Balloon Dilation Seems Safe, Effective for Sleeve Gastrectomy Stenosis

By Marilynn Larkin

December 12, 2019

NEW YORK (Reuters Health) - Endoscopic balloon dilation (EBD) appears to be a safe, minimally invasive alternative to surgical revision for sleeve gastrectomy stenosis (SGS), a systematic review and meta-analysis reveals.

"Esophageal reflux disease and development of pre-cancerous Barrett's esophagus are the most common complications of sleeve gastrectomy that we see as gastroenterologists," Dr. Christopher Thompson of Brigham and Women's Hospital in Boston told Reuters Health by email. "Stenosis of the gastric sleeve presents with more severe symptoms, including inability to tolerate food, nausea, vomiting, reflux symptoms, and abdominal pain."

"This condition has traditionally required surgical revision," he said. However, a relatively new endoscopic treatment has emerged.

Dr. Thompson and colleagues searched the literature through July 2018 on outcomes of EBD for SGS. As reported in Gastrointestinal Endoscopy, among the initial 205 identified citations, 18 studies were analyzed, including 426 patients from the U.S., France, New Zealand, Kuwait, Egypt, Brazil, Romania, Israel, and Taiwan.

Overall, participants' average age was 41.7 years, about 70% were women, the average body mass index was 40.1, and the average number of dilations was 1.8 per person.

Seventeen studies reported the type of balloon; nine used the controlled radial expansion balloon, 12 used the Rigiflex II balloon, and some studies used both types. Balloons were selected based on availability, physician experience, or accessibility of the stricture site.

The overall EBD success rate was 76%. Success was achieved in 90% of proximal and 70% of distal SGS cases.

Obstructive symptoms typically presented weeks to months after laparoscopic SG. Success rates were 59% for early SGS (within three months of the procedure) and 61% for late SGS.

Lack of response to EBD required subsequent stent placement or revisional surgery. Seventeen percent of patients underwent secondary salvage surgery, with a success rate of 91%.

The authors conclude that EBD "should be used as first-line therapy for SGS."

Dr. Thompson said, "To minimize complications, it is important to not use large pneumatic balloons in the first several weeks following surgery. It is best to be cautious in this early time period and to use smaller hydrostatic balloons."

"Additionally, when using pneumatic balloons, it is also important to start with the smaller 30 mm balloons and use a staged approach, never increasing balloon size in a single session," he said. "It is also important for centers that adopt this approach to have experience in advanced endoscopic techniques to minimize the risk of, and best handle, complications should they arise, including advanced hemostasis techniques and suturing for the management of perforations."

Dr. Varun Kumar, a medical gastroenterologist at CareMount Medical in New York, commented in an email to Reuters Health, "The success rate of 76% is very encouraging, with only 17% of patients requiring a salvage procedure."

"This is a retrospective study, which has its own underlying limitations," he said. "However, it appears that patients with a proximal stenosis may benefit the most from balloon dilation. The 1% complication rate of GI bleeding and perforation is something to be discussed at length with patients prior to procedure. However, I believe this to be an acceptable risk percentage."

The cost of an endoscopic balloon dilation is likely to be significantly less than surgical resection or stent placement, he noted, although additional studies are needed to assess this.

"Clinician experience as well as availability were the determining factors on the size and length of the balloons that were used during the procedure," he added. "This issue needs to be standardized with future studies."

"At this time, this type of procedure should be done in a bariatric center of excellence with a gastroenterologist who has experience with balloon dilation, along with a surgeon who is readily available in case of complication or failure," he concluded.

SOURCE: Gastrointestinal Endoscopy, online November 27, 2019.