Endoscopic Trans-Oral Outlet Reduction in Combination with Gastroplasty (TORe-G) Is a Novel Technique That Is Highly Efficacious and Safe for Weight Loss in Patients With Failed Roux-en-Y Gastric Bypass (RYGB)

Abstract

Introduction: Enlargement of the remnant gastric pouch or gastro-jejunal (GJ) stoma is associated with weight regain after Roux-en-Y Gastric Bypass (RYGB) surgery. Although evidence exists regarding outcomes of GJ outlet reduction in terms of weight loss, the efficacy of gastric pouch revision is still unclear. There are no published results using endoscopic trans-oral outlet reduction (TORe) in combination with gastroplasty of the entire gastric pouch from the gastro-esophageal (GE) junction to the GJ stoma (TORe-G) utilizing an endoscopic full thickness suturing device (Overstitch, Apollo Endosurgery, Austin Tx). We thus report the first description of using (TORe-G) to treat patients with failed RYGB. Methods: Patients who underwent a combined GJ stoma reduction and gastroplasty for inadequate weight loss [5% EWL from nadir) post-RYGB along with evidence of GJ diameter of ≥ 2 cm and dilation of gastric pouch were included. The procedure involved ablation of the peristomal mucosa and gastric pouch using argon plasma coagulation (APC) and placement of interrupted plications using 2-0 prolene sutures for a targeted GJ diameter of ˜5-8 mm and reducing gastric pouch volume to ˜30 mL. Results: A total of 20 subjects (90% females) with median age of 55 years (IQR 42.2-61) and median duration since RYGB of 10 years (IQR 6.2-12) were evaluated. Median follow up was 4.5 months (range 1-9 months). Median (IQR) baseline weight was 225 (198.2-287.2) lbs and BMI was 37.9 (32.7-44.8) kg/m2. Significant weight loss was seen in 100% of study patients post-revision (p < 0.001) (Figure 1). Median (IQR) %EWL seen at 1, 3, and 6 and 9 months was 21.3% (11.3-30), 39.35% (14.9-53.6), 52.8% (14.3-70.9), and 62.8% (57.2-68.3), respectively. Total weight loss [median (IQR)] was 10 lbs (7.5-25), 19 lbs (15-28), 17 lbs (10-37), and 24.5 lbs (15.5-48.5), respectively. Total percent weight loss [median (IQR)] was 5.1% (3.7-9.1), 8.6% (7.05-10.8), 8.5% (5.7-15.5) and 13% (10.6-17), respectively. None of the covariates including age, interval time since RYGB, and percent weight regained since RYGB predicted weight loss post revision. No major adverse events were observed.Figure 1Conclusion: We demonstrate for the first time the efficacy and safety of TORe-G to re-establish weight loss in patients with failed RYGB using a full thickness endoscopic suturing device. TORe-G resulted in robust weight loss, and may lead to superior restriction compared with TORe alone. Further comparative studies are needed.