Management of Weight Regain

Fig. 16.1

The Apollo OverStitch device (Apollo EndoSurgery)

Transoral Outlet Reduction (TORe) Using the OverStitch Device

TORe using the OverStitch full-thickness suturing platform has been shown effective at inducing clinically significant long-term weight loss in patients who experienced weight regain after RYGB [27–29]. Mean weight loss experienced 12 months after the procedure ranges from 5.7 to 10.6 kg, with % excess weight loss ranging from 11.3% to over 25%. Improved outcomes are consistently seen when APC is combined with full-thickness TORe [23].

Procedures are typically performed under general anesthesia with endotracheal intubation. A routine upper endoscopy is first completed to evaluate the diameter and health of the anastomosis along with the size of the gastric pouch. Pouch diameter and length can be used to estimate gastric volume (diameter x length). The OverStitch platform is then mounted on the distal tip double-channel endoscope (GIF-2T160 or 180 Olympus America, Central Valley, Pennsylvania, USA) which allows the use of the Helix device for tissue acquisition for deep suture placement and the catheter-based actuating needle for driving and reloading sutures.

Prior to performing the TORe procedure, the authors prefer to use APC along the gastric side of the anastomosis to prepare the tissue for suturing and to minimize bleeding. An esophageal overtube may be placed prior to passing the suturing system through the esophagus in order to protect the esophagus from repeated intubations with the suturing device but is not employed across all expert centers.

Multiple suturing patterns have been used and studied for TORe including simple interrupted, figure of eight, and purse string. The end goal is to reduce the aperture to 8–10 mm (Fig. 16.2), as smaller diameters are associated with increased nausea and vomiting that result in higher stitch loss and poorer weight loss outcomes. Endoscopists can expect to use anywhere from 1 to 12 sutures depending on the size of the GJA and suturing technique employed. The patient is maintained NPO for 24 hours after the procedure. The authors occasionally prescribe a 5-day course of antibiotics and at least 2 weeks of proton pump inhibitor therapy along with a liquid diet for at least 2 weeks after the procedure, with gradual progression to solid food over the next 2 weeks. Nausea and abdominal pain are the most common symptoms after the procedure, but with intraoperative dexamethasone or aprepitant injection, these are reduced significantly. A small proportion (<2%) can experience stenosis after revision, necessitating endoscopy to perform balloon dilation of the stenosed GJA.

../images/442926_1_En_16_Chapter/442926_1_En_16_Fig2_HTML.jpg — Fig. 16.2

GJA pre- and post-TORe

Simple Interrupted

The simple interrupted technique is illustrated in Fig. 16.3. After the OverStitch device is mounted on the endoscope and APC has been performed around the mucosa, stitches are placed through the gastric mucosa with aid of the tissue helix from the lower left to the upper right. The revised GJA may be edematous afterward, but a standard endoscope should transverse the aperture in order to ensure patency. Figure of eight suturing pattern is employed in a similar fashion, and at times a combination of simple interrupted and figure of eight sutures is used due to the GJA anatomy.

../images/442926_1_En_16_Chapter/442926_1_En_16_Fig3_HTML.jpg — Fig. 16.3

TORe using simple interrupted suture technique. The GJA is reduced to approximately 8–10 mm

Purse-String Technique

The second most common suturing technique used for TORe is the purse-string technique . This technique involves using a single suture (or in some cases two running sutures) placed around the margin of the GJA in a continuous ring. APC is used to ablate the gastric side of the GJA prior to suture placement. After the running suture has made at least one full circle around the GJA, a balloon is then passed through the second endoscope channel and inflated inside the anastomosis to 6–8 mm. The suture is then tightened around the balloon and cinched (Fig. 16.4). The advantages of the purse-string technique include the low number of sutures used, control over the final aperture by using the balloon to tighten the suture, and superior weight loss outcomes compared to simple interrupted techniques [28, 29].

../images/442926_1_En_16_Chapter/442926_1_En_16_Fig4_HTML.jpg — Fig. 16.4

TORe using a purse-string technique. The suture is tightened and cinched over a through-the-scope balloon to size the final aperture

Tubular Reinforced TORe

A novel approach to TORe involves the creation of a reinforced tubular sleeve proximal to the revised GJA anastomosis. The reinforced proximal tubular sleeve uses the same triangular suturing pattern as the endoscopic sleeve gastroplasty, reducing the size of the pouch. The GJA is reduced first using a combination of interrupted and figure of eight sutures, and the proximal sleeve gastroplasty is then created (Fig. 16.5). The technique was developed for those with an eccentric GJA location, making it difficult to perform the purse-string technique with a concomitantly enlarged gastric pouch. Unpublished data suggests superior weight loss outcomes at 3 months compared to simple interrupted suturing.

../images/442926_1_En_16_Chapter/442926_1_En_16_Fig5_HTML.jpg — Fig. 16.5

Reinforced “tubular” TORe. A reinforced tubular gastroplasty exit proximal to the revised GJA is performed

Pouch Revision

A variety of novel endoscopic techniques have more recently been employed to reduce the size of the gastric pouch . One study described the use of radiofrequency ablation (Barrx™, Medtronic, Minneapolis, MN) across the entire pouch and GJA in 25 patients. The authors repeated the procedure at 4 and 8 months if the patients had not met target weights. At 12 months, the median %EWL was 18.4% [IQR 10.8–33.7] with an absolute weight loss of 14 kg. The majority of patients (>80%) required three RFA treatments over the course of the study [30]. Further comparative trials are needed.

Sleeve Gastrectomy Revision

While the bariatric endoscopists have traditionally focused on RYGB, a few case series have reported successful revision of the sleeve gastrectomy using the full-thickness suturing platform as an alternative to conversion to RYGB, or “re-sleeving” with endoscopic suture gastroplasty for the treatment of weight regain or primary failure. A pilot series of five patients reported 12-month mean % EWL of 33% with %weight loss ranging from 6.7% to 17.2% [31]. Further retrospective studies are forthcoming.

Conclusion

Advances in endoluminal techniques have allowed endoscopists to manage a variety of complications after bariatric surgery in a safe and effective fashion. With the rising prevalence of obesity and number of bariatric surgeries being performed, endoscopists are poised to play an instrumental role in the advanced management of bariatric patients who experience leaks, fistulas, and weight regain. Endoscopic revisions of the anatomical factors associated with weight regain are effective at inducing weight loss and weight stabilization. TORe with full-thickness suturing techniques is effective in the revision of dilated GJAs and should be offered to patients as part of a comprehensive treatment approach with level 1 data supporting its use. Concomitant pouch revision is regaining popularity, with innovative treatments such as RFA and pouch gastroplasty representing the newest endoscopic approaches.