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Objective assessment of luminal diameter and distensibility by an impedance planimetry system before and after pneumatic dilation in gastric sleeve stenosis
University of Michigan, Division of Gastroenterology and Hepatology, Ann Arbor, MichiganUniversity of Michigan, Department of Surgery, Ann Arbor, Michigan
Sleeve gastrectomy has increased in popularity in recent years. Despite its low adverse event rate, its increased prevalence has yielded an increase in the incidence of complications.
Depending on the severity of the stenosis, this complication commonly causes reflux, regurgitation, and obstructive symptoms such as nausea, vomiting, and abdominal pain.
Endoscopic balloon dilation, specifically using a pneumatic balloon, is the primary mode of management. However, there are limited existing diagnostic criteria to quantify the severity of the stenosis and to predict response to treatment. Impedance planimetry systems use a balloon catheter device, which is traditionally used to diagnose achalasia through measurements of lumen diameter and distensibility. This technology is being investigated in GSS as a means of quantifying severity of stenosis.
Functional lumen imaging probe is useful for the quantification of gastric sleeve stenosis and prediction of response to endoscopic dilation: a pilot study.
Here, we demonstrate the use of impedance planimetry as a means of objective assessment of gastric luminal diameter and distensibility before and after pneumatic dilation (Video 1, available online at www.giejournal.org).
A 64-year-old woman presented with a history of sleeve gastrectomy performed 3 years earlier. Her postoperative course was uncomplicated. She recalled subtle symptoms of nausea and reflux, which she attributed to her new anatomy, but overall felt well. Two years later, her symptoms progressed, and she developed persistent nausea, intermittent vomiting, regurgitation, and abdominal pain. Endoscopy demonstrated bilious fluid in the esophagus and gastric lumen with moderate to severe narrowing of the gastric lumen (Figs. 1 and 2). Before pneumatic balloon dilation, the impedance planimetry system catheter was advanced to the level of the gastric stenosis (Fig. 3), and measurements of diameter and distensibility were recorded (Fig. 4). The catheter was then removed, and a 30-mm pneumatic balloon was advanced under endoscopic and fluoroscopic guidance to the level of the incisura. The pneumatic balloon was inflated to reach a pressure per square inch of 20. Pneumatic balloon dilation was performed, with an expected ring of relative ischemia suggesting effective dilation (Fig. 5). The balloon was deflated and removed, and the impedance planimetry system catheter was reinserted. Measurements were again obtained after treatment and demonstrated improvement in diameter and distensibility (Fig. 6).
Figure 1Pooling of bilious fluid in the esophagus and proximal gastric lumen.
Figure 2Index endoscopy demonstrating a more patent proximal gastric lumen (A) with moderate to severe narrowing of the incisura/mid-body of the stomach distally (B).
Figure 6Postdilation impedance planimetry system measurements demonstrating improvement in diameter (19.4 mm) and distensibility (18.8 CSA mm2/mm Hg) in comparison to predilation measurement.
After the procedure, the patient was discharged home on the same day. She had considerable improvement of her symptoms, corresponding with the improved measurements obtained by the impedance planimetry system. She still experienced mild dysphagia and abdominal pain, so a repeat pneumatic dilation was performed 4 weeks later, again with improvement in impedance planimetry measurements. She has remained symptom free at over 6 months after these procedures.
In conclusion, objective assessment of luminal diameter and distensibility by impedance planimetry before and after pneumatic dilation is novel and technically feasible and may be a useful tool in evaluating response and predicting failures of balloon dilation in the treatment of GSS.
Disclosure
Dr Schulman is a consultant for Apollo Endosurgery, Boston Scientific, MicroTech, Olympus, and GI Dynamics and is a grant recipient for GI Dynamics. Ms Janes is a grant recipient of Beckman-Coulter. All other authors disclosed no financial relationships.
Functional lumen imaging probe is useful for the quantification of gastric sleeve stenosis and prediction of response to endoscopic dilation: a pilot study.
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