the passage of a diagnostic endoscope without resistance (picture 1). Distal to the anastomosis is a short, blind limb of jejunum alongside the efferent Roux limb, resulting in a "shepherd's hook" configuration [9]. The length of the Roux limb is variable, typically ranging from 100 to 150 cm. However, in the "distal bypass" modification, the Roux limb is extremely long, as the biliopancreatic limb is connected to the ileum approximately 150 cm proximal to the ileocecal valve. It is important that the endoscopist review the operative report and/or speak with the surgeon in the setting of "distal" gastric bypass, as there can be considerable variation in the limb lengths among surgeons and centers.
The endoscopic findings in the bypassed stomach have not been well characterized due to technical difficulties in reaching the bypassed stomach via transoral endoscopy. Based upon studies using double balloon enteroscopy, the majority of bypassed stomachs demonstrate gastritis (erosive, erythematous, atrophic, or hemorrhagic), even in patients with a normal preoperative endoscopy [10,11]. The clinical significance of the gastritis is uncertain.
The upper endoscopy report should include the following (figure 1):
●Distance from the incisors to the squamocolumnar junction
●Distance from the incisors to the gastrojejunal anastomosis
●Estimated diameter of the gastrojejunal anastomosis (stoma)
●Size of hiatal hernia (if present)
●Appearance of the gastric pouch staple line
●Extent of the endoscopic examination (distance from the incisors to the maximum depth of the visualized Roux limb)
●Whether the jejunojejunal anastomosis was reached
Endoscopic equipment — A standard upper endoscope can be used to evaluate patients with RYGB for procedures in which the extent of the examination is the gastric pouch or the proximal Roux limb (figure 2). However, a colonoscope or small bowel enteroscope may be needed to reach the jejunojejunal anastomosis, depending upon the length of the Roux limb.
Retrograde evaluation of the biliopancreatic limb and bypassed stomach is challenging in patients who have undergone RYGB, but can be accomplished in some cases with a colonoscope, a small bowel enteroscope, or a single or double balloon enteroscope [12-14].
Deep small bowel enteroscopy has been used to examine the bypassed stomach in patients who have undergone RYGB. The reported success rates have been as high as 88 percent, even in patients who have undergone long limb (up to 150 cm) RYGB [10,11,15,16]. Methods for deep small bowel enteroscopy include single or double balloon enteroscopy, and these methods are discussed in more detail separately. (See "Overview of deep small bowel enteroscopy".)
Balloon-assisted enteroscopy uses balloons attached to an overtube with or without a balloon at the tip of the enteroscope (figure 3). The balloons anchor the enteroscope and overtube, pleating the small bowel on to the overtube as the enteroscope is advanced through the small bowel.
Abnormal endoscopic findings
Risk factors — Factors that have been associated with greater likelihood for detecting an abnormality on endoscopic examination after RYGB include presence of selected symptoms (ie, dysphagia, nausea, vomiting, and upper gastrointestinal bleeding) and time interval since surgery (ie, within six months after surgery) [4-6]. In a study of 49 symptomatic patients, 85 percent had abnormal endoscopic findings within the first six postoperative months compared with 47 percent of patients evaluated after six months [4]. (See "Bariatric operations: Early (fewer than 30 days) morbidity and mortality", section on 'Risk factors and prevention'.)
Stomal (anastomotic) stenosis
●Clinical presentation – Stomal (anastomotic) stenosis or stricture most often occurs at the gastrojejunal (GJ) anastomosis or less frequently at the jejunojejunal anastomosis. Stomal stenosis manifests clinically when the anastomosis narrows to a diameter of <10 mm [17]. Symptoms associated with anastomotic stricture usually develop gradually. Typical symptoms include dysphagia, nausea, vomiting and early satiety but without abdominal pain [4,8,18].
Data have suggested that most strictures occur in two to three months after surgery. In a systematic review of 21 observational studies including 896 patients with GJ stricture, the mean time interval from surgery to either stricture diagnosis or intervention was 67 days (range 30 to 539 days) [19].
Patient-related risk factors for stomal stenosis include use of nonsteroidal anti-inflammatory drugs, tobacco, or alcohol [20]. Surgical factors include mechanical tension or ischemia at the anastomotic site.
●Diagnosis – Stomal stenosis is suspected in patients who present with nausea, vomiting, early satiety, and/or dysphagia after RYGB. However, the positive predictive value of these symptoms for stomal stenosis is approximately 40 percent, and endoscopic visualization is needed to confirm the diagnosis [4,21]. Anastomotic stricture is diagnosed with endoscopy when the stoma appears <10 mm in diameter and/or there is resistance to the passage of a diagnostic gastroscope (typical outer diameter 9 to 10 mm) through the GJ anastomosis (picture 2) [22]. Stomal stenosis may be associated with marginal ulceration, and the endoscopic examination also evaluates for coexisting ulceration. (See 'Gastrojejunal ulceration and bleeding' below.)
●Initial management – Endoscopic dilation is performed for most patients with anastomotic stricture following RYGB because endoscopic dilation using through-the-scope (TTS) balloons or (less commonly) wire-guided push (bougie) dilators is effective and safe. Most patients can be successfully treated within one to three endoscopic dilation sessions, and surgical revision is infrequently necessary [6,19]. If more than one endoscopic session is required, the time interval between sessions usually ranges from two to six weeks [19].
TTS balloon dilators are commonly used given their ease of use, safety, and the ability to perform multiple dilations under direct endoscopic visualization. Endoscopists should exercise caution when attempting to pass a balloon dilator beyond a tight stenosis (ie, anastomotic stricture that cannot be traversed by the gastroscope) because of the short blind stump of jejunum immediately (and sometimes directly) beyond the GJ anastomosis. In these situations, fluoroscopic guidance or use of a narrow-caliber endoscope (ie, outer diameter ≤6 mm) may be necessary.
The goal of endoscopic dilation is relief of symptoms by increasing the diameter of the stoma. The choice of dilator (size, type) is informed by the severity and initial diameter of the stenosis, the time since surgery, extent of endoscopic visualization, presence of marginal ulceration, and endoscopist preference. Studies describing the use of balloon dilators have utilized balloons ranging in size from 10 to 18 mm [6,23-29], with some suggesting an optimal goal for lumen diameter of 15 mm [3,23,25]. As an example, for a patient with a stomal stenosis with an initial diameter of 10 mm that can be traversed with the gastroscope, we usually begin dilation with a 10 mm TTS balloon and serially dilate with larger diameter balloons.
We generally target stomal diameter ranging from 12 to 15 mm, although a smaller diameter is acceptable if symptoms resolve. If symptoms do not resolve after the initial dilation session, we repeat the procedure in two to four weeks.
Technical aspects of dilation using balloon or wire-guided push dilators are discussed in more detail separately. (See "Endoscopic interventions for nonmalignant esophageal strictures in adults", section on 'Endoscopic dilation'.)
Perforation has been reported in approximately 2 percent of patients undergoing dilation for stomal stenosis [19]. The risk can be minimized by starting with a dilator that is approximately the diameter of the stoma and increasing the size gradually.
Endoscopic dilation of gastrojejunal anastomotic strictures is safe and effective with low overall complication rates. In a meta-analysis of 21 studies including 896 patients with gastrojejunal anastomotic stricture who had endoscopic dilation and were followed for mean duration of 25 months, the rate of symptomatic response was 97 percent [19]. Most patients responded to one endoscopic session for dilation, while 38 percent required more than one session. The overall rate of adverse events was 4 percent, and most adverse events were perforations (21 patients).
●Subsequent management – For patients who do not have symptomatic improvement with endoscopic dilation of stomal stricture, other endoscopic interventions have been reported, although their benefit is uncertain [1,28]:
•Removal of suture material at the site of the stenosis. (See 'Luminal suture material' below.)
•Needle-knife electrocautery incision of an obstructed stoma [6].
•Endoscopic stenting, but adverse events such as pain and stent migration have been commonly reported [30-32].
Patients with a chronic stomal stricture that is refractory to multiple endoscopic dilations generally require surgical revision of the GJ anastomosis. (See "Bariatric operations: Late complications with acute presentations", section on 'Stomal stenosis'.)
Stoma/pouch enlargement — Weight regain after bariatric surgery can be attributed to several mechanisms, most commonly lack of compliance with diet and exercise [33,34]. Enlargement of the gastric pouch or dilation of the gastrojejunal anastomosis (stoma) may contribute to weight regain after RYGB surgery by allowing more liberal food intake. A dilated stoma may also contribute to postprandial dumping syndrome by allowing rapid passage of food into the small bowel [35]. (See "Bariatric operations: Late complications with subacute presentations".)
Endoscopic techniques for reducing enlarged stomas or pouches include endoscopic mechanical devices (eg, suturing or plication devices, over-the-scope metal clips) and thermal therapy (eg, argon plasma coagulation) [36]. Selecting a technique is individualized and is informed by equipment availability, endoscopist preference, and stoma/pouch size.
●Mechanical methods – Reduction of stomal diameter and reversal of weight regain after RYGB may be achieved using mechanical methods such as endoscopic suturing devices or over-the-scope endoscopic clips. In a systematic review of 26 studies including 1148 patients who had full-thickness endoscopic suturing for weight regain after RYGB, the pooled absolute weight loss at three and 12 months was 8.5 ± 2.9 kg and 7.6 ± 4.3 kg, respectively [36].
Application of an endoscopic over-the-scope clip (OTSC, also referred to as a cap-mounted endoscopic clip) is another approach that may reverse weight gain due to a dilated pouch outlet. In a study of 94 patients, an OTSC system was utilized to reduce the gastric pouch outlet size in patients who, at two years after gastric bypass, had weight gain of at least 10 percent, redevelopment of comorbidities, increased volume per meal, or increased frequency of meals [37]. The mean diameter of the gastrojejunal anastomosis was reduced from 35 mm to 8 mm, an average reduction of approximately 80 percent. Although follow-up was limited, the results were promising in terms of weight loss, with a decline in mean body mass index (BMI) from 32.8 kg/m2 to 27.4 kg/m2 at one year after application of the OTSC. (See "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond", section on 'Uses for over-the-scope endoscopic clips'.)
●Thermal therapy – Argon plasma coagulation (APC) is an endoscopic thermal technique for treating weight regain by resurfacing the gastrojejunal anastomosis, and it is usually performed in combination with a mechanical method. Because of its safety, ease of performance, and wide availability, APC has largely replaced other nonmechanical methods such as sclerotherapy [38-41]. With this technique, focal coagulation injury is induced by applying APC directly onto the gastric mucosa circumferentially around the anastomosis. This may result in edema, ulceration, and eventually fibrosis, leading to reduction in the stomal diameter. Initial experience utilizing this technique has been promising, and small studies have demonstrated benefit in terms of reducing the stomal diameter and weight loss [42]. (See "Argon plasma coagulation in the management of gastrointestinal hemorrhage", section on 'Technique'.)
Anastomotic leak and fistula — Anastomotic leaks are the extravasation of luminal contents due to a disruption of the tissue at the surgical anastomosis, whereas fistulas are abnormal connections between two hollow organs (eg, gastrogastric) or a hollow organ and skin (eg, gastrocutaneous) [20]. Fistulas result from chronic healing of local inflammation caused by leaks. Clinical findings related to gastrogastric fistulas in patients who have undergone RYGB commonly include weight regain, marginal ulcers, and heartburn. While a large staple line dehiscence or fistula is usually easily identified with endoscopic visualization and may even allow passage of the endoscope into the bypassed/defunctionalized segment (picture 3), a small staple line dehiscence or fistula may have the appearance of a small diverticulum and may be easily overlooked. The clinical features, diagnosis and management of anastomotic leaks and fistulas following RYGB are discussed in more detail separately:
For patients who require endoscopic therapy for leak or fistula following RYGB, the choice of therapy is informed by factors such as size of the defect, presence of infection, hemodynamic status, available equipment and endoscopist expertise, while a consensus-based approach has not been established. Endoscopic methods for closing leaks and/or fistulas include:
●Self-expandable stents – Data are accumulating on the temporary placement of self-expandable stents (eg, fully covered metal stent) as an alternative to revisional surgery for anastomotic leaks and fistulas. However, conclusions cannot be drawn yet regarding optimal treatment protocol. In a systematic review of 15 studies including 149 patients with gastric bypass complicated by leak, placement of a self-expandable stent was associated with successful leak closure in 96 percent of patients (95% CI 91-100 percent) [43]. In an analysis of 493 patients who had self-expandable stents placed for leaks related to either gastric bypass or gastric sleeve surgery, stent migration was reported in 23 percent of patients (95% CI 19-28 percent). Measures to reduce the risk of stent migration include fixing the stent in place with sutures or with an OTSC. Other stent-related adverse events include gastrointestinal bleeding and pain.
●Clipping – An OTSC system is also an option for managing fistulas and leaks after bariatric surgery if the orifice size is ≤20 mm. In a systematic review of 17 studies including 85 patients who had OTSC placement for gastric leak or fistula after gastric bypass or gastric sleeve surgery, OTSC was associated with successful leak/fistula closure rate of 67 percent [43]. Adverse events were infrequently reported but included clip migration and gastric stenosis.
●Tissue sealants – Fibrin glue application is another technique that has been used in small series to successfully close fistulas after bariatric surgery, either alone or in conjunction with other techniques such as endoscopic clip placement, suturing, and/or stent placement [44-47]. In a systematic review of 10 studies including 63 patients with fistula, use of fibrin glue alone at a median of 13 days after bariatric surgery was associated with fistula closure rate ranging from 93 to 100 percent [43]. Complications related to fibrin glue were infrequently reported but included fever and pain [48].
Gastrojejunal ulceration and bleeding — Upper gastrointestinal bleeding that occurs early in the post-operative course (typically defined as bleeding occurring within 48 hours after surgery) usually arises from the staple lines (gastric pouch, excluded stomach) or anastomoses (gastrojejunostomy, jejunojejunostomy), whereas a marginal ulcer is suspected in patients who present with bleeding after the early postoperative period [49].
●Staple line or anastomotic bleeding – Endoscopic management of acute gastrointestinal bleeding in the early postoperative period can be challenging because of the risk of disrupting the still-immature staple lines and anastomoses, as well as the relative inaccessibility of the jejunojejunostomy and bypassed stomach. Thus, therapeutic endoscopy should be reserved for patients who develop bleeding associated with hemodynamic changes and do not respond to medical therapy. (See "Approach to acute upper gastrointestinal bleeding in adults".)
Successful endoscopic therapy of early postoperative bleeding arising from the gastric pouch, gastrojejunostomy, or jejunojejunostomy has been described in case reports and case series [50-53]. Endoscopic interventions for hemostasis, such as mechanical ligation with endoscopic clips, epinephrine injection, and thermal therapy, have been used in this setting. Hemostatic powder may be used as temporizing measure when active bleeding cannot be controlled with other methods. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Endoscopic therapy'.)
As an example, in a study including 30 patients with intraoperative, immediate (ie, within four hours of surgery) or early postoperative upper gastrointestinal bleeding after laparoscopic RYGB, 27 patients underwent endoscopy [50]. Endoscopic intervention was performed in 23 patients (85 percent) using epinephrine injection, heater probe, clips, or a combination of these methods. Rebleeding rates were high, with 16 patients (59 percent) experiencing a second episode of bleeding (five patients required a second endoscopy), and three patients experiencing a third bleeding episode. No patients required reoperation, and there were two procedure-related adverse events (aspiration and perforation at the gastrojejunostomy).
●Marginal ulcers – The diagnosis of marginal ulcer is usually confirmed with endoscopic visualization. Marginal ulcers occur at an anastomosis and are typically located on the posterior aspect of the jejunal side of the gastrojejunal anastomosis (picture 4). They may be associated with stomal stenosis or occur at sites where suture material is present.
Risk factors for and medical management of marginal ulcers are discussed separately. (See "Bariatric operations: Late complications with acute presentations", section on 'Marginal ulcers'.)
Patients with bleeding related to a marginal ulcer are managed similarly to patients with peptic ulcer bleeding. (See "Overview of the treatment of bleeding peptic ulcers".)
Luminal suture material — Unraveled nonabsorbable suture material within the lumen of the gastrojejunal anastomosis following RYGB can result in pain, marginal ulcers, and obstructive symptoms (secondary to food entrapment/bezoar formation) (picture 5) [6,54]. However, symptoms related to suture material are uncommon. In addition, during the last decade, luminal suture material is uncommon because most gastrojejunal anastomoses are stapled rather than hand-sewn.
Endoscopic intervention for unraveled nonabsorbable suture material is required only for symptomatic patients, and suture material that is incidentally found at the time of endoscopy is typically left in place [3]. Removal of suture material can be accomplished by cutting the sutures with endoscopic scissors and then extracting it with biopsy or rat-toothed forceps [6,54,55]. Although the clinical relevance of suture erosion is uncertain, one case series reported symptom resolution or improvement in over 80 percent of patients after removal of the eroded sutures [54].
Biliary obstruction — Rapid weight loss can contribute to gallstone formation. Endoscopic intervention for choledocholithiasis (stones in the common bile duct) can be challenging in some patients because of altered anatomy related to the Roux-en-Y configuration (figure 1). As a result, endoscopic retrograde cholangiopancreatography (ERCP) after RYGB requires a modified approach because the major papilla is not readily accessible via a duodenoscope that is advanced transorally due to the length of the bowel that must be traversed (table 1). Methods for performing ERCP in patients with Roux-en-Y anatomy are discussed separately. (See "ERCP in patients with Roux-en-Y anatomy".)
SLEEVE GASTRECTOMY
Post-surgical anatomy — Sleeve gastrectomy results in a long, tubular conduit along the lesser curvature of the stomach (figure 4). (See "Laparoscopic sleeve gastrectomy".)
A duodenal switch may be performed in conjunction with sleeve gastrectomy, which creates a duodeno-ileal anastomosis visible just distal to the intact gastric pylorus (figure 5). (See "Bariatric procedures for the management of severe obesity: Descriptions", section on 'Biliopancreatic diversion with duodenal switch'.)
Endoscopic equipment — A standard upper endoscope (gastroscope) can be used to evaluate patients following sleeve gastrectomy. (See "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)".)
Abnormal endoscopic findings
Stricture — Stricture of the gastric sleeve is one potential complication of sleeve gastrectomy [56,57]. Strictures are most often located at the level of the incisura angularis, or more proximally at the gastroesophageal junction, although they may develop at any point along the staple line. Some strictures are the result of torsional scarring along the staple line, which adds a twisting component to the stricture. An acute stricture typically presents with obstructive symptoms such as nausea, vomiting, and poor tolerance of oral intake. By contrast, patients with chronic strictures often present with symptoms such as acid reflux. The diagnosis of a gastric sleeve stricture can be confirmed with endoscopic examination or radiologic imaging with upper gastrointestinal series. Patients with short strictures who do not respond to medical management with proton pump inhibitors can be treated with endoscopic balloon dilation. The diagnosis and management of acute or chronic sleeve strictures are discussed in more detail separately. (See "Laparoscopic sleeve gastrectomy", section on 'Stricture'.)
Endoscopic dilation is typically performed with either a through-the-scope (TTS) or pneumatic balloon (eg, Rigiflex balloon). Choice of balloon (size, type) is informed by stricture characteristics (ie, location, initial diameter, length), response to previous dilation, equipment availability, and endoscopist preference [58]. More than one endoscopic session may be required to achieve symptomatic improvement, and for such cases, endoscopic dilation is generally repeated in two to four weeks. Technical aspects of endoscopic balloon dilation are discussed in more detail separately. (See "Endoscopic interventions for nonmalignant esophageal strictures in adults", section on 'Endoscopic dilation'.)
If symptoms do not resolve after dilating the stricture to a maximum diameter of 20 mm, further dilation with a pneumatic balloon (eg, Rigiflex balloon, diameter size, 30 mm) is an option. (See "Pneumatic dilation and botulinum toxin injection for achalasia", section on 'Pneumatic dilation'.)
Endoscopic balloon dilation is a minimally invasive alternative to surgical revision that appears to be safe and effective for treating focal strictures of the gastric sleeve [58,59]. In a systematic review of 18 studies including 426 patients with gastric sleeve stricture, endoscopic balloon dilation was associated with a symptom resolution rate of 76 percent (95% CI 67 to 86 percent) [58]. Among the studies that reported the type of balloon used, nine studies used a controlled radial expansion-TTS balloon and 12 studies used a larger pneumatic balloon, with some studies using both types of balloons. Serious adverse events occurred in four patients (0.9 percent) and included perforation that was managed surgically and gastrointestinal bleeding.
Technical aspects of endoscopic balloon dilation are discussed in more detail separately. (See "Endoscopic interventions for nonmalignant esophageal strictures in adults", section on 'Endoscopic dilation' and "Pneumatic dilation and botulinum toxin injection for achalasia", section on 'Pneumatic dilation'.)
Sleeve leak — A sleeve gastrectomy is more susceptible to postoperative leak than Roux-en-Y gastric bypass because of its long staple line and high intraluminal pressure that is generated by a narrowly-sleeved stomach sealed between the lower esophageal sphincter and an intact pylorus. However, sleeve leaks are generally uncommon [60]. Endoscopic therapy may be an option for patients with a sleeve leak who are hemodynamically stable, while the approach is informed by leak characteristics (eg, size, timing of onset), endoscopist expertise/preference, and equipment availability [61]. (See "Laparoscopic sleeve gastrectomy", section on 'Leak'.)
Endoscopic interventions that have been studied for gastric sleeve leaks include [43,61-63]:
●Stent placement – In a systematic review of 37 studies including 344 patients with gastric sleeve complicated by a leak, self-expandable metal stent (SEMS) placement was associated with successful leak closure in 92 percent of patients (95% CI, 88-95 percent) [43].
●Over-the-scope endoscopic clip (OTSC) closure – In a systematic review of 10 studies including 73 patients with gastric sleeve leak, OTSC placement was associated with successful leak closure in 63 patients (86 percent) [64]. Adverse events included a leak in 9 percent of patients and clip migration, stenosis, or tear, with each of those events occurring in 2 percent of patients.
ADJUSTABLE GASTRIC BAND
Post-surgical anatomy — Laparoscopic adjustable gastric banding (AGB) is a purely restrictive procedure that compartmentalizes the upper stomach by placing a tight, adjustable prosthetic band around the entrance to the stomach (figure 6). Endoscopy reveals a variable degree of extrinsic, circumferential compression on the proximal stomach/gastric cardia, usually within a few centimeters of the esophagogastric junction (picture 6). The remainder of the upper gastrointestinal tract appears unchanged. (See "Bariatric procedures for the management of severe obesity: Descriptions", section on 'Laparoscopic adjustable gastric banding' and "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)", section on 'Procedure'.)
Endoscopic equipment — A standard upper endoscope can be used to evaluate patients following purely restrictive procedures such as laparoscopic adjustable gastric banding. (See "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)".)
Abnormal endoscopic findings
Band erosion — Band erosion into the gastric wall is a potential complication of AGB surgery. Band erosion may be suspected in patients who regain weight after AGB or who develop abdominal pain, vomiting, gastrointestinal bleeding, intra-abdominal abscess, or fistula formation. (See "Bariatric operations: Late complications with subacute presentations", section on 'Band erosion'.)
Treatment for band erosion usually involves surgical removal of the eroded band, with or without a revisional bariatric operation. However, surgical therapy can be complicated because of an inflammatory reaction involving the proximal stomach and left lobe of the liver.
Endoscopic intervention for band erosion has been described as an alternative to surgical removal and has utilized several methods to transect the eroded band (eg, endoscopic scissors, band cutters) [65-68]. Most advanced endoscopists perform endoscopic band removal only if the buckle of the band is visible endoscopically (ie, it has eroded into the lumen of the stomach).
A two-step endoscopic technique has been described utilizing temporary, self-expandable plastic stent placement to promote full intragastric migration of the band (by causing pressure-induced necrosis between the band and gastric wall), followed by band transection and extraction [67]. Band transection is accomplished under endoscopic control by threading and gripping the band with a guidewire that is progressively tightened to cut the band.
Esophageal dilation — Esophageal dilatation proximal to the band device (or pseudoachalasia syndrome) may develop when the gastric band is excessively inflated or in the setting of excessive amounts of food intake. Patients may present with reflux symptoms or intolerance to liquids and solids. Esophageal dilation can be identified radiographically (eg, upper gastrointestinal series, computed tomography of the chest) but may also be appreciated on endoscopic examination [69-71]. This complication is not managed endoscopically, and treatment is discussed separately. (See "Bariatric operations: Late complications with subacute presentations", section on 'Esophageal dilatation or esophagitis'.)
SUMMARY AND RECOMMENDATIONS
●Indications – For patients who have undergone bariatric surgery, upper endoscopy is indicated for the evaluation of commonly reported symptoms such as abdominal pain, nausea, vomiting, and dysphagia. Other symptoms that are evaluated with endoscopy include weight regain, upper gastrointestinal bleeding, and reflux. (See 'Indications' above.)
The evaluation and management for patients with adverse events related to bariatric surgery are discussed in more detail separately:
•(See "Bariatric operations: Early (fewer than 30 days) morbidity and mortality".)
•(See "Bariatric operations: Late complications with subacute presentations".)
●Endoscopic findings – Expected endoscopic findings for patients after bariatric surgery are:
•Roux-en-Y gastric bypass – Examination of the stomach is limited to the gastric pouch that is approximately 3 to 5 cm in length (figure 1). The gastrojejunal anastomosis, or stoma, is generally 10 to 12 mm in diameter and should easily permit the passage of a diagnostic endoscope without resistance (picture 1). Distal to the anastomosis is a short, blind limb of jejunum alongside the efferent Roux limb, resulting in a "shepherd's hook" configuration. The length of the Roux limb is variable, typically ranging from 100 to 150 cm. (See 'Post-surgical anatomy' above.)
•Sleeve gastrectomy – Sleeve gastrectomy results in a long, tubular conduit along the lesser curvature of the stomach (figure 4). (See 'Post-surgical anatomy' above.)
•Adjustable gastric band – Placement of an adjustable gastric band results in a variable degree of extrinsic, circumferential compression on the proximal stomach/gastric cardia, usually within a few centimeters of the esophagogastric junction (picture 6). (See 'Post-surgical anatomy' above.)
●Adverse events related to Roux-en-Y gastric bypass – They include the following (see 'Roux-en-Y gastric bypass' above):
•Stomal (anastomotic) stenosis – For most patients with stomal (anastomotic) stricture, endoscopic dilation using a through-the-scope (TTS) balloon or less commonly, a wire-guided push dilator is performed because it is effective and safe. Choice of balloon (ie, type, initial size) is guided by several factors including stricture characteristics (eg, initial diameter), extent of endoscopic visualization, and endoscopist preference.
•Stoma/pouch enlargement – Endoscopic techniques for reducing enlarged stomas or pouches include use of a suturing or plication device, over-the-scope endoscopic clip, or thermal therapy.
•Marginal ulcer – Marginal ulcers are visualized endoscopically at an anastomosis and are often located on the posterior aspect of the jejunal side of the gastrojejunal anastomosis (picture 4). Patients with a bleeding marginal ulcer are managed similarly to patients with a bleeding peptic ulcer. (See "Overview of the treatment of bleeding peptic ulcers".)
•Biliary obstruction – Management of choledocholithiasis with endoscopic retrograde cholangiopancreatography (ERCP) after Roux-en-Y gastric bypass may be challenging because the region of the major papilla is difficult to access. Multiple approaches have been used to address this issue and are discussed separately (table 1). (See "ERCP in patients with Roux-en-Y anatomy".)
●Adverse events related to sleeve gastrectomy – They include the following (see 'Sleeve gastrectomy' above and "Laparoscopic sleeve gastrectomy"):
•Gastric sleeve stricture – For patients with a focal stricture of the gastric sleeve, endoscopic balloon dilation is an alternative to surgery.
•Gastric sleeve leak – For patients with gastric sleeve leak who are hemodynamically stable, the approach to endoscopic therapy is informed by leak characteristics (eg, size, timing of onset), endoscopist preference, and equipment availability. Endoscopic interventions such as stent placement or over-the-scope clip closure may be an alternative to surgery.
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