A protocolized approach to endoscopic hydrostatic versus pneumatic balloon dilation therapy for gastric sleeve stenosis: a multicenter study and meta-analysis

Background: Gastric sleeve stenosis (GSS) is reported in .7% to 4% of cases after sleeve gastrectomy. Two endoscopic balloon dilation techniques are available with no clear consensus on the therapeutic approach. Objectives: To compare the treatment efficacy and safety between hydrostatic and pneumatic balloon dilations for GSS. Setting: Academic referral centers, United States and a meta-analysis. Methods: Consecutive patients who presented with GSS and underwent endoscopic hydrostatic and/or pneumatic balloon dilations at 3 tertiary care hospitals were included. Clinical success was defined as an improvement of symptoms that allowed the patient to avoid further interventions. A systematic literature search was performed to identify relevant studies for meta-analysis. Results: Of 46 patients, 13 had pneumatic dilation only, 26 had hydrostatic dilation only, and 7 had pneumatic dilation after failed hydrostatic dilation. Clinical success was not significantly different among the 3 groups with the success rates of 30.8%, 57.6%, and 57.1% (P = .25) after single dilation and 61.5%, 63.6%, and 71.4% (P = .90) after serial dilations in the pneumatic group, hydrostatic group, and pneumatic after failed hydrostatic group, respectively. Patients who failed hydrostatic balloon dilation (n = 7) had a success rate of 71.4% with subsequent pneumatic dilation. Two serious adverse events were observed in the pneumatic group, whereas none were observed in the hydrostatic group. A meta-analysis of 16 studies involving 360 patients demonstrated higher clinical success with single pneumatic balloon dilation compared with hydrostatic balloon dilation (62.2% versus 36.4%; P = .007) with higher adverse events (3 versus 0 events). Conclusions: Hydrostatic balloon dilation should be considered as an initial modality for GSS given its acceptable success rate and high safety profile. In those who fail hydrostatic balloon dilation, a subsequent step-up approach to pneumatic balloon dilation or revisional surgery should be attempted.