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Szvarca D, Jirapinyo P. Endoscopic Management of Weight Regain After Bariatric Surgery. Gastrointest Endosc Clin N Am 2024; 34:639-654. [PMID: 39277296 DOI: 10.1016/j.giec.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
Weight regain, also known as recurrent weight gain, is common following bariatric surgeries. While anti-obesity medications and surgical revisions offer effective treatment options, they are not without their challenges and limitations. Over the last few decades, there have been significant advancements in endoscopic interventions to address weight regain following bariatric surgery. These procedures have demonstrated feasibility, safety, efficacy, and durability, offering minimally invasive treatment options for this patient population.
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Affiliation(s)
- Daniel Szvarca
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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2
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Xie J, Wang Y. Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article. Int J Surg 2024; 110:3666-3679. [PMID: 38489549 PMCID: PMC11175773 DOI: 10.1097/js9.0000000000001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
As a chronic, multifactorial disease, obesity is associated with a global social and economic burden. This condition significantly affects normal daily life and healthy social interactions, and shortens the life expectancy of patients. Compared with traditional weight-loss methods, the emergence of bariatric surgery has effectively improved the management of obesity. Furthermore, bariatric surgery can also inhibit the progression of multiple metabolic diseases. Despite its potential advantages, bariatric surgery cannot completely eliminate the possibility of weight regain and inadequate weight loss following the procedure. For super-obese patients, bariatric surgery still remains a surgical risk. In addition, the psychological problems and poor eating habits of obese patients also affect the weight loss effect and daily life. Thus, various adjuvant therapies involving multiple disciplines have attracted people's attention. Recently, it has been recognized that the combination of multiple interventions based on bariatric surgery is more advantageous than a single intervention in alleviating the complex and diverse metabolic diseases associated with obesity. The combined therapy considerably enhances the long-term efficacy of bariatric surgery and plays a positive role in the mental health and social lives of patients. In this article, the authors review this multidisciplinary combination therapy to enhance the current understanding of the treatment of obesity.
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Affiliation(s)
| | - Yong Wang
- Center of Bariatric and Metabolic Surgery, Fourth Affiliated Hospital of China Medical University, Liaoning, People’s Republic of China
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3
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Franken RJ, Franken J, Sluiter NR, de Vries R, Euser S, Gerdes VEA, de Brauw M. Efficacy and safety of revisional treatments for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis. Obes Rev 2023; 24:e13607. [PMID: 37515352 DOI: 10.1111/obr.13607] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023]
Abstract
Weight regain or inadequate weight loss following Roux-en-Y gastric bypass poses a significant clinical challenge. Our objective was to evaluate various revisional techniques for addressing weight regain and insufficient weight loss after Roux-en-Y gastric bypass through a systematic review and meta-analysis. We performed a literature search (in PubMed and Embase) on revisional interventions in collaboration with a medical information specialist. Measured outcomes included body mass index at intervention, total weight loss during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals. Thirty-nine studies were included: four studies reported on argon plasma coagulation, four studies on transoral outlet reduction, nine studies on transoral outlet reduction + argon plasma coagulation, four studies on pouch/gastrojejunal anastomosis revision, five on laparoscopic gastric banding, two studies on laparoscopic gastric banding + pouch resizing, 10 on distalization-RYGB, and one on duodenal switch. All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures had a short follow-up and resulted in modest and temporary weight loss. Surgical revision techniques were successful for weight loss in longer term follow-up, at the expense of high complication rates.
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Affiliation(s)
- Rutger J Franken
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
| | - Josephine Franken
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
| | - Nina R Sluiter
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
| | | | - Sjoerd Euser
- Department of Epidemiology, Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands
| | - Victor E A Gerdes
- Department of Internal Medicine, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
- Department of Vascular Medicine, AUMC, Amsterdam, the Netherlands
| | - Maurits de Brauw
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
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4
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Shenoy A, Schulman AR. Advances in endobariatrics: past, present, and future. Gastroenterol Rep (Oxf) 2023; 11:goad043. [PMID: 37483864 PMCID: PMC10361810 DOI: 10.1093/gastro/goad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/07/2023] [Accepted: 07/07/2023] [Indexed: 07/25/2023] Open
Abstract
The obesity epidemic in the USA and worldwide is well documented and continues to grow. Endoscopic metabolic and bariatric therapies may offer a less invasive approach than surgical intervention. This article will review advances in endobariatrics over the last several decades, addressing the past and current state of bariatric and metabolic endoscopy. Food and Drug Administration-cleared devices and interventions currently under investigation are described including gastric devices, gastric remodeling procedures, small-bowel devices, duodenal ablation, as well as procedures to address weight regain after bariatric surgery. Future studies evaluating gastric and duodenal combination therapy, adjunctive pharmacotherapy, as well as individualized precision-health algorithms are underway.
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Affiliation(s)
- Abhishek Shenoy
- Corresponding author. Division of Gastroenterology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI 48105, USA. Tel: +1-908-3381691; Fax: +1-734-9365458;
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
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Gurian GC, Watanabe LM, Nonino CB, Barato M, Ferreira-Julio MA, Arantes FA, Sivieri T, Noronha NY, Souza DSR, Fernandes-Ferreira R, Pinhel MADS. Efficacy of the argon plasma coagulation in patients with weight regain after gastric bypass: a randomized control trial. Endosc Int Open 2023; 11:E43-E51. [PMID: 36644534 PMCID: PMC9839426 DOI: 10.1055/a-1971-6417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/25/2022] [Indexed: 01/15/2023] Open
Abstract
Background and study aims Endoscopic procedure using argon plasma coagulation (APC) promotes a progressive reduction in gastrojejunal anastomosis diameter. The present study aimed to evaluate the efficacy of the APC in patients with weight regain in the postoperative periods of gastric bypass. Patients and methods This was a randomized controlled trial conducted with 66 patients who were randomly assigned selected (using lottery method) and divided into two groups: study group (SG), 38 patients (APC treatment); and control group (CG), 28 patients (only endoscopy procedure). We considered 30 days,180 days, and one year as short-term, medium-term, and long-term, respectively. The parameters analyzed were total weight loss (TWL), excess weight loss (%EWL), total weight loss (%TWL), and reduction of weight regain (%RWR). Furthermore, a biopsy for neoplastic histological changes was carried out for the APC group. For statistical analysis, values of P < 0.05 were considered significant. Results The %TWL and %RWR were higher in the SG in short, medium, and long terms, when compared to the same periods in the CG ( P < 0.001). One year after follow-up, the final weight did not reach the statistical difference between groups. Biopsy performed in SG 1 year after APC did not reveal neoplastic histological changes. Conclusions APC effectively treats weight regain after bariatric surgery in the short and medium-term. An important "new" weight gain was observed in the long-term, showing that obesity is a chronic disease that requires multidisciplinary and family care for life. Also, APC is a safe procedure with low adverse event rates.
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Affiliation(s)
- Gustavo Carvalho Gurian
- Hospital de Base de São José do Rio Preto – Department of Endoscopy – São José do Rio Preto – SP – Brazil
| | - Lígia Moriguchi Watanabe
- Ribeirao Preto Medical School – Department of Health Sciences – University of São Paulo – Brazil
| | - Carla Barbosa Nonino
- Ribeirao Preto Medical School – Department of Health Sciences – University of São Paulo – Brazil
| | - Mariana Barato
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
| | - Maysa Araújo Ferreira-Julio
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
| | - Francisco Alves Arantes
- Hospital de Base de São José do Rio Preto – Department of Endoscopy – São José do Rio Preto – SP – Brazil
| | - Thiago Sivieri
- Sao José do Rio Preto Medical School – Department of Metabolic and Bariatric Surgery – São José do Rio Preto – SP – Brazil
| | - Natália Yumi Noronha
- Ribeirao Preto Medical School – Department of Health Sciences – University of São Paulo – Brazil
| | - Dorotéia Silva Rossi Souza
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
| | - Rafael Fernandes-Ferreira
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
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Zotarelli-Filho IJ, de Quadros LG, Neto MG, Rajapaksa SW, Vidanapathirana J, Filho DR, Nogueira-de-Almeida CA. Prospective Meta-analysis of Weight Loss Regained and Success Rate of Argon Plasma Coagulation to Suture and Surgery Procedures Post-bariatric Surgery: Status of the Art of Endoscopic Treatment. Rev Recent Clin Trials 2023; 18:239-250. [PMID: 37608668 DOI: 10.2174/1574887118666230822110724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/14/2023] [Accepted: 07/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND This study performed a meta-analysis to compare the safety and efficacy of argon plasma coagulation (APC) concerning suture (SUT) and surgery (SUR). METHODS The One-Way tests were applied, with p <0.05 significant. The value of R2 was analyzed (heterogeneity), and the risk of bias of articles was evaluated. RESULTS A total of 34 studies were found, eight about APC, twenty about SUT, and six about SUR. For the percentage of Weight Loss Regained (%WLR), the means for APC, SUT, and SUR were 19.39 ± 10.94, 26.06 ± 16.71, and 17.05 ± 9.85, and for success rate (%SR), the means were 89.75 ± 16.75, 86.80 ± 11.44, and 76.00 ± 21.57, respectively with p >0.05, with R2 ≥ 50%. CONCLUSION The APC proved to be efficient and safe like the other techniques.
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Affiliation(s)
- Idiberto José Zotarelli-Filho
- Faculty of Medicine of Sao Jose do Rio Preto/SP, Brazil
- Associação Brasileira de Nutrologia/Brazilian Association of Nutrology, Catanduva, Sao Paulo, Brazil
- College of Palliative Medicine of Sri Lanka, Colombo, Sri Lanka
| | - Luiz Gustavo de Quadros
- Kaiser Day Hospital, Sao Jose do Rio Preto, Sao Paulo, Brazil
- ABC Medical School, Surgery Department, Santo Andre, Sao Paulo, Brazil
| | | | | | - Janaki Vidanapathirana
- College of Palliative Medicine of Sri Lanka, Colombo, Sri Lanka
- Director of Policy Analysis & Development, Ministry of Health, Sri Lanka
| | - Durval Ribas Filho
- Faculty of Medicine of Sao Jose do Rio Preto/SP, Brazil
- Associação Brasileira de Nutrologia/Brazilian Association of Nutrology, Catanduva, Sao Paulo, Brazil
| | - Carlos Alberto Nogueira-de-Almeida
- Associação Brasileira de Nutrologia/Brazilian Association of Nutrology, Catanduva, Sao Paulo, Brazil
- Federal University of Sao Carlos, Department of Medicine, Sao Carlos, Sao Paulo, Brazil
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Endoscopic gastric plication for the treatment of weight regain after Roux-en-Y gastric bypass (with video). Gastrointest Endosc 2022; 96:51-56. [PMID: 35259393 PMCID: PMC9233122 DOI: 10.1016/j.gie.2022.02.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastric plication involves inverting the stomach with tissue anchor placement to achieve serosa-to-serosa apposition. One potential application of gastric plication is the treatment of weight regain after Roux-en-Y gastric bypass (RYGB), a procedure also known as plication transoral outlet reduction (P-TORe). This study aims to assess technical feasibility, safety, and efficacy of P-TORe. METHODS This was a registry study of RYGB patients who underwent P-TORe for weight regain. The primary outcome was the amount of weight loss and clinical success rate, defined as percentage of total weight loss (TWL) of at least 5% at 12 months. Secondary outcomes were technical success, adverse events (AEs), and predictors of weight loss. RESULTS One hundred eleven RYGB patients underwent P-TORe. Average body mass index (BMI) was 38.5 ± 7.5 kg/m2. Baseline gastrojejunal anastomosis (GJA) and pouch sizes were 17 ± 6 mm and 5 ± 2 cm, respectively. The primary outcome was total weight loss, defined as patients experiencing 9.5% ± 8.5% TWL at 12 months. Clinical success rate was 73%. Technical success rate was 100%. Argon plasma coagulation (APC) was performed around the GJA in all patients (100%) before plication placement. The total number of plications per case was 7 ± 3. Overall AE rate was 12.6%. These included GJA stenosis (9.9%), melena because of marginal ulceration (1.8%), and deep vein thrombosis (.9%). The severe AE rate was 0%. Predictors of weight loss were the amount of weight regain and baseline pouch length. CONCLUSIONS This novel P-TORe technique combining APC with gastric plication appears to be technically feasible, safe, and effective at treating weight regain after RYGB.
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McCarty TR, Kumar N. Revision Bariatric Procedures and Management of Complications from Bariatric Surgery. Dig Dis Sci 2022; 67:1688-1701. [PMID: 35347535 DOI: 10.1007/s10620-022-07397-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
Abstract
Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Nitin Kumar
- HSHS Medical Group, Springfield, IL, 62704, USA.
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9
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Bulajic M, Vadalà di Prampero SF, Boškoski I, Costamagna G. Endoscopic therapy of weight regain after bariatric surgery. World J Gastrointest Surg 2021; 13:1584-1596. [PMID: 35070065 PMCID: PMC8727177 DOI: 10.4240/wjgs.v13.i12.1584] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/14/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023] Open
Abstract
Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological, anatomical and metabolic factors. Surgical revision of these patients has significant risks and limited benefits. Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective, safe, less invasive and even reproducible treatment. We herein discuss the indication, selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery. Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.
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Affiliation(s)
- Milutin Bulajic
- Department of Gastroenterology and Digestive Endoscopy, Mater Olbia Hospital, Olbia 07026, Italy
| | | | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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10
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Dolan RD, Jirapinyo P, Thompson CC. Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison. Gastrointest Endosc 2021; 94:945-950. [PMID: 34126065 PMCID: PMC8908793 DOI: 10.1016/j.gie.2021.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/05/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y gastric bypass (RYGB) and can be corrected with endoscopic or surgical revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (AE) rates and weight loss profiles between endoscopic and surgical revisional techniques over a 5-year period. METHODS This is a retrospective matched cohort study of RYGB patients who underwent endoscopic or surgical revision for weight regain with an enlarged GJA (>12 mm). Patients who underwent endoscopic revision (ENDO group) were matched 1:1 to those undergoing surgical revision (SURG group) based on completion of 5-year follow-up, age, sex, body mass index, initial weight loss, and weight regain. Demographics, GJA size, serious AEs, and weight profiles were collected. The primary outcome was comparison of serious AE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the serious AE rate, and a Student t test was used for weight comparisons. RESULTS Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The AE rate in the ENDO group (6.5%) was lower than the SURG group (29.0%, P = .043). Zero and 6 (19.4%) serious (severe) AEs occurred in the ENDO and SURG groups, respectively (P = .02). There was no significant difference in weight loss at 1, 3, and 5 years. CONCLUSIONS Endoscopic revision of the GJA is associated with significantly fewer total and serious AEs and similar long-term weight loss when compared with surgical revision.
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11
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Dolan RD, McCarty TR, Jirapinyo P, Thompson CC. Endoscopic revision of gastric bypass using plication technique: an adjustable approach. VideoGIE 2021; 6:311-315. [PMID: 34278094 PMCID: PMC8270786 DOI: 10.1016/j.vgie.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Russell D Dolan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Tankel J, Ahmed AR. Gastrojejunostomy in Roux-En-Y Gastric Bypass for Morbid Obesity: Linear Stapler Length Does Not Affect Mid-term Outcomes. Surg Laparosc Endosc Percutan Tech 2021; 31:794-798. [PMID: 33973943 DOI: 10.1097/sle.0000000000000947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to compare whether different linear stapler lengths used to form the gastrojejunostomy during laparoscopic Roux-En-Y gastric bypass affects mid-term weight loss outcomes. MATERIALS AND METHODS A retrospective single center analysis was performed. Surgical technique was identical other than either a 35 or 45 mm linear stapler being used to form the gastrojejunostomy. Multivariate regression was used to assess the relationship between the different stapler lengths and weight loss outcomes 2 years following surgery. RESULTS Of the 97 patients identified, 67 (69.1%) were included in the study. There were 30 patients in the 35 mm group and 37 in the 45 mm group. The groups were comparable in terms of basic demographic data and preoperative weight characteristics. There was no significant difference in weight loss outcomes 2 years following surgery when comparing between the different linear stapler lengths. CONCLUSION Thirty-five versus 45 mm linear stapler lengths does not affect mid-term weight loss outcomes.
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Affiliation(s)
- James Tankel
- Imperial College Weight Loss Centre, Imperial College Healthcare Trust, St Mary's Hospital, London, UK
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13
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Yavuz A, Akan K, Ulaşoğlu C, Tuncer İ, Çolak Y. An Alternative Method for Treating Dumping Syndrome Using Hemoclips. Cureus 2021; 13:e14869. [PMID: 34113505 PMCID: PMC8177030 DOI: 10.7759/cureus.14869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Surgeries for obesity can lead to complications. Dumping syndrome is one such complication caused by the quick passage of hyperosmolar chyme from the stomach to the duodenum. Mild cases can be cured with dietary modification and medical treatment. However, refractory cases may need invasive treatment options, such as transoral outlet reduction or surgery. We successfully treated a 48-year-old female with dumping syndrome, using a combination of argon plasma coagulation and hemoclips to narrow the pyloric lumen. We suggest that this new technique could be a cheap and easily accessible alternative to surgery, especially in countries where the specialised devices needed to treat such cases are unavailable.
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Affiliation(s)
- Arda Yavuz
- Gastroenterology and Hepatology, Istanbul Medeniyet University Göztepe Research and Training Hospital, Istanbul, TUR
| | - Kübra Akan
- Gastroenterology, Istanbul Medeniyet University Göztepe Research and Training Hospital, Istanbul, TUR
| | - Celal Ulaşoğlu
- Gastroenterology, Istanbul Medeniyet University Göztepe Research and Training Hospital, Istanbul, TUR
| | - İlyas Tuncer
- Gastroenterology and Hepatology, Istanbul Medeniyet University Göztepe Research and Training Hospital, Istanbul, TUR
| | - Yaşar Çolak
- Gastroenterology and Hepatology, Istanbul Medeniyet University Göztepe Research and Training Hospital, Istanbul, TUR
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Relly R, Mati S, Aviv CN, Fishman S. Endoscopic trans-oral outlet reduction after bariatric surgery is safe and effective for dumping syndrome. Surg Endosc 2021; 35:6846-6852. [PMID: 33398583 DOI: 10.1007/s00464-020-08190-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Dumping syndrome (DS) is a common complication of bariatric surgery. Treatments include dietary and behavioral changes, as well as pharmacotherapy and revision surgery. All can be costly or hard to adhere to. In recent years, evidence accumulates in favor of endoscopic trans-oral outlet reduction (TORe) as an effective treatment for DS, targeting the pathophysiology of rapid gastric clearance. The objective of this study is to assess the safety and efficacy of TORe for DS in a single referral center. METHODS Patients after bariatric surgery suffering DS were followed, and data were retrospectively analyzed. Diagnosis and post-procedural assessment of DS were made clinically using Sigstad score. During the procedure, the anastomotic rim was cauterized. Afterwards, 2 non-interrupted "8-figure" sutures were placed, resulting in imbrication of additional gastric tissue on top of the anastomosis and narrowing to <1 cm at the end of the procedure. Patients were instructed to keep a liquid diet for 14 days and follow-up continued for 6 months. RESULTS Between 8/2018 and 9/2019 TORe was carried out in 13 patients (M:F = 3:10) with mean age of 45.1 (range 25-56) and BMI of 33.5 (range 28.1-40.3). Average time since recent surgery was 5.5 years (range 1-9). Mean pre-procedure anastomosis diameter was 25.2 mm (range 15-30) and was reduced to a mean of 5.6 mm (range 5-10). Three patients (23%) were admitted overnight due to inability to drink which resolved spontaneously. No major complications were reported. At 6 months, the Sigstad score was significantly reduced (19.4 ± 3.6 vs 5.2 ± 5.5, P < 0.001), and 11/13 (85%) of patients had a complete resolution of their dumping symptoms. In addition, BMI decreased by a mean of 2.3 kg/m2 (-1 to 7.5, p = 0.002). CONCLUSION TORe is a safe and effective treatment for patients suffering dumping syndrome and should be considered early in the treatment of DS.
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Affiliation(s)
- Reicher Relly
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel
| | - Shnell Mati
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel
| | - Cohen Nathaniel Aviv
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel
| | - Sigal Fishman
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel.
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15
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Schulman AR, Watson RR, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Jirapinyo P, Krishnan K, Kumta NA, Melson J, Pannala R, Parsi MA, Trikudanathan G, Trindade AJ, Maple JT, Lichtenstein DR. Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos). Gastrointest Endosc 2020; 92:492-507. [PMID: 32800313 DOI: 10.1016/j.gie.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type. METHODS The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized. RESULTS Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving. CONCLUSIONS Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.
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Affiliation(s)
- Allison R Schulman
- Department of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rabindra R Watson
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Guru Trikudanathan
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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16
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Istfan NW, Anderson WA, Hess DT, Yu L, Carmine B, Apovian CM. The Mitigating Effect of Phentermine and Topiramate on Weight Regain After Roux-en-Y Gastric Bypass Surgery. Obesity (Silver Spring) 2020; 28:1023-1030. [PMID: 32441476 PMCID: PMC7250052 DOI: 10.1002/oby.22786] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/23/2020] [Accepted: 02/10/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Weight regain (WR) after Roux-en-Y gastric bypass surgery (RYGB) starts to occur 2 years after surgery, ultimately affecting at least 25% of patients. A limited number of studies have evaluated the impact of antiobesity medications (AOMs) on this phenomenon. METHODS This study reviewed the electronic medical records of 1,196 patients who underwent RYGB between 2004 and 2015. WR was evaluated by comparing each patient's weight during subsequent postoperative office visits to nadir weight (lowest weight after RYGB, n = 760), taking into consideration the interval during which WR occurred. Patients who were prescribed AOMs and came to follow-up visits were classified as adherent users, whereas those who missed their follow-up visits were considered nonadherent. This study used a linear mixed model, Cox regression, and generalized equation estimator to determine the impact of AOMs on WR trajectory, hazard ratio for time to event, and odds ratio for repeated event occurrence, respectively. RESULTS Despite the lack of a unified protocol for using AOMs, the three statistical models converged to show that phentermine and topiramate, used individually or in combination, can significantly reduce WR after RYGB. CONCLUSIONS Phentermine and topiramate are effective in mitigating WR after RYGB. Further studies are needed to help ascertain optimal use of AOMs after bariatric surgery.
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Affiliation(s)
- Nawfal W. Istfan
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Wendy A. Anderson
- Section of Minimally Invasive Surgery, Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Donald T. Hess
- Section of Minimally Invasive Surgery, Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Liqun Yu
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Brian Carmine
- Section of Minimally Invasive Surgery, Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Caroline M. Apovian
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
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17
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Jirapinyo P, Kumar N, AlSamman MA, Thompson CC. Five-year outcomes of transoral outlet reduction for the treatment of weight regain after Roux-en-Y gastric bypass. Gastrointest Endosc 2020; 91:1067-1073. [PMID: 31816315 PMCID: PMC7183415 DOI: 10.1016/j.gie.2019.11.044] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Transoral outlet reduction (TORe) is a common endoscopic treatment for patients with weight regain after Roux-en-Y gastric bypass (RYGB) with a dilated gastrojejunal anastomosis (GJA). This study aims to assess long-term efficacy of TORe. METHODS This was a retrospective review of prospectively collected data on RYGB patients who underwent TORe for weight regain or inadequate weight loss. The primary outcome was efficacy of TORe at 1, 3, and 5 years. Secondary outcomes were procedure details, safety profile, and predictors of long-term weight loss after TORe. RESULTS Three hundred thirty-one RYGB patients underwent 342 TORe procedures and met inclusion criteria. Of these, 331, 258, and 123 patients were eligible for 1-, 3- and 5-year follow-ups, respectively. Mean body mass index was 40 ± 9 kg/m2. Pre-TORe GJA size was 23.4 ± 6.0 mm, which decreased to 8.4 ± 1.6 mm after TORe. Patients experienced 8.5% ± 8.5%, 6.9% ± 10.1%, and 8.8% ± 12.5% total weight loss (TWL) at 1, 3, and 5 years with follow-up rates of 83.3%, 81.8%, and 82.9%, respectively. Of 342 TORe procedures, 76%, 17.5%, 4.4%, and 2.1% were performed using single purse-string, interrupted, double purse-string, and running suture patterns, respectively, with an average of 9 ± 4 stitches per GJA. Pouch reinforcement suturing was performed in 57.3%, with an average of 3 ± 2 stitches per pouch. There were no severe adverse events. Some patients (39.3%) had additional weight loss therapy (pharmacotherapy or procedure), with 3.6% getting repeat TORe. Amount of weight loss at 1 year (β = .43, P = .01) and an additional endoscopic weight loss procedure (β = 8.52, P = .01) were predictors of percentage of TWL at 5 years. CONCLUSIONS TORe appears to be safe, effective, and durable at treating weight regain after RYGB.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nitin Kumar
- Hospital Sisters Health System, Effingham, Illinis, USA
| | - Mohd Amer AlSamman
- The Warren Alpert Medical School of Brown University, The Miriam Hospital, Providence, Rhode Island, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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18
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Goh YM, James NE, Goh EL, Khanna A. The use of endoluminal techniques in the revision of primary bariatric surgery procedures: a systematic review. Surg Endosc 2020; 34:2410-2428. [PMID: 32112253 PMCID: PMC7214483 DOI: 10.1007/s00464-020-07468-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 02/19/2020] [Indexed: 01/05/2023]
Abstract
Background Weight regain following primary bariatric surgery is attributed to anatomical, behavioural and hormonal factors. Dilation of the gastrojejunal anastomosis is a possible cause of weight regain after roux-en-Y gastric bypass (RYGB). However, surgical revision has significant risks with limited benefits. Endoluminal procedures have been suggested to manage weight regain post-surgery. This systematic review aims to assess efficacy of endoluminal procedures. Methods Studies where endoluminal procedures were performed following primary bariatric surgery were identified. Main outcome measures were mean weight loss pre- and post-procedure, excess weight loss, recurrence rates, success rates and post-procedure complications. Results Twenty-six studies were included in this review. Procedures identified were (i) endoluminal plication devices (ii) other techniques e.g. sclerotherapy, mucosal ablation, and Argon Plasma Coagulation (APC) and (iii) combination therapy involving sclerotherapy/mucosal ablation/APC and endoscopic OverStitch device. Endoluminal plication devices show greatest initial weight loss within 12 months post-procedure, but not sustained at 18 months. Only one study utilising sclerotherapy showed greater sustained weight loss with peak EWL (19.9%) at 18 months follow-up. Combination therapy showed the greatest sustained EWL (36.4%) at 18 months. Endoluminal plication devices were more successfully performed in 91.8% of patients and had lower recurrence rates (5.02%) compared to sclerotherapy and APC, with 46.8% success and 21.5% recurrence rates. Both procedures demonstrate no major complications and low rates of moderate complications. Only mild complications were noted for combination therapy. Conclusions The paucity of good quality data limits our ability to demonstrate and support the long-term efficacy of endoluminal techniques in the management of weight regain following primary bariatric surgery. Future work is necessary to not only clarify the role of endoluminal plication devices, but also combination therapy in the management of weight regain following primary bariatric surgery. Electronic supplementary material The online version of this article (10.1007/s00464-020-07468-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yan Mei Goh
- Imperial College London, London, UK. .,Department of General Surgery, Milton Keynes University Hospital, Milton Keynes, UK.
| | | | - En Lin Goh
- Imperial College London, London, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Achal Khanna
- Department of General Surgery, Milton Keynes University Hospital, Milton Keynes, UK
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19
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A Real-World, Insurance-Based Algorithm Using the Two-Fold Running Suture Technique for Transoral Outlet Reduction for Weight Regain and Dumping Syndrome After Roux-En-Y Gastric Bypass. Obes Surg 2019; 29:2225-2232. [DOI: 10.1007/s11695-019-03828-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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20
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Hourneaux De Moura DT, Thompson CC. Endoscopic management of weight regain following Roux-en-Y gastric bypass. Expert Rev Endocrinol Metab 2019; 14:97-110. [PMID: 30691326 DOI: 10.1080/17446651.2019.1571907] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population. AREAS COVERED We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care. EXPERT COMMENTARY Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.
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Affiliation(s)
- Diogo Turiani Hourneaux De Moura
- a Division of Gastroenterology, Hepatology and Endoscopy , Harvard Medical School, Brigham and Women's Hospital , Boston , MA , USA
| | - Christopher C Thompson
- a Division of Gastroenterology, Hepatology and Endoscopy , Harvard Medical School, Brigham and Women's Hospital , Boston , MA , USA
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21
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Gan J, Wang Y, Zhou X. Whether a Short or Long Alimentary Limb Influences Weight Loss in Gastric Bypass: a Systematic Review and Meta-Analysis. Obes Surg 2018; 28:3701-3710. [PMID: 30187422 DOI: 10.1007/s11695-018-3475-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Roux-en-Y gastric bypass, the most commonly performed procedure in bariatric surgery, still lacks a consensus on whether alimentary limb length (ALL) influences weight loss. Studies were identified by searching multiple electronic databases. Studies with enough data including body mass index (BMI) loss and percent excess weight loss (% EWL) were eligible. The statistical analysis was performed with Stata 14.0. In total, eight studies with 1714 patients were included. The meta-analysis suggested that short ALLs weakened the efficacy of Roux-en-Y gastric bypass in terms of BMI loss (standard mean deviation (SMD), - 0.33 [95% confidence intervals (CI), - 0.60, - 0.05], p = 0.021) with 3 years of follow-up and % EWL (SMD, - 0.17 [95% CI, - 0.31, - 0.04], p = 0.013) with 2 years of follow-up. The subgroup analysis demonstrated that the group with a BMI ≥ 50 kg/m2 had a significant SMD between the use of short and the standard ALLs (- 0.71 [95% CI, - 1.07, - 0.35], p = 0.000), while the subgroup with a BMI < 50 kg/m2 (SMD, - 0.29 [95% CI, - 0.78, 0.20], p = 0.247) did not. Compared with a standard ALL (130-150 cm), a short ALL (40-100 cm) may reduce the efficacy of the Roux-en-Y gastric bypass surgery, while a long ALL (170-250 cm) did not significantly improve the effects in terms of BMI loss and % EWL. In addition, a potential view of the meta-analysis indicated patients with a BMI < 50 kg/m2 might get more benefits with a short ALL, while those patients with a BMI ≥ 50 kg/m2 might benefit more from a standard ALL.
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Affiliation(s)
- Jiadi Gan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, 330006, Jiangxi Province, China
- First and Second Clinical Medical College, Nanchang University, Nanchang, 330006, China
| | - Yingjin Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, 330006, Jiangxi Province, China
- First and Second Clinical Medical College, Nanchang University, Nanchang, 330006, China
| | - Xiaodong Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Road, Donghu District, Nanchang, 330006, Jiangxi Province, China.
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22
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Abstract
BACKGROUND Many surgeons prefer a narrow gastrojejunostomy in gastric bypass believing that this provides greater weight loss. The question is whether the anastomosis remains at its initial diameter, whether it narrows or widens over time. This study tests the hypothesis that the initial diameter of the anastomosis varies over time. MATERIALS AND METHODS One hundred obese had undergone surgery. Group A with anastomosis 1.5 cm wide and group B with anastomosis 3 cm wide. One-year follow-up was done for 83 patients. The size of the anastomosis diameter was evaluated using a balloon for cardia dilation. RESULTS Comparing the results of surgery with the values presented 1 year after the procedure, (i) BMI decreased from 43.3 ± 6.6 to 28.7 ± 7.0 kg/m2 for group A and 44.6 ± 5.9 to 29.1 ± 6.3 kg/m2 for group B, (ii) the total weight loss was 30.6 ± 4.7% for group A and 31.9 ± 5.2% for group B, and (iii) the initial 1.5-cm anastomosis in group A measured 2.3 ± 1.0 cm while the initial 3-cm anastomosis in group B measured 2.7 ± 1.0 cm 1 year after surgery. No statistically significant difference was found for any of the variables evaluated before and after the surgical procedure. CONCLUSION Calibrated anastomosis has no utility in increasing weight loss in gastric bypass.
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Affiliation(s)
- A C Valezi
- Surgery Department, State University of Londrina, 777 Santos st, Londrina, PR, 86020-041, Brazil.
| | - J Mali
- Surgery Department, State University of Londrina, 777 Santos st, Londrina, PR, 86020-041, Brazil
| | - M A Menezes
- Surgery Department, State University of Londrina, 777 Santos st, Londrina, PR, 86020-041, Brazil
| | - R O Sato
- Mater Dei Hospital of Londrina, Londrina, Brazil
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23
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Barrichello S, Galvão Neto MDP, Ferreira de Souza T, Guimarães Hourmeaux de Moura E, Minata M, Oliveira de Quadros AP, Waisberg J, Grecco E, Macedo G, Silva M, de Quadros LG. Increased Gastric Retention Capacity, Assessed by Scintigraphy, after APC Treatment of Dilated Gastrojejunal Anastomosis. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 25:327-330. [PMID: 30480051 DOI: 10.1159/000486561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/02/2018] [Indexed: 01/24/2023]
Abstract
Background Weight regain occurs in about 20% of patients after Roux-en-Y gastric bypass (RYGB). Studies have reported that in most cases this regain is associated with dilatation of the gastrojejunal anastomosis. To correct this dilatation, one of the methods used is the application of argon plasma coagulation (APC). Case The authors report the case of a 39-year-old woman submitted to RYGB who had weight regain. In the endoscopic evaluation, the patient presented with dilatation of the gastrojejunal anastomosis, for which treatment with APC and an adjusted diet was proposed. After 3 sessions of APC, the patient presented with a reduction of the anastomosis diameter, weight loss, and increased satiety to food, with an increased gastric emptying time evidenced by scintigraphy. Conclusion APC proved to be a safe and efficacious method.
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Affiliation(s)
- Sérgio Barrichello
- Hospital das Clínicas de São Paulo, Medical School of the University of São Paulo (USP), São Paulo, Brazil
| | | | - Thiago Ferreira de Souza
- Hospital das Clínicas de São Paulo, Medical School of the University of São Paulo (USP), São Paulo, Brazil.,ABC Medical School, São Paulo, Brazil
| | | | - Maurício Minata
- Hospital das Clínicas de São Paulo, Medical School of the University of São Paulo (USP), São Paulo, Brazil
| | | | - Jaques Waisberg
- Hospital das Clínicas de São Paulo, Medical School of the University of São Paulo (USP), São Paulo, Brazil
| | | | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal
| | - Marco Silva
- Gastroenterology Department, Centro Hospitalar de São João, Porto Medical School, Porto, Portugal
| | - Luiz Gustavo de Quadros
- Hospital das Clínicas de São Paulo, Medical School of the University of São Paulo (USP), São Paulo, Brazil
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24
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Brunaldi VO, Jirapinyo P, de Moura DTH, Okazaki O, Bernardo WM, Galvão Neto M, Campos JM, Santo MA, de Moura EGH. Endoscopic Treatment of Weight Regain Following Roux-en-Y Gastric Bypass: a Systematic Review and Meta-analysis. Obes Surg 2018; 28:266-276. [PMID: 29082456 DOI: 10.1007/s11695-017-2986-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its high efficacy, some patients regain part of their lost weight. Several endoscopic therapies have been introduced as alternatives to treat weight regain, but most of the articles are relatively small with unclear long-term data. To systematically assess the efficacy of endoscopic therapies for weight regain after RYGB. We searched MEDLINE, EMBASE, Scopus, Web of Science, Cochrane, OVID, CINAHL/EBSCo, LILACS/Bireme, and gray literature. Primary outcomes were absolute weight loss (AWL), excess weight loss (EWL), and total body weight loss (TBWL). Thirty-two studies were included in qualitative analysis. Twenty-six described full-thickness (FT) endoscopic suturing and pooled AWL, EWL, and TBWL at 3 months were 8.5 ± 2.9 kg, 21.6 ± 9.3%, and 7.3 ± 2.6%, respectively. At 6 months, they were 8.6 ± 3.5 kg, 23.7 ± 12.3%, and 8.0 ± 3.9%, respectively. At 12 months, they were 7.63 ± 4.3 kg, 16.9 ± 11.1%, and 6.6 ± 5.0%, respectively. Subgroup analysis showed that all outcomes were significantly higher in the group with FT suturing combined with argon plasma coagulation (APC) (p < 0.0001). Meta-analysis included 15 FT studies and showed greater results. Three studies described superficial-thickness suturing with pooled AWL of 3.0 ± 3.8, 4.4 ± 0.07, and 3.7 ± 7.4 kg at 3, 6, and 12 months, respectively. Two articles described APC alone with mean AWL of 15.4 ± 2.0 and 15.4 ± 9.1 kg at 3 and 6 months, respectively. Full-thickness suturing is effective at treating weight regain after RYGB. Performing APC prior to suturing seems to result in greater weight loss. Head-to-head studies are needed to confirm our results. Few studies adequately assess effectiveness of other endoscopic techniques.
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Affiliation(s)
- Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo Medical School, Dr. Arnaldo Av, 455, São Paulo, 01246-903, Brazil.
| | | | - Diogo Turiani H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo Medical School, Dr. Arnaldo Av, 455, São Paulo, 01246-903, Brazil
| | - Ossamu Okazaki
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo Medical School, Dr. Arnaldo Av, 455, São Paulo, 01246-903, Brazil
| | - Wanderley M Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo Medical School, Dr. Arnaldo Av, 455, São Paulo, 01246-903, Brazil
| | - Manoel Galvão Neto
- Unit of Endoscopy-Gastro Obeso Center, Barata Ribeiro St. 237, Sao Paulo, Brazil
| | | | - Marco Aurélio Santo
- Bariatric and Metabolic Surgery Unit, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Eduardo G H de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo Medical School, Dr. Arnaldo Av, 455, São Paulo, 01246-903, Brazil
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25
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Deden LN, Cooiman MI, Aarts EO, Janssen IMC, Gotthardt M, Hendrickx BW, Berends FJ. Gastric pouch emptying of solid food in patients with successful and unsuccessful weight loss after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2017; 13:1840-1846. [PMID: 28935201 DOI: 10.1016/j.soard.2017.07.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/25/2017] [Accepted: 07/25/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), approximately 10% of patients have insufficient weight loss (excess body mass index loss<50%). Gastric pouch emptying may have a role in weight loss. OBJECTIVES To compare pouch emptying of patients with poor weight loss and patients with successful weight loss after RYGB. SETTING A research-intensive nonacademic hospital and center of expertise in bariatric surgery in the Netherlands METHODS: Female patients were included from among patients with the least (poor weight loss group [P-WL]) and the most weight loss (successful weight loss group [S-WL]) in our center 2 years after RYGB. Pouch emptying scintigraphy was performed after ingestion of a radiolabeled solid meal. Emptying curves, intestinal content (IC) at meal completion and after 15, 30, 45, and 60 minutes, half emptying time, and maximal pouch emptying rate were compared. RESULTS Five individuals were included in P-WL and 5 in S-WL, on average 2.5 ± .3 years after RYGB. Total weight loss was 18 ± 4.1% in P-WL and 44 ± 5.7% in S-WL (P<.001). In P-WL, a fast initial pouch emptying and exponential emptying curve was observed, compared with a slower initial emptying and more linear curve in S-WL. Faster emptying in P-WL was also shown by a larger ICmeal (42 ± 18% versus 4.0 ± 3.3%,), IC15 (76 ± 15% versus 35 ± 22%), and IC30 (85 ± 12% versus 54 ± 25%), and a greater maximal pouch emptying rate (17 ± 4.7 versus 5.6 ± 3.4%/min) compared with S-WL (P<.05). A linear correlation was found between total weight loss and maximal pouch emptying rate (Pearson R = .82, P = .004). CONCLUSIONS Pouch emptying for solid food was faster in patients with the least weight loss compared with patients with the most weight loss after RYGB. If pouch emptying is an important mechanism in weight loss, altering the pouch outlet may improve poor weight loss management.
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Affiliation(s)
- Laura N Deden
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Mellody I Cooiman
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Edo O Aarts
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ignace M C Janssen
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Martin Gotthardt
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Baudewijn W Hendrickx
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frits J Berends
- Vitalys Clinic, Velp, the Netherlands; Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
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Outcomes following 50 consecutive endoscopic gastrojejunal revisions for weight gain following Roux-en-Y gastric bypass: a comparison of endoscopic suturing techniques for stoma reduction. Surg Endosc 2016; 31:2667-2677. [PMID: 27752820 DOI: 10.1007/s00464-016-5281-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 10/04/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Approximately 20-30 % of morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGB) will experience significant weight regain in the years following surgery. Endoscopic gastrojejunal revision (EGJR) has been shown to be a safe, effective and less invasive alternative to revisional surgery, with promising weight loss outcomes. However, minimal data exist regarding how to perform the procedure most effectively and what factors may predict good outcomes. We compared weight loss outcomes between patients undergoing endoscopic stoma revision by one of two full-thickness suturing techniques. METHODS A retrospective review of patients undergoing EGJR between 06/2012 and 09/2015 was performed. Included patients were adults 18-74 years of age who had experienced weight regain ≥2 years after initial RYGB with stoma dilation ≥15 mm in diameter. Revision was done with either an interrupted (IRT) or purse-string (PST) suture technique. A linear mixed effects model was constructed to predict postoperative weight loss. RESULTS Fifty revisions (IRT = 36, PST = 14) were performed in 47 patients (92 % female, mean age of 50.9 ± 10.9 years and body mass index of 41.4 ± 7.1 kg/m2). Technical success (stoma diameter ≤10 mm) was achieved in all cases. Final diameter was significantly smaller in the PST group, 6.6 ± 2.2 mm versus 4.8 ± 1.8 mm (p < 0.01), resulting in a significantly greater % stoma reduction (76.8 ± 8.5 % vs. 84.2 ± 5.1 %, p < 0.01) versus the IRT group. PST resulted in greater % excess weight loss over time compared to IRT. Sixteen comorbid conditions resolved among 12 patients. No major complications occurred. CONCLUSION Endoscopic revision of the gastric outlet results in meaningful weight loss and comorbidity resolution in select patients experiencing weight regain following RYGB. A PST revision likely results in higher and more sustainable weight loss when compared to IRT.
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Kumar N. Weight loss endoscopy: Development, applications, and current status. World J Gastroenterol 2016; 22:7069-7079. [PMID: 27610017 PMCID: PMC4988299 DOI: 10.3748/wjg.v22.i31.7069] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/10/2016] [Accepted: 06/28/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Malli CP, Sioulas AD, Emmanouil T, Dimitriadis GD, Triantafyllou K. Endoscopy after bariatric surgery. Ann Gastroenterol 2016; 29:249-257. [PMID: 27366025 PMCID: PMC4923810 DOI: 10.20524/aog.2016.0034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/08/2016] [Indexed: 12/16/2022] Open
Abstract
Obesity is a global epidemic with significant morbidity and mortality. Weight loss results in reduction of health risks and improvement in quality of life, thus representing a goal of paramount importance. Bariatric surgery is the most efficacious choice compared to conservative alternatives including diet, exercise, drugs and behavioral modification to treat obese patients. Following bariatric operations, patients may present with upper gastrointestinal tract complaints that warrant endoscopic evaluation and the various bariatric surgery types are often linked to complications. A subset of these complications necessitates endoscopic interventions for accurate diagnosis and effective, minimal invasive treatment. This review aims to highlight the role of upper gastrointestinal endoscopy in patients who have undergone bariatric surgery to evaluate and potentially treat surgery-related complications and upper gastrointestinal symptoms.
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Affiliation(s)
- Chrysoula P. Malli
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Athanasios D. Sioulas
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Theodoros Emmanouil
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - George D. Dimitriadis
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Research Institute and Diabetes Center, Attikon University General Hospital, Medical School, National and Kapodistrian University, Athens, Greece
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Endoluminal Revision (OverStitch TM , Apollo Endosurgery) of the Dilated Gastroenterostomy in Patients with Late Dumping Syndrome After Proximal Roux-en-Y Gastric Bypass. Obes Surg 2016; 26:1978-84. [DOI: 10.1007/s11695-016-2266-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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30
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Kumar N, Thompson CC. Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc 2016; 83:776-9. [PMID: 26344204 DOI: 10.1016/j.gie.2015.08.039] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 08/15/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Nitin Kumar
- Developmental Endoscopy Lab, Brigham and Women's Hospital, Boston, Massachusetts, USA
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31
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da Rocha L, Ayub Pérez O, Arantes V. Endoscopic management of bariatric surgery complications: what the gastroenterologist should know. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Gallo AS, DuCoin CG, Berducci MA, Nino DF, Almadani M, Sandler BJ, Horgan S, Jacobsen GR. Endoscopic revision of gastric bypass: Holy Grail or Epic fail? Surg Endosc 2015; 30:3922-7. [PMID: 26675939 DOI: 10.1007/s00464-015-4699-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 11/18/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Approximately 20-30 % of patients who undergo Roux-en-Y gastric bypass (RYGB) will not meet the goals of weight loss surgery. Revisional surgery is associated with higher morbidity compared to initial operative management, and results in terms of weight loss have been inconsistent. Endoscopic plication has been seen as a less invasive option, with encouraging initial results. The objective was to analyze the outcomes after Restorative Obesity Surgery, Endolumenal (ROSE) procedure. METHODS We retrospectively analyzed patients who underwent ROSE between 5/2008 and 11/2013. All patients had failure of weight loss or regain weight after RYGB. Demographics, operative data, and follow-up were recorded. RESULTS Twenty-seven patients underwent ROSE. One patient was excluded due to lack of follow-up. Twenty-five (96 %) patients were female. Mean time since initial RYGB was 11.9 ± 4.3 years. Mean initial weight and BMI were 236 ± 47 lb and 40.6 ± 8.1 kg/m(2), respectively. Mean OR time was 77 ± 30 min. Preoperative average pouch length and stoma diameter were 6.8 ± 2.3 and 2.1 ± 0.7 cm, respectively. On average, 4 ± 1.6 stitches were placed. Final pouch length and stoma diameter were 3.4 ± 1.6 (50 % reduction) and 0.86 ± 0.4 cm (61 % reduction). A total of 12 (46 %) and seven (28 %) patients underwent EGD at 3 and 12 months postoperatively. The mean pouch length and stoma diameter were 5 ± 1.9 (26.5 % reduction) and 1.2 ± 0.7 cm (42.9 % reduction) at 3 months and 6.14 ± 1.6 (10 % reduction) and 2.2 ± 1.2 cm (4.7 % increase) at 12 months, respectively. The %EWL was 8.9, 9.3, 8, 6.7, -10.7, -13.5, -5.8, -4.5 at 3, 6, 12, 24, 36, 48, 60, and 72 months, respectively. CONCLUSION Although endoscopic plication achieved the intended reduction in the pouch and stoma diameter at 3 months, these tend toward the preoperative diameter at 12 months. This anatomical failure and the lack of follow-up may explain why most patients failed to achieve sustainable weight loss.
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Affiliation(s)
- Alberto S Gallo
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA. .,Baptist Health Louisville, 4001 Kresge Way Suite 200, Louisville, KY, 40207, USA.
| | - Christopher G DuCoin
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Martin A Berducci
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Diego F Nino
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Moneer Almadani
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Bryan J Sandler
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Santiago Horgan
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Garth R Jacobsen
- Minimally Invasive Surgery Department, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
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Endoscopic management of bariatric surgery complications: what the gastroenterologist should know. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 81:35-47. [PMID: 26552500 DOI: 10.1016/j.rgmx.2015.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/16/2015] [Accepted: 06/18/2015] [Indexed: 12/11/2022]
Abstract
Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.
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Baretta GAP, Alhinho HCAW, Matias JEF, Marchesini JB, de Lima JHF, Empinotti C, Campos JM. Argon plasma coagulation of gastrojejunal anastomosis for weight regain after gastric bypass. Obes Surg 2015; 25:72-9. [PMID: 25005812 DOI: 10.1007/s11695-014-1363-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The failure of approximately 20 % of obese patients who undergo Roux-en-Y gastric bypass (RYGB) to maintain weight loss over the following 18-24 months is related to the surgical procedure, to the patient, or both. Although the underlying mechanisms are uncertain, one factor that has been postulated is the dilation of the gastrojejunal anastomosis. The objective was to evaluate the safety and efficacy of the serial use of argon plasma coagulation (APC) in reducing the diameter of the dilated gastrojejunal anastomosis and post-RYGB weight regain. METHODS We carried out a prospective, nonrandomized study of 30 patients, with no control or sham group, monitoring RYGB weight regain associated with dilation of the gastrojejunal anastomosis over a postoperative period of 18 months. Each patient underwent three sessions of APC in the anastomosis separated by 8 weeks, with a final endoscopic examination 8 weeks after the last session. RESULTS There was a loss of 15.48 kg (range = 8.0-16.0 kg) of the 19.6 kg (range = 7.0-39.0 kg) of regained weight after RYGB and a reduction of 66.89 % in the final anastomotic diameter, with statistically significant reductions between each APC session. Previous body mass index significantly decreased up to the final examination, and the final weight was close to but not at the same level as the nadir. CONCLUSIONS Our study indicates that the use of APC to treat weight regain after RYGB is a safe and effective procedure and promotes a reduction in gastrojejunal anastomosis, final weight, and BMI, with a low rate of complications.
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Affiliation(s)
- Giorgio A P Baretta
- Universidade Federal do Paraná, 1375 Alameda Presidente Taunay, 80430-000, Curitiba, PR, Brazil,
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Moon RC, Teixeira AF, Jawad MA. Treatment of weight regain following roux-en-Y gastric bypass: revision of pouch, creation of new gastrojejunostomy and placement of proximal pericardial patch ring. Obes Surg 2015; 24:829-34. [PMID: 24446076 DOI: 10.1007/s11695-014-1188-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the literature, weight regain or failure of weight loss has been reported in up to 35% of patients after Roux-en-Y gastric bypass (RYGB). Several revisional procedures have been suggested to reinitiate further weight loss in this group of patients, and placing a silastic ring around the pouch proximal to the gastrojejunostomy is one among those procedures. The aim of our study is to evaluate and compare the safety and efficacy of salvage banding using a pericardial patch after RYGB for further weight loss. Between December 2009 and April 2013, a total of 46 patients underwent revision with pericardial patch ring after RYGB for weight regain/failure of weight loss. A retrospective review of a prospectively collected database was performed, noting the outcomes and complications of the procedure. The mean body mass index at the time of revision was 40.1 ± 6.8 kg/m2. Mean percentage of excess weight loss was 23.4 ± 15.7%, 39.0 ± 27.4%, and 18.9 ± 20.5% at 6, 12 and 24 months after revision, respectively. Eight (17.4%) patients required a total of 11 readmissions due to nausea, vomiting, dysphagia and abdominal pain. Six (13.0%) patients underwent a total of six reoperations, including four patients with laparoscopic removal of the pericardial patch and another revision of RYGB, and two patients with repair of perforated ulcers. Revision with pericardial patch ring after gastric bypass for weight regain or failure of weight loss may not be feasible, safe and effective.
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Affiliation(s)
- Rena C Moon
- Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center, Orlando Health, 89 W Copeland Drive, 1st Floor, Orlando, FL, USA
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Stavropoulos SN, Modayil R, Friedel D. Current applications of endoscopic suturing. World J Gastrointest Endosc 2015; 7:777-789. [PMID: 26191342 PMCID: PMC4501968 DOI: 10.4253/wjge.v7.i8.777] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 02/13/2015] [Accepted: 04/29/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic suturing had previously been considered an experimental procedure only performed in a few centers and often by surgeons. Now, however, endoscopic suturing has evolved sufficiently to be easily implemented during procedures and is more commonly used by gastroenterologists. We have employed the Apollo OverStitch suturing device in a variety of ways including closure of perforations, closure of full thickness defects in the gastrointestinal wall created during endoscopic full thickness resection, closure of mucosotomies during peroral endoscopic myotomy, stent fixation, fistula closure, post endoscopic submucosal dissection, endoscopic mucosal resection and Natural Orifice Transluminal Endoscopic Surgery defect closures, post-bariatric surgery gastrojejunal anastomosis revision and primary sleeve gastroplasty.
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Endoluminal flexible endoscopic suturing for minimally invasive therapies. Gastrointest Endosc 2015; 81:262-9.e19. [PMID: 25440675 DOI: 10.1016/j.gie.2014.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/03/2014] [Indexed: 12/12/2022]
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Aminian A, Corcelles R, Daigle CR, Chand B, Brethauer SA, Schauer PR. Critical appraisal of salvage banding for weight loss failure after gastric bypass. Surg Obes Relat Dis 2014; 11:607-11. [PMID: 26093767 DOI: 10.1016/j.soard.2014.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 11/06/2014] [Accepted: 11/18/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Placement of an adjustable gastric band (AGB) over the gastric pouch after RYGB failure has had varied results. The aim of this study was to evaluate safety and outcomes of AGB after RYGB failure. METHODS Twenty-eight patients who underwent laparoscopic placement of an AGB around the gastric pouch as a revisional procedure for inadequate weight loss or recidivism after RYGB between 2008-2011 were identified. RESULTS Twenty-four (86%) patients had a dilated gastric pouch and/or stoma. The mean operative and adhesiolysis times were 137.9±52.3 minutes and 83±51 minutes, respectively. History of a previous open RYGB was associated with a longer adhesiolysis time (P = .03). Three (11%) major intraoperative and 5 (18%) early postoperative complications occurred. Late complications (all requiring band removal) were observed in 6 (21%) patients and included ineffectiveness (n = 2), dysphagia/esophageal dilation (n = 2), band erosion (n = 1), and peritonitis (n = 1). In all 4 patients with a normal-sized pouch and stoma at the time of band placement, the band was removed. After a mean follow-up of 38.3±14.8 months, the mean body mass index (BMI) change and median excess weight loss (EWL) after salvage banding were -3.6±4.5 kg/m(2) and 12.7%, respectively. In the subset of patients with a dilated pouch/stoma, BMI less than 42 kg/m(2) at the time of band placement was associated with a significantly higher EWL (41.4%±37.0%) compared with a baseline BMI>42 kg/m(2) (12.1%±7.2%, P = .03). CONCLUSIONS Salvage banding is technically challenging due to dense adhesions, carries significant morbidity, and is associated with only 13% additional EWL. However, this approach may still be an option in carefully selected patients, such as those with previous laparoscopic RYGB who have a dilated pouch and/or stoma and lower BMI.
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Affiliation(s)
- Ali Aminian
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ricard Corcelles
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Gastrointestinal Surgery, Hospital Clinic Barcelona, Barcelona, Spain
| | | | - Bipan Chand
- Department of Surgery, Loyola University, Chicago, Illinois
| | - Stacy A Brethauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Philip R Schauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.
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Henderson JB, Sorser SA, Atia AN, Catalano MF. Repair of esophageal perforations using a novel endoscopic suturing system. Gastrointest Endosc 2014; 80:535-7. [PMID: 25127954 DOI: 10.1016/j.gie.2014.03.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 03/20/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Joseph B Henderson
- St. Luke's Medical Center, Pancreatic Biliary Center, Milwaukee, Wisconsin, USA
| | - Serge A Sorser
- St. Luke's Medical Center, Pancreatic Biliary Center, Milwaukee, Wisconsin, USA
| | - Antwan N Atia
- St. Luke's Medical Center, Pancreatic Biliary Center, Milwaukee, Wisconsin, USA
| | - Marc F Catalano
- St. Luke's Medical Center, Pancreatic Biliary Center, Milwaukee, Wisconsin, USA
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40
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Kumar N, Thompson CC. Endoscopic management of complications after gastrointestinal weight loss surgery. Clin Gastroenterol Hepatol 2013; 11:343-53. [PMID: 23142331 DOI: 10.1016/j.cgh.2012.10.043] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/23/2012] [Accepted: 10/26/2012] [Indexed: 02/07/2023]
Abstract
As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.
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Affiliation(s)
- Nitin Kumar
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Dakin GF, Eid G, Mikami D, Pryor A, Chand B. Endoluminal revision of gastric bypass for weight regain--a systematic review. Surg Obes Relat Dis 2013; 9:335-42. [PMID: 23561960 DOI: 10.1016/j.soard.2013.03.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 01/29/2013] [Accepted: 03/01/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a challenging problem for patients and bariatric surgeons alike. Traditional operative strategies to combat weight regain are technically challenging and associated with a high morbidity rate. Endoluminal interventions are thus an attractive alternative that may offer a good combination of results coupled with lower periprocedure risk that might one day provide a solution to this increasingly prevalent problem. The purpose of this article is to systematically review the available literature on endoluminal procedures used to address weight regain after RYGB, with specific attention to the safety profile, efficacy, cost, and current availability. This review focuses only on endoluminal procedures that are performed for weight regain after RYGB, as opposed to primary endoluminal obesity procedures. METHODS This study was a retrospective review. RESULTS Several methods of endoluminal intervention for weight regain are reviewed, ranging from injection of inert substances to suturing and clipping devices. The literature review shows the procedures on the whole to be well tolerated with limited efficacy. The majority of the literature is limited to small case series. Most of the reviewed devices are no longer commercially available. CONCLUSIONS Endoluminal therapy represents an intriguing strategy for weight regain after RYGB. However, the current and future technologies must be rigorously studied and improved such that they offer durable, repeatable, cost-effective solutions.
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Abstract
Obesity affects more than one third of adults in the United States and is associated with increased morbidity, mortality, and health care costs compared with normal weight adults. Current therapies include medical management consisting of therapeutic lifestyle change and pharmacotherapy, which has limited effectiveness, and bariatric surgery, which is currently the most effective therapy, but is limited by complications, long-term weight regain, and limited access. Endoscopic therapies are currently under investigation to treat weight regain after bariatric surgery and as a primary treatment for obesity, addressing the current gap in the treatment of obesity.
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Affiliation(s)
- Shelby Sullivan
- Division of Gastroenterology, Center for Human Nutrition, Washington University School of Medicine, St Louis, MO 63110, USA.
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