Transoral Outlet Reduction for Therapy of Weight Regain After Gastric Bypass

Abstract

Introduction: Enlargement of gastrojejunal anastomosis aperture is associated with weight regain in patients with Roux-en-Y gastric bypass (RYGB). Endoscopic transoral outlet reduction (TORe) has proven safe and effective for treatment of weight regain. The objective of this study was to evaluate the safety and the efficacy in weight loss of endoscopic outlet reduction in single Italian center.FigureMethods: The series included consecutive post-RYGB patients with weight regain and enlarged gastrojejunal anastomosis aperture (>15 mm). Endoscopic reduction was performed with Overstitch (Apollo Endosurgery) which is a full-thickness endoscopic suturing device. All the procedures were done at the Digestive Endoscopy Unit of the Catholic University of Rome. The procedure was done with the Overstitch and Olympus double channel operative endoscope. An Overtube was placed before the procedure in all patients. Before suturing the outlet rims were cauterized with pulsed pulsed Argon Plasma on 40 Watts. Results: Thirty-five patients who had weight regained after RYGB (BMI > 30) underwent TORe from January 2015 to February 2017. Baseline mean BMI was 37.9 (range 31-50) and weight was 106.8 kg (range 77-132). Mean procedure time was 34 minutes (range 15-60) and a mean number of 2.3 stitches per patient were placed (range 2-4) on the level of the gastric outlet. After suturing the patency of the new redone outlet was tested with standard gastroscope. There were three (9%) complications of which two were mild (1 intraoperative bleeding that arrested spontaneously and 1 patient with fever due to small retrogastric collection treated with antibiotics), while one patient (5.2%) had gastric perforation that required urgent surgery. Mean hospital stay was 2.4 days (range 1-10). Telephonic follow-up was done at 1, 3 and 6 months. Thirty-two patients completed at least 1 month follow up. Mean weight loss at 1 month follow-up was 9.3 kg, at 3 months was 12.7 kg while at 6 months was 15 kg. Only one patient regained weight compared to baseline during the 6 months follow up. Conclusion: In our experience TORe was a safe and effective procedure in patients with weight regain after RYGB. Longer follow-up and larger clinical trials are needed to establish the durability of these results and to better understand the role of TORe after RYGB and the methods for proper selection of the patients.