Clinical Success of Endoscopic Therapies for Management of Gastrojejunal Strictures Following Roux-En-Y Gastric Bypass Surgery: A Systematic Review and Meta-Analysis

Introduction: Gastrojejunal anastomotic strictures occur in up to 20% of patients following Roux-en-Y gastric bypass (RYGB). Through-the-scope balloon dilation (TTS-BD) is highly effective but multiple dilation sessions are required to achieve symptomatic improvement. Recently, lumen apposing metal stents (LAMS) have been utilized for these strictures with high clinical success rates. The primary objective was to assess the clinical success of TTS-BD and LAMS in the management of anastomotic strictures following RYGB. Methods: Individualized searches of all major databases were performed for studies evaluating TTS-BD and LAMS among patients with RYGB and gastrojejunostomy stricture. The primary outcome was sustained clinical success, defined as resolution of symptoms after endoscopic therapy without the need for surgical intervention. Results: A total of 23 included studies (n=1195) evaluated TTS-BD while 5 included studies (n=147) evaluated LAMS. Fifty-two percent of patients required one TSS-BD session, 23.8% required 2 sessions, and the remaining 23.5% required ≥3 dilations. The pooled clinical success rate for TTS-BD (Figure 1a) was 96.4% (95% CI: 94.5-98.3, I2=72.0%). A total of 1.9% patients required surgery due to failed response. Perforation following TTS-BD was seen in 1.5% cases. Among the patients that underwent LAMS, mean stent dwelling time was 84±56.6 days. Most patients required one stent placement (71.7%), while 28.3% required repeat stenting. The pooled clinical success rate for LAMS (Figure 1b) was 79.9% (95% CI: 58.5.2-100, I2:95.6%). A total of 6.8% patients required surgery; however, LAMS were utilized for anastomotic strictures refractory to TTS-BD in 80% of included studies. The rate of LAMS migration was 12.3% in reported cases. Finally, 3 studies directly compared TTS-BD vs LAMS and did not find a significant difference in clinical success between the two strategies (OR 3.23 (95% CI: 0.8-11.9, I2: 37.4%). Conclusion: Endoscopic techniques are highly effective in the management of gastrojejunal anastomotic strictures among patients with RYGB. The clinical success with TTS-BD and LAMS are similar; however, LAMS may potentially reduce the number of endoscopic sessions to achieve symptom improvement. Future prospective or randomized trial data comparing TTS-BM vs LAMS is needed to evaluate outcomes.Figure 1.: This meta-analysis was performed by calculating pooled proportions with rates estimated using random effects models and comparator studies evaluated using odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics.