Anastomotic stenosis after Roux-en-Y gastric bypass: A rational approach to treatment.

BACKGROUND: Anastomotic stenosis, a common sequela to Roux-en-Y gastric bypass, has a reported incidence of 1.6-27% and recurs in 17-33%. No universal guidelines for optimal treatment exist. The aim of this study was to develop guidelines to treat stenosis that achieve the lowest rate of recurrence while avoiding the complications of excessive dilation. METHODS: This prospective 2-part study enlisted consecutive patients undergoing Roux-en-Y gastric bypass who developed an anastomotic stenosis. In the first part, all patients, regardless of the grade of stenosis, underwent dilation to 12 mm and were followed up for recurrence. In the second part, patients underwent dilation according to the grade of stenosis (12 mm for low, 13.5 mm for medium, 15 mm for high) and were followed up for recurrence. RESULTS: Among 1345 consecutive Roux-en-Y gastric bypass patients, 204 developed an anastomotic stenosis (15.2%). No differences were found in gender, mean age, preoperative body mass index, or weight loss at 1 year. In part 1, the recurrence rate for low-, medium-, and high-grade stenosis was 2.6%, 34.4%, and 35.9%. In part 2, the corresponding rates were 9.7%, 26.3%, and 43.6%. The corresponding mean number of additional dilations per patient with recurrence in part 1 was 1.0, 1.5, and 2.1 and, in part 2, were 1.0, 1.0 and 1.2. CONCLUSION: The results of this study have shown that the stenosis grade can predict the risk of recurrence and determine the optimal balloon size. Definitive treatment was achieved in >90% of patients with low-grade stenosis dilated to 12 mm. Medium- and high-grade stenosis predicted > or =25% recurrence, but increasing the balloon size reduced the number of additional dilations required for patients with recurrence.