Intraoperative Prevention of Stenosis for Laparoscopic Sleeve Gastrectomy
Ramon Vilallonga, MD, PhD, Jacques Himpens, MD
Division of Bariatric Surgery, AZ St. Blasius, Dendermonde, Belgium (all authors).
Introduction: Many different medical and surgical modalities have been described for the treatment of late strictures after laparoscopic sleeve gastrectomy (LSG), including observation, endoscopic dilatations, seromyotomy (SM), and wedge resection of the sleeve stomach including the stricture. Strictures after LSG are preventable with the appropriate surgical technique of the LSG: when stenosis is apparent perioperatively, SM or stricturoplasty (SP) of the stenosis may be performed at that time to prevent the development of a stricture.
Case and Technique Description: We present two cases. The first is a 30-year-old morbidly obese woman (body mass index 40 kg/m2) who underwent an LSG at our institution. Stapling was performed over a 34-Fr bougie. After complete transection, a stenosis of the sleeve was observed in the upper part of the stomach. An SP, including a full-thickness longitudinal incision, was performed over the stenotic area and then closed transversely with a full-thickness running suture of resorbable monofilament material 2/0.
The second case is of a 29-year-old woman (body mass index 36 kg/m2) who had a revisional surgery with an adjustable gastric band removal and an LSG performed in one stage at the end of the procedure. A stenosis was detected at the level of the incisura angularis, hence an SM was performed.
In both patients, an omental patch was added over the SP and SM. A drain was left in the abdominal cavity along the SG and remained until discharge from the hospital. A nasogastric tube was placed per routine for 24 hours. The postoperative courses were uneventful for both patients, and they were discharged at postoperative days 3 and 4, respectively.
Conclusion: An intraoperative approach for iatrogenic stenosis in the primary LSG may include SM and SP. Both techniques are challenging and should avoid chronic and long-term complications related to stenosis during primary LSG.
Key Words: Sleeve gastrectomy, Stricture, Stenosis, Stricturoplasty, Complications management.