S1869 Transoral Gastric Outlet Reduction in a Patient With Billroth II Anastomosis for the Treatment of Severe Bile Acid Reflux

Abstract

INTRODUCTION: Endoscopic transoral outlet reduction (TORe) utilizing a full thickness endoscopic suturing device is a minimally invasive therapeutic option in bariatric surgery patients who have experienced weight gain. This procedure can be therapeutic not only for weight gain after Roux-en-Y Gastric Bypass (RYGB), but also can be used in patients who underwent Billroth II procedure with biliary reflux symptoms. CASE DESCRIPTION/METHODS: A 68-year-old female patient with a past medical history of hypertension, dyslipidemia and prior Billroth II procedure for management of peptic ulcer disease presented with severe epigastric pain and bloating after meals refractory to PPI use. She underwent an EGD and was diagnosed with severe biliary gastritis. Transoral endoscopic gastric outlet reduction was recommended for this patient. A diagnostic flexible endoscope was advanced to the site of gastroduodenal anastomosis. Then, the gastric mucosa on the side of the anastomosis was aggressively ablated using argon plasma coagulation (APC). An endoscopic scissor was then used for trimming the previous suture remnants. A double channel scope was then inserted with the OverStitch device. A 2-0 Prolene suture was placed at the 3 O'clock position using full thickness running suture technique. A total of 4 bites were used. The suture was subsequently tightened with the creation of pseudo-pyloric opening. A total of one cinch was deployed to keep the suturing material permanently reinforced. No complications occurred throughout the procedure. Post-procedure follow up was normal with complete resolution of the patient's symptoms. DISCUSSION: Transoral endoscopic gastric outlet reduction is an emerging procedure used to manage weight gain after RYGB. The two-fold running suture technique is a novel method that can be used very effectively in this procedure. We have demonstrated that transoral outlet gastric reduction is not only effective for patients who have gained weight after RYGB, but also therapeutic in the improvement of biliary reflux symptoms after Billroth II procedure.Figure 1.: Argon plasma coagulation of the anastomotic margin.Figure 2.: Endoscopic suturing using the Apollo OverStitch device.Figure 3.: Creation of pseudo-pyloric opening.