24 // THE NEW GASTROENTEROLOGIST WINTER 2017
PRACTICAL TEACHING CASE
The correct answer is B: endoscopic suture remov- al. As the prevalence of bariatric surgery increas- es to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbar- iatric patients.1 In one case series of patients un- dergoing EGD for upper GI symptoms post-RYGB,
normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in
4%, and gastro-gastric fistula in 2.6% of cases. 2 Another
series reported unraveled suture material thought to be
contributing to upper GI symptoms in up to 10% of cases. 3 Suture material is found by a mean of 34 weeks after
RYGB, and presenting symptoms include abdominal pain
in 65%, nausea 52%, dysphagia 22%, and melena in 13%.
Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a
mechanical obstruction to foodstuff as it passes through
the gastrojejunal anastomosis. A series of 29 therapeutic
endoscopic suture removal cases reported resolution or
improvement of symptoms in 83% of patients and no
complications or anastomotic leaks. 3
Tools available for suture removal are diverse (Figure
B) and should be selected based on the appearance of the
unraveled suture material. First, when possible the suture
material should be untangled to allow for examination of
the number and location of sutures involved, as well to
evaluate the underlying mucosa for defects or ulceration.
In the best case, more sutures may be removed if a grasp-
ing tool like a biopsy forcep is used to grip the suture
where it emanates from the mucosa, then the scope is driv-
en onto this area and the tool is firmly and quickly pulled
back into the biopsy channel to break the suture. Other
techniques include use of endoscopic scissors and loop
cutters to trim and remove the suture material, though
loop cutters may jam on braided or silk suture and are
generally reserved for cutting monofilament.
While symptomatic management with antiemetics and
analgesics (answer A) is important in managing this patient,
it will not lead to definitive management of her underlying
condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic
suture removal, but it is premature to recommend this. An
upper GI series (answer D) would be helpful in diagnosing
a gastro-gastric fistula in this patient population, but the
endoscopic evaluation suggests suture material leading to
food bolus impaction and gut irritation is the cause of her
symptoms. Finally, while the patient’s symptoms of intermittent obstruction raise concerns for gastrojejunal stenosis,
the endoscopic exam showed a normal-caliber stoma. Thus,
stomal dilation (answer E) is incorrect. n
1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al.
The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and
effective in the assessment and management of complications following
gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc.