Gastrojejunal stricture after gastric bypass and efficacy of endoscopic intervention

The Roux-en-Y gastric bypass procedure (RYGBP) is an effective treatment for morbid obesity. Anastomotic strictures are a common complication after RYGBP. This study examines the frequency of post-RYGBP gastrojejunal strictures (GJS), methods of evaluation, and the outcome of endoscopic intervention. Medical records of patients who had RYGBP for morbid obesity at our institution during four consecutive years were reviewed for patient demographics, medical comorbidities, surgical technique, and outcomes. Radiographic and endoscopic findings of those patients suspected to have GJS were noted. The impact of patient-related variables and surgical technique on risk of GJS, time to diagnosis of GJS, and treatment outcomes for GJS was determined. Of 888 patients, 503 had open RYGBP (57%) and 385 laparoscopic RYGBP (43%). Ninety-four patients (10.6%) underwent esophagogastroduodenoscopy (EGD) for possible GJS and 58 (6.5%) were found to have anastomotic stricture. Laparoscopic RYGBP was associated with increased incidence of GJS (43/385, 11.1%) compared with open RYGBP (15/503 or 2.9%, P = 0.0003). A total of 125 dilations were performed with an average of 2.2 dilations per patient. None of the strictures needed surgical revision. There were four perforations (3.2%) related to EGD. Mean time to diagnosis of GJS was 66.2 days. Eighty-seven of 94 patients underwent radiologic upper gastrointestinal (UGI) evaluation prior to EGD. UGI evaluation demonstrated a positive predictive value (PPV) of only 66% [95% confidence interval (CI) 52-77], and negative predictive value (NPV) of 83% (95% CI 65-93). Laparoscopic GBP is associated with increased risk of GJS. Endoscopic dilation of GJS is an effective treatment with minimal risk. Radiographic studies appear to have poor specificity for diagnosis of GJS and have a low positive predictive value. EGD should be performed in all suspected cases of GJS.