Outlet Reduction Research Articles

Su2033 - Argon Plasma Coagulation is Effective in Roux-En-Y Gastric Bypass Patients that do not Achieve Weight Loss Goals after Sutured Transoral Outlet Reduction (TORe)

Su2033 - Argon Plasma Coagulation is Effective in Roux-En-Y Gastric Bypass Patients that do not Achieve Weight Loss Goals after Sutured Transoral Outlet Reduction (TORe)

641 - Five Year Outcomes following Transoral Outlet Reduction (TORe) Show Effective and Durable Treatment of Weight Regain after ROUX-EN-Y Gastric Bypass

641 - Five Year Outcomes following Transoral Outlet Reduction (TORe) Show Effective and Durable Treatment of Weight Regain after ROUX-EN-Y Gastric Bypass

613 - Transoral Outlet Reduction Utilizing a Pursestring Suture Pattern is Safe and Effective for the Treatment of Weight Regain after Roux-En-Y Gastric Bypass

613 - Transoral Outlet Reduction Utilizing a Pursestring Suture Pattern is Safe and Effective for the Treatment of Weight Regain after Roux-En-Y Gastric Bypass

Reconstructive Management Options of Delayed Complications Following Bladder Outlet Surgery.

Technological advancements in urologic endoscopy within the last decades have improved outcomes following bladder outlet reduction surgery while minimizing risks of short- and intermediate-term complications. This review aims to examine late complications of endoscopic reduction of the prostate and the various treatment options available. Urinary incontinence, ejaculatory dysfunction, urethral strictures, bladder neck contractures, and fistula formations are the most common delayed complications following bladder outlet reduction surgery. Evaluation of these complications typically involves a combination of endoscopic examination, urodynamic findings, pelvic imaging, and review of pre-existing symptoms. Treatment options range from conservative measures such as pelvic floor muscle therapy to complex reconstructive procedures including anti-incontinence surgery, urethral reconstruction, and permanent urinary diversion. Although rare, late complications of bladder outlet reduction surgery are important to recognize in order to manage appropriately. Careful evaluation involving multiple diagnostic modalities with consideration for referral to a dedicated reconstructive urologist may be warranted in complex cases.

Demonstration of transoral gastric outlet reduction: 2-fold running suture technique.

Demonstration of transoral gastric outlet reduction: 2-fold running suture technique.

Tobacco retail outlet restrictions: health and cost impacts from multistate life-table modelling in a national population

BackgroundSince there is some evidence that the density and distribution of tobacco retail outlets may influence smoking behaviours, we aimed to estimate the impacts of 4 tobacco outlet reduction interventions...

Effect of best management practice implementation on sediment and phosphorus load reductions at subwatershed and watershed scale using SWAT model

Identification of areas contributing disproportionately high amount of pollutants (i.e., critical source areas (CSAs)) to streams is important to efficiently and effectively target best management practices (BMPs). Process-based models are commonly used to identify CSAs and evaluate the impact of alternative management practices on pollutant load reductions. The objective of this study was to use the Soil and Watershed Assessment Tool (SWAT) to identify CSAs at the subwatershed level and evaluate the impact of alternative BMPs on sediment and total phosphorus (TP) load reductions in the Pleasant Valley watershed (50km2) in South Central Wisconsin (USA). The Nash-Sutcliffe efficiency, percent bias, and coefficient of determination ranged from 0.58 to 0.71, −12.87 to 38.33, and 0.67 to 0.79, respectively, indicating that SWAT was able to predict stream flow, sediment and TP loadings at a monthly time-step with sufficient accuracy. Based on the SWAT simulation results, annual average (2006–2012) subwatershed yield for sediment and TP ranged from 0.06 to 3.14tonsha−1yr−1 and 0.04 to 1.9kgha−1yr−1, respectively. The croplands were the major source of sediment and TP in this watershed (≥84%). Reduction in sediment and TP loading ranged from 66% to 99% at the subwatershed level after conversion of croplands to Conservation Reserve Program (CRP) grasslands in subwatersheds identified as CSAs. On the other hand, reduction in sediment and TP loading with implementation of no-till practices ranged from only 14% to 25%. At the watershed outlet, sediment and TP loading reduction was ≤15% after conversion of croplands to CRP grasslands and implementation of no-till practices because only about 8% of the watershed area was targeted for BMPs and/or resuspension of sediment deposited on the stream bed masked the downstream improvements in water quality.

Su1054 Transoral Outlet Reduction for Therapy of Weight Regain After Gastric Bypass

Su1054 Transoral Outlet Reduction for Therapy of Weight Regain After Gastric Bypass

Continuing Medical Education Exam: April 2016

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Yang D, Amin S, Gonzalez S, et al. Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 2016;83:720-9. Costamagna G, Iacopini F, Bizzotto A, et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker’s diverticulum. Gastrointest Endosc 2016;83:765-73. Kumar N, Thompson C. Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc 2016;83:776-9. Naravadi V, Gupta N, Early D, et al. Prevalence of advanced histological features and synchronous neoplasia in patients with flat adenomas. Gastrointest Endosc 2016;83:795-9. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Endoluminal closure of gastrogastric fistula

Gastrogastric fistulas have a reported incidence of 1.3%–12% after gastric bypass for treatment of morbid obesity. The fistula can occur as a result of incomplete division of the stomach or staple line dehiscence, in the setting of a chronic or perforated marginal ulcer, or as a sequela of staple line leak. In the acute setting, patients can present with tachycardia, fevers, and abdominal pain. However, the development of a gastrogastric fistula in a chronic setting is more subtle: Patients may experience weight regain, postprandial abdominal pain with associated marginal ulcers, and esophageal reflux. Management traditionally consists of surgical revision with associated morbidity [ [1] Corcelles R. Jamal M.H. Daigle C.R. Rogula T. Brethauer S.A. Schauer P.R. Surgical management of gastrogastric fistula. Surg Obes Relat Dis. 2015; 11: 1227-1232 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar ]. Here we report on a treatment option that consists of endoscopic intervention with complete closure of the fistula with added benefits of same-day surgery, decreased operative time, no incisions, and minimal morbidity [ 2 Kantsevoy S.V. Thuluvath P.J. Successful closure of a chronic refractory gastrocutaneous fistula with a new endoscopic suturing device (with video). Gastrointest Endosc. 2012; 75: 688-690 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar , 3 Kumar N. Thompson C.C. Transoral outlet reduction for therapy of weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc. Epub 2015 sep 5; Google Scholar ].

FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY.

ABSTRACTBackground: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled.Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice.Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery.Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained.Conclusion: Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

Peroral endoscopic reduction of dilated gastrojejunal anastomosis after bariatric surgery: Techniques and efficacy.

To investigate the techniques and efficacy of peroral endoscopic reduction of dilated gastrojejunal anastomosis after bariatric surgery. An extensive English language literature search was conducted using PubMed, MEDLINE, Medscape and Google to identify peer-reviewed original and review articles using the keywords "bariatric endoscopic suturing", "overstitch bariatric surgery", "endoscopic anastomotic reduction", "bariatric surgery", "gastric bypass", "obesity", "weight loss". We identified articles describing technical feasibility, safety, efficacy, and adverse outcomes of overstitch endoscopic suturing system for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass (RYGB). All studies that contained material applicable to the topic were considered. Retrieved peer-reviewed original and review articles were reviewed by the authors and the data extracted using a standardized collection tool. Data were analyzed using statistical analysis as percentages of the event. Four original published articles which met our search criteria were pooled. The total number cases were fifty-nine with a mean age of 46.75 years (34-63 years). Eight of the patients included in those studies were males (13.6%) and fifty-one were females (86.4%). The mean time elapsed since the primary bypass surgery was 5.75 years. The average pre-endoscopic procedure body mass index (BMI) was 38.68 (27.5-48.5). Mean body weight regained post-RYGB surgery was 13.4 kg from their post-RYGB nadir. The average pouch length at the initial upper endoscopy was 5.75 cm (2-14 cm). The pre-intervention anastomotic diameter was averaged at 24.85 mm (8-40 mm). Average procedure time was 74 min (50-164 min). Mean post endoscopic intervention anastomotic diameter was 8 mm (3-15 mm). Weight reduction at 3 to 4 mo post revision noted to be an average of 10.1 kg. Average overall post revision BMI was recorded at 37.7. The combined technical and clinical success rate was 94.9% (56/59) among studied participants. Endoscopic suturing can be technically feasible, effective and safe for transoral outlet reduction in patients with weight regain following RYGB.

Weight loss endoscopy: Development, applications, and current status.

Obesity and its comorbidities - including diabetes and obstructive sleep apnea - have taken a large and increasing toll on the United States and the rest of the world. The availability of commercial, clinical, and operative therapies for weight management have not been effective at a societal level. Endoscopic bariatric therapy is gaining acceptance as more effective than diet and lifestyle measures, and less invasive than bariatric surgery. Various endoscopic therapies are analogues of the restrictive or bypass components of bariatric surgery, utilizing gastric remodeling or intestinal anastomosis to achieve proven weight loss and metabolic benefits. Others, such as aspiration therapy, employ novel mechanisms of action. Intragastric balloons have recently been approved by the United States Food and Drug Administration, and a number of other technologies have completed large multicenter trials (such as AspireAssist aspiration therapy and Primary Obesity Surgery Endolumenal). Endoscopic sleeve gastroplasty and transoral outlet reduction for endoscopic revision of gastric bypass have proven safe and effective in a number of studies. As devices are approved for use, data will continue to accumulate for safety, effectiveness, and cost effectiveness. Bariatric endoscopists should be prepared to appropriately target and apply various endoscopic bariatric therapies in the context of a comprehensive long-term weight management program.

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)

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.

Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up

Dilated gastrojejunal anastomosis aperture is associated with weight regain after Roux-en-Y gastric bypass (RYGB). Transoral outlet reduction (TORe) has proved safe and effective for the treatment of weight regain. The objective of this study was to determine the long-term weight trend and number needed to treat for TORe. This prospective series included consecutive post-RYGB patients with weight regain and a gastrojejunal anastomosis aperture greater than 15 mm. TORe was performed with a full-thickness endoscopic suturing device. A total of 150 patients who had regained 49.9% ± 3.6% of the weight lost after gastric bypass (4.1 ± 0.3 kg/y after nadir) before TORe. At TORe, body mass index was 40.2 ± 0.8 kg/m(2) and weight was 110.7 ± 2.2 kg. At 1 year, weight loss was 10.5 ± 1.2 kg or 24.9 ± 2.6% excess weight loss (EWL); at 2 years, weight loss was 9.0 ± 1.7 kg or 20.0% ± 6.4% EWL; at 3 years, weight loss was 9.5 ± 2.1 kg or 19.2% ± 4.6% EWL. The number needed to treat for arrest of weight regain was 1.0 at 6 months, 1.1 at 1 year, and 1.2 at 2 and 3 years. The number needed to treat to maintain weight loss of ≥5 kg from TORe was 1.2 at 6 months, 1.5 at 1 year, 1.9 at 2 years, and 2.0 at 3 years. TORe safely and effectively arrested weight regain and provided durable weight loss with a low number needed to treat. Patients with weight regain after RYGB should be evaluated for dilation of the gastrojejunal anastomosis, as TORe can be part of a multidisciplinary strategy to address post-RYGB weight regain.

The pursestring technique for endoscopic revision of gastric bypass

A significant proportion of patients regain weight after Roux-en-Y gastric bypass. Endoscopic revision of dilated gastrojejunal anastomosis, called transoral outlet reduction (TORe), has proven effective and allows patients to avoid reoperation. Traditionally, TORe has been performed with an interrupted stitching technique with placement of stitches across the anastomosis. In this video, we demonstrate the pursestring and double pursestring techniques for TORe.

Su1515 Gastric Pouch Anastomotic Outlet Reduction Using the Endoscopic Over the Scope Clip System for Weight Regain After Roux-EN-Y Gastric Bypass

Su1515 Gastric Pouch Anastomotic Outlet Reduction Using the Endoscopic Over the Scope Clip System for Weight Regain After Roux-EN-Y Gastric Bypass

Tu1473 Transoral Outlet Reduction (TORE) Versus Surgical Revision for Weight Regain After Gastric Bypass: A Matched Cohort Study

Tu1473 Transoral Outlet Reduction (TORE) Versus Surgical Revision for Weight Regain After Gastric Bypass: A Matched Cohort Study

Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal

ObjectiveTo inform endgame strategies in tobacco control, this study aimed to estimate the impact of interventions that markedly reduced availability of tobacco retail outlets. The setting was New Zealand, a...

Mo2038 Transoral Outlet Reduction (TORe) for Weight Regain After Gastric Bypass: Long-Term Follow-Up and Number Needed to Treat

Mo2038 Transoral Outlet Reduction (TORe) for Weight Regain After Gastric Bypass: Long-Term Follow-Up and Number Needed to Treat