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1 From the Departments of Radiology (P.L.V., E.E.d.L., H.A.S.) and Surgery (B.S.), University of Virginia Health System, Lee St, HSC 800170, Charlottesville, VA 22908. From the 1999 RSNA scientific assembly. Received March 19, 2001; revision requested April 23; revision received June 25; accepted July 5.
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MATERIALS AND METHODS: Forty-one FGBDs were performed in 28 patients with symptoms of gastric outlet obstruction following gastric restrictive surgery for morbid obesity. The efficacy of FGBD was determined using five end points: (a) no recurring symptoms for an interval of at least 3 months, or recurring symptoms treated either (b) surgically, (c) with endoscopically guided balloon dilation (EGBD), (d) with FGBD, or (e) medically.
RESULTS: Following initial FGBD, 11 of 28 patients (39%) remained asymptomatic during at least 3 months of follow-up. Recurrent dysphagia occurred in 17 patients (60%), who were treated either surgically (n = 3), with EGBD (n = 4), with FGBD (n = 9), or medically (n = 1). Of the nine patients who underwent a second FGBD, two became asymptomatic. The seven patients who remained symptomatic were treated with surgery (n = 3), EGBD (n = 1), or FGBD (n = 3). Of the three patients treated with a third FGBD, one became asymptomatic. Overall, FGBD was effective in 14 (50%) of 28 patients.
CONCLUSION: Among patients with symptoms of obstruction following gastric surgery for morbid obesity, 50% experienced relief of symptoms following FGBD.
Index terms: Gastrointestinal tract, interventional procedures, 729.12168 • Interventional procedures, utilization • Obesity, 48.837 • Stomach, interventional procedures, 729.12168, 729.126 • Stomach, stenosis or obstruction, 729.458
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Fluoroscopically guided balloon dilation (FGBD) has also been shown to be effective in dilating anastomotic strictures of the gut (7–9). With this technique, the balloon catheter is advanced over a wire, positioned across the stricture, and inflated under fluoroscopic guidance. At our institution, FGBD is routinely performed to treat a variety of strictures of the gastrointestinal tract. The purpose of the current study was to retrospectively evaluate the efficacy of FGBD in patients with symptoms of gastric obstruction following surgery for morbid obesity.
| MATERIALS AND METHODS |
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On the basis of information gathered during the chart review, the following five end points were used to determine the efficacy of FGBD in treating symptoms of obstruction following gastric restrictive surgery for morbid obesity: (a) relief of symptoms following the procedure with no recurring symptoms and thus no subsequent intervention during a minimum follow-up of 3 months, (b) recurrence of symptoms following FGBD and subsequent treatment with surgical intervention, (c) recurrence of symptoms and subsequent treatment with EGBD, (d) recurrence of symptoms and treatment with repeat FGBD, and (e) development of symptoms believed by the surgeon to be of a nonmechanical cause (ie, persistent dysphagia, nausea, and vomiting despite normal radiographic or endoscopic findings that were not suggestive of obstruction) for which medical treatment was given.
Records were available for 29 of the 32 patients. One of the 29 patients had experienced relief of symptoms after FGBD, but less than 3 months of follow-up information was available, so this patient was excluded from the study. Thus, the study group consisted of 28 patients, including eight men and 20 women ranging in age from 22 to 66 years (mean, 41 years). Eleven of these patients were included in a previous study (7). Nine of the 28 patients had undergone vertical banded gastroplasty, and 19 had undergone gastric bypass surgery. Thirteen of the patients had previously undergone EGBD for dysphagia (performed by the surgeon who had performed the initial gastric surgery), and all patients were referred to our service for FGBD because of persistent symptoms. The time between the gastric surgery and the first FGBD ranged from 2.1 to 251 weeks (mean, 28.5 weeks).
Immediately prior to FGBD, esophagogastrography was performed in all patients to delineate the gastric outlet for planning the procedure. All FGBD procedures were performed by one of two experienced operators (E.E.d.L., H.A.S.) with the technique described previously (7,8). Before the procedure, written and verbal informed consent were obtained from each patient. Local anesthesia was provided with benzocaine 20% oral spray (Hurricane; Beutlich, Waukegan, Ill). Conscious sedation was obtained with 1 to 4 mg of intravenous midazolam hydrochloride (Roche Laboratories, Nutley, NJ) and/or 12.5–25.0 mg of intravenous promethazine hydrochloride (Phenergan; Wyeth-Ayerst Laboratories, Philadelphia, Pa). Intravenous analgesia was provided with 25–50 mg of meperidine hydrochloride (Demerol; Sanofi Winthrop Pharmaceuticals, New York, NY) or 20–100 µg of fentanyl citrate (Sublimaze; Taylor Pharmaceuticals, Decatur, Ill).
Each FGBD procedure began with the oral insertion of a shortened feeding tube or curved angiographic catheter that was advanced across the strictured gastric outlet. A straight or J-shaped guide wire (Cook, Bloomington, Ind) was inserted through the feeding tube or catheter into the gut distal to the stricture. The feeding tube or catheter was then exchanged for a 20-mm diameter angioplasty-type polyethylene balloon catheter (Medi-tech/Boston Scientific, Watertown, Mass), which was advanced over the guide wire. The balloon was carefully positioned so that its midportion straddled the narrowed outlet portion of the gastric pouch. Under fluoroscopic control, the balloon was subsequently inflated with diatrizoate meglumine (Hypaque 60%; Nycomed, Princeton, NJ) diluted to 1/3 concentration with normal saline.
As the balloon was inflated, a "waist" appeared in the midportion of the balloon at the level of the anastomosis in all cases. In our experience, such a waist is nearly always seen at an anastomosis, including anastomoses in patients who have undergone surgery for morbid obesity. The balloon was further inflated until the waist disappeared and was kept inflated for 1–3 minutes. In all cases, the pressures required to eliminate the waist never exceeded 3 atm (3 x 105 Pa), the maximum pressure recommended by the manufacturer of the catheter. Pressure was monitored with an in-line pressure gauge. Each dilation procedure consisted of two to three inflations of the balloon. The balloon was deflated for a 1-minute interval between each inflation.
Following the final dilation, the balloon was fully deflated and the guide wire was removed. The balloon catheter was then withdrawn across the dilated area while 300 milligrams of iodine per milliliter (iohexol, Omnipaque; Nycomed, Princeton, NJ) was injected through the main lumen of the catheter to allow the operator to verify that neither perforation of the gut nor disruption of the anastomosis had occurred. Because postprocedure contrast material–enhancement techniques are not accurate in assessing the effectiveness of the procedure, we used such a technique solely to evaluate for complications (7). The entire procedure typically required approximately 30 minutes.
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| DISCUSSION |
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The effect of EGBD on patients who have gastric obstructive symptoms after surgery for morbid obesity has been studied. In one series of 655 patients who had undergone either vertical banded gastroplasty or gastric bypass surgery, 40 developed gastric outlet obstruction (4). An initial EGBD provided relief of symptoms in 22 of these patients (55%) during follow-up of 4 months to 4 years. In another series of 180 patients, 15 developed gastric outlet obstruction (5). Six of the 12 patients (50%) who underwent EGBD had relief of symptoms during follow-up of 4 months to 2.8 years after a single dilation. In another series involving 541 patients, 22 developed gastric outlet obstruction; eight of the 22 patients (36%) experienced relief of symptoms following EGBD during follow-up of 2.5 to 5 years (6).
FGBD has also been used for treatment of gastrointestinal strictures. In one series, 92 patients with strictures of the gastrointestinal tract underwent one or more FGBDs (9). Among these patients, clinical follow-up in 80 showed that 66 (83%) remained asymptomatic after 1 year following the final FGBD. However, no data were presented showing the clinical outcome of a single FGBD procedure, and none of the FGBDs were performed to treat obstructive symptoms following gastric surgery for morbid obesity. In another series of 20 patients who had various gastrointestinal strictures but who had not undergone surgery for morbid obesity, nine (45%) experienced relief of symptoms following a single FGBD (10).
To our knowledge, there have been no studies specifically addressing the effect of FGBD in patients with gastric outlet obstruction following gastric surgery for morbid obesity. However, our early experience with FGBD included 24 patients who had undergone gastric surgery. Fifteen of these patients had undergone either gastric bypass surgery or vertical banded gastroplasty for morbid obesity, and 11 are included in the current series of 28 patients (7).
The reported results of FGBD are comparable to those for EGBD. However, EGBD potentially involves a greater risk of incurring a complicating laceration or perforation, because in EGBD, only the gut proximal to the stricture is visualized after the dilator enters the stricture (11). As a result, the relatively sharp tip of the balloon catheter cannot be seen, and iatrogenic laceration or perforation of the wall of the gut could occur when the catheter is advanced. Fluoroscopy allows visualization of both the stricture and the gut beyond it, thereby permitting visual control of the entire balloon catheter and its tip during placement and inflation. FGBD also permits immediate postprocedure injection of contrast material, allowing the operator to visually check for iatrogenic perforation or laceration of the gut. On the other hand, FGBD involves the use of ionizing radiation but EGBD does not.
A limitation of this study was that evaluation of the efficacy of FGBD was determined in a retrospective fashion. As a result, our study did not allow prediction of which patients would benefit most from FGBD. In addition, the criteria for obstructive symptoms were based on the relatively subjective assessment of a surgeon experienced in surgery for morbid obesity. Nevertheless, the results of this study indicate that in patients with symptoms of gastric outlet obstruction following surgery for morbid obesity, FGBD is safe and easy to perform and may result in effective treatment of the symptoms.
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