Weight regain after bariatric surgery is common and can be managed with surgical interventions or less morbid endoscopic techniques. These endoscopic approaches target structural postoperative changes that are associated with weight regain, most notably dilation of the gastrojejunal anastomosis aperture. Purse string suture placement, as well as argon plasma coagulation application to the anastomosis, may result in significant and durable weight loss. Furthermore, various endoscopic approaches may be used to safely and effectively manage other complications of bariatric surgery that may result in poor weight loss or weight regain after surgery, including fistula formation.
Key points
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Weight regain after bariatric surgery is common and can be managed with less invasive endoscopic techniques.
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Endoscopic techniques target structural postoperative changes that are associated with weight regain, most notably dilation of the gastrojejunal anastomosis aperture.
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Purse string suture placement, as well as argon plasma coagulation application to the anastomosis, may result in significant and durable weight loss.
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Various endoscopic approaches may be used to safely and effectively manage complications of bariatric surgery, including ulceration and fistula.
Introduction
Obesity is a lifelong condition of pandemic proportion that requires long-term multidisciplinary management leading up to and beyond any single intervention. Even after restrictive and metabolic surgeries like a Roux-en-Y gastric bypass (RYGB), patients have the potential to experience significant weight regain, which is why a long-term care team is necessary for management of obesity. An emerging member of this care team is the bariatric endoscopist. The field of endobariatrics includes revision procedures for patients who experience weight regain after bariatric surgery, as well as primary endoscopic procedures for the management of obesity. This field also provides medical management of obesity as well as minimally invasive endoscopic treatments for various complications of bariatric surgery including perforations, leaks, stenosis, and fistulas, to name a few. This article focuses on the currently available endoscopic revision procedures for patients who experience weight regain after bariatric surgery, and also touches on endoscopic techniques in the management of other complications of bariatric surgery that may contribute to weight regain including ulcerations and fistulae.
Introduction
Obesity is a lifelong condition of pandemic proportion that requires long-term multidisciplinary management leading up to and beyond any single intervention. Even after restrictive and metabolic surgeries like a Roux-en-Y gastric bypass (RYGB), patients have the potential to experience significant weight regain, which is why a long-term care team is necessary for management of obesity. An emerging member of this care team is the bariatric endoscopist. The field of endobariatrics includes revision procedures for patients who experience weight regain after bariatric surgery, as well as primary endoscopic procedures for the management of obesity. This field also provides medical management of obesity as well as minimally invasive endoscopic treatments for various complications of bariatric surgery including perforations, leaks, stenosis, and fistulas, to name a few. This article focuses on the currently available endoscopic revision procedures for patients who experience weight regain after bariatric surgery, and also touches on endoscopic techniques in the management of other complications of bariatric surgery that may contribute to weight regain including ulcerations and fistulae.
Patient evaluation for weight regain after bariatric surgery
Prior to offering endoscopic revision procedures, an appropriate infrastructure must be in place. As a part of a multidisciplinary center offering care to the bariatric patient, the customary endoscopy suite will need to make some adjustments to provide safe, dignified, and high-quality care for this patient population. Common adaptations needed to safely and comfortably accommodate bariatric patients include:
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Bariatric specialty furniture for the clinic and endoscopy suite including the waiting areas
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Appropriately sized bathrooms, reinforced toilets and room structure including larger doorways
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Bariatric-rated stretchers and tables for the procedural arena
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Anesthesia team attuned to and comfortable with bariatric patients
As part of the evaluation of the patient with weight regain after bariatric surgery, it is important to obtain a thorough medical history and physical examination. Comorbid conditions that may increase risk associated with procedural sedation are noted, especially because some endoscopic techniques may be safely performed with only conscious sedation, reducing the cost and time required by monitored anesthesiologist care. Prior operative reports should be reviewed to determine the patient’s surgical anatomy including any postoperative complications that may have occurred and that will aid in endoscopic procedural planning. The patient’s presurgical weight, postsurgical nadir weight, and total weight regained should be recorded. It is important to discuss lifestyle issues related to weight regain, including diet and exercise habits, to determine other contributing factors to the patient’s weight regain. In particular, dietary habits to avoid include grazing, rather than eating discrete meals at defined times and consumption of soft calories or sliders, rather than solid whole foods that require chewing and digestion. These 2 eating habits must be addressed prior to consideration of any endoscopic therapy. Appropriate referrals to a dietician, lifestyle coach, and/or psychologist should be made depending on the individual patient.
The cause of weight regain after bariatric surgery is generally multifactorial, but in some cases, reversible medical causes may be at play. Evaluation for medical conditions contributing to weight regain after gastric bypass include:
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Iron studies—Iron deficiency anemia must be corrected
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TSH and free T4—hypothyroidism and other relevant endocrinopathies should be addressed
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Exercise and physical therapy—movement limitations including arthritis should be addressed if possible
Most patients with unresolved obesity, or those who have redeveloped obesity (BMI >30 kg/m 2 ) and have had all of the previously listed issues addressed should be considered candidates for endoscopic therapy. This is especially true with the presence of comorbid conditions related to obesity (ie, diabetes, hypertension, hyperlipidemia, fatty liver disease, obstructive sleep apnea, or arthritis).
Endoscopic bariatric revision procedures
Currently available endoscopic techniques for weight loss in the postbariatric surgery patient are primarily aimed at patients who have undergone RYGB, and less commonly those with laparoscopic sleeve gastrectomy (LSG) anatomy. Cumulative numbers of patients who have undergone RYGB in the United States are steadily increasing. Up to 20% of these patients fail to achieve therapeutic success, defined as 50% excess weight loss at 1 year, and another 30% of patients will experience some degree of weight regain, which has no consensus definition, but may be defined as 15% increase from nadir weight. This phenomenon of weight regain can affect patient quality of life, lead to return or worsening of comorbid medical conditions, and increases health care expenditure. Although maladaptive eating behaviors and sedentary lifestyle may contribute to weight regain, some reversible structural issues related to the patient’s pouch and anatomy also contribute. Surgical revision, including limb-lengthening procedures, are effective and used in up to 13% of RYGB patients with weight regain. However, these are associated with complication rates of up to 50% and mortality rates more than double that of the original surgery, likely owing to the complexity of the non-native abdominal cavity with associated scars, adhesions, and altered anatomy. Out of this landscape, minimally invasive endoscopic methods of revision for weight regain after surgical bypass have emerged, targeting the dilated gastric pouch and gastrojejunal anastomosis through use of electrocautery and/or endoscopic suturing or plication techniques.
One landmark study has shown that dilation of the aperture of the gastrojejunal anastomosis (GJA) after surgery is correlated with weight regain after RYGB. In a multivariable logistic regression model, enlarged stomal size was the single greatest predictor of weight regain, and a linear relationship between stomal aperture and weight regain was revealed. Based on these data, stomal diameter greater than or equal to 15 mm may be defined as dilated, and endoscopic revision of the anastomosis should be considered.
Argon Plasma Coagulation
Given the association between dilated GJA and weight regain after RYGB, techniques to reduce the outlet diameter through formation of scar tissue was originally studied using sclerotherapy and more recently through application of argon plasma coagulation (APC). Endoscopic sclerotherapy, similar to sclerotherapy of esophageal varices, was accomplished using submucosal needle injection of sodium morrhuate around the gastrojejunal GJA to create edema, scarring, and ideally reduction in aperture of the anastomosis. Because of safety concerns and decreasing availability of sodium morrhuate, as well as the availability of a safer and more easily applied technique using APC, sclerotherapy is no longer utilized. A study of 28 patients receiving sclerotherapy demonstrated that the majority (64%) of patients lost more than 75% of their regained weight after an average 2.3 procedures repeated every 3 to 6 months apart. Anastomotic diameters greater than 15 mm are less likely to benefit from this technique and may benefit more from an endoscopic suturing revision procedure. A similar but newer and safer technique utilizing APC has gained popularity over sclerotherapy. In this technique, APC resurfacing of the GJA is accomplished through application of cautery to the gastric side of the anastomosis by touching the tip of a straight-fire APC catheter to the target area. Unlike with most APC techniques, contact with the mucosa is made intentionally to allow for deeper submucosal cautery. This creates a focal coagulation injury to the mucosa as well as the deeper submucosal layers. In 1 study of 30 patients who underwent 3 sessions of APC for weight regain of average 43.2 lbs after their RYGB, an average of 34 lbs were lost. The stomal diameter was reduced 66.9% after completion of these 3 sessions. The authors use pulsed APC with settings of flow 0.8 L/s, effect 2 and 55W. Circumferential resurfacing therapy is applied around the anastomosis in 2 to 3 rings of focal coagulation ( Fig. 1 ). Edema, ulceration, and scar tissue formation result in gradual aperture reduction. To allow for maximal healing and to prevent bleeding ulceration, patients are maintained on a twice-daily proton pump inhibitor (PPI), as well as a liquid diet for 45 days after the procedure. Patients typically return for repeat therapy every 8 to 10 weeks for 3 to 4 sessions until the desired aperture size and satiety effect is reached. One international prospective nonrandomized study of 30 patients using APC at 90W revealed that after 3 treatment sessions every 8 weeks, an average 15.5 kg of the average 19 kg regained after bariatric surgery were lost.
The Transoral Outlet Reduction and Purse String
Using the OverStitch platform (Apollo Endosurgery, Austin, Texas) the Transoral Outlet Reduction, or TORe procedure, is used internationally and at many centers across the United States to reduce the aperture of the GJA through use of a purse string suture of the anastomosis. The OverStitch device ( Fig. 2 ) is attached to the distal end of a double-channel therapeutic endoscope, which allows for both use of the catheter-based actuating needle for driving and reloading suture, as well as deployment of a helix device to allow for tissue retraction and deeper suture placement.
For the TORe procedure, an esophageal overtube is placed to protect the proximal esophagus from trauma that may occur with repeated intubations of the suturing device, as it may be removed and replaced through the esophagus during the procedure. To prepare the outlet for suturing, the gastric mucosa adjacent to the anastomosis is treated with APC (forced coagulation, 0.8 L/min, 30 W), and then full-thickness sutures are placed with the needle driven from the jejunal to gastric side of the anastomosis to reduce the aperture ( Fig. 3 ). One study of TORe that included 25 patients with dilated GJA resulted, on average, in an aperture reduction from 26.4 mm to 6 mm, with weight loss of 11.7 kg (69.5% of the regained weight was lost) at 6 months without adverse events. In this study, smaller apertures resulted in increased nausea and vomiting and higher stitch loss with subsequent weight loss failure. As such, a modified technique using a purse string suture pattern was developed. Depending on the size of the outlet, 8 to 12 running stitches are placed using a single suture to create a purse string. Upon completion of the purse string, the suture is tightened over an 8 mm through-the-scope esophageal balloon to size the final outlet diameter.
