Tunnel Vision: Novel Treatment of an Anastomotic Stricture after Revisional Roux-en-Y Gastric Bypass Surgery
Bibliographic record
Abstract
Purpose: There are currently 220,000 bariatric surgical procedures performed yearly in the USA and Canada. The most complex procedures involve revision of prior bariatric surgery. Gastroenterologists are increasingly seeing patients postoperatively because of postoperative complications. This is a 47 year old male with a history of morbid obesity, obstructive sleep apnea, and severe nonischemic cardiomyopathy who had a vertical banded gastroplasty 27 years prior to referral for revisional surgery. His weight was 369 lb. with a body mass index (BMI) of 52. He underwent an open revision with formation of a hand sewn anastomosis in a Roux-en-Y gastric bypass complicated by the presence of extensive scarring of the proximal stomach. Postoperatively, the patient complained of dysphagia. An EGD performed 10 days after surgery revealed no outlet at the gastrojejunal anastomosis. Parenteral nutrition was started and CT scan of the abdomen revealed extensive fibrosis measuring 5 cm in length between the gastric pouch and the jejunal lumen. The patient then underwent open laparotomy with enterotomy to assist endoscopic balloon dilation and subsequent successful placement of a duodenal stent (Boston Scientific Wallflex duodenal stent, 9 cm × 2.2 cm). The patient tolerated a diet by mouth for 1 month after stent placement, but subsequently complained of recurrent dysphagia with nausea and vomiting. EGD at that time showed extensive tissue ingrowth at the stent. Balloon dilation was performed at this time, and was repeated 2 weeks later. At that time, the stricture was injected with 1 mL of triamcinolone (40 mg/mL) in each of 4 quadrants after balloon dilation. The patient then resumed a diet by mouth, discontinued parenteral nutrition, and required no further intervention. At 14 months after surgery, he has lost 119 lb. (BMI of 35). We herein report a case of an extremely recalcitrant anastomotic stricture after Roux-en-Y gastric bypass which was unique in that the fibrotic area was 5 cm in length, and was endoscopically stented by creating intraoperatively a tunnel between the gastric pouch and the jejunum. Gastroenterologists will continue to see increasing numbers of patients in the post-gastric bypass period. If possible, it is crucial to minimize risk factors for complications, and for GI physicians to work collaboratively with bariatric surgeons to develop new techniques for management of atypical complications.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.000 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".