Weight Gain Following Bariatric Surgery As a Result of Large Gastric Stoma: Stomal Revision Using Endoscopic Suturing Technology

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Obesity has reached epidemic proportions in US. Roux-en-Y gastric bypass (RYGB) is a commonly done surgical procedure with proven efficacy. RYGB involves creation of a small gastric pouch with a stomal diameter of approx 12 mm combined with distal small bowel bypass causing both volume restriction and malabsorption which results in weight loss. Complications of RYGB include dilation of the gastric stoma resulting in loss of the restrictive component which causes weight gain. Revision surgery is complex with high morbidity. Endoscopic stomal revision might be a reasonable alternative. Data on endoscopic stomal revision are limited. There are no data on feasibility of endoscopic suturing to reduce the stomal diameter and to see if this would result in resumption of weight loss. Methods: Patients noted to have weight gain after RYGB and noted to have stomal dilation on imaging and/ endoscopy were referred for endoscopic therapy. All procedures were done under general anesthesia. Standard upper endoscopy was initially performed and electrocautery with heater probe was used to denude the surface of the stoma to obtain proper surgical anastomosis with the suturing device. Using the Sew-Rite (Wilson-Cook, Salem, NC) endoscopic suturing device, suturing was done circumferentially to achieve a stomal diameter ≦12 mm. Successful endotherapy was defined as reduction of stomal diameter ≦12 mm and >75% loss of gained weight after initial weight loss. Results: 7 patients (6F, 1M, age 31-47) underwent endoscopic stomal revision over 2-year-period. Stomal diameter was ≧2 cm in all patients prior to endoscopic therapy. 5 of 7 patients underwent successful endoscopic revision of the gastric stoma. Revision was not possible in 2 patients due to extreme angulation of the stoma preventing successful placement of sutures. Post revision, the stomal diameter was 8-12 mm. All patients were followed at 4-8 week intervals and weight was recorded. Mean pre RYGB weight was 318 lbs. Following surgery, weight decreased to a mean of 168 lbs. After the initial weight loss, there was a mean weight gain of 72 lbs that was directly attributed to the large stoma size. There were no complications related to endoscopic stomal revision. Conclusions: 1) Endoscopic stomal revision using a suturing device is feasible and safe. 2) Endoscopic suturing of a large gastric stoma results in reclaiming the restrictive component of the bypass surgery as shown by subsequent weight loss, which is sustained. 3) Larger studies and longer term follow-up data are needed.