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Overstitch revision surgery

Endoluminal revision of the dilated pouch after RYGB

A novel endoluminal approach for surgical revision (OverstitchTM, Apollo Endosurgery) of the dilated pouch outlet after proximal Roux-en-Y gastric bypass in late dumping syndrome
Researchers assessed the viability, safety and efficacy of this procedure in 20 patients who had developed late dumping syndrome
Indication for surgical revision was defined as simultaneous dilatation of the gastro-jejunostomy >3.5cm and pathological findings that indicated hypoglycemic hyperinsulinemia
OverstitchTM endoluminal endoscopic suturing represents a promising novel therapeutic option involving minimal trauma and offering rapid reconvalescence

Dumping syndrome is a common postoperative complication of gastric surgery procedures. The syndrome is class-divided in early and late dumping. Early dumping syndrome occurs shortly after ingestion of nutrition. Symptoms are fatigue, lassitude, drowsiness and desire for reclining. By comparison, late dumping appears 2 to 3 hours after food intake. Up to date pathophysiology remains relatively unclear, but corresponding to early dumping an assumed reason is the quick influx of carbohydrates with reactive overshoot of pancreatic insulin output, whereas physical reaction in early dumping is more a vasomotor disturbance due to a volume shift into the bowel 1-8.

Dr Christine Stier, Sana Klinikum, Offenbach, Germany

The increasing number of bariatric procedures worldwide, explicitly the Roux-en-Y gastric bypass, led to an agglomeration of this entity and a focus to its treatment options9-14. Morphologically, dumping syndrome mostly correlates with an enlargement of the pouch outlet. Conservative therapy includes nutritional amendment with more frequent meals containing less carbohydrates and more protein and fiber15. Next treatment step would be complementary pharmacotherapy with Acarbose, diminishing carbohydrate resorption16-23. Failure of the conservative treatment leads to surgical procedures as ultima ratio option, including laparoscopic revision of the outlet, implant of bands and rings at the pouch level and, if those fail even reconstruction of the gastric bypass to natural anatomy with reinstallation of the pyloric function24-32.

Figure 1: OverStitchTM outlet revision, running suture with running reinforcement suture

A novel option of treatment is the endoluminal surgery to restrict the gastro-jejunostomy using a endoscopic suturing device (OverStitchTM, Apollo)33-39. We assessed the viability, safety and efficacy of this procedure in 20 patients with a mean age of 40.64 years, who had developed late dumping syndrome.

Figure 2: Continuous glucose monitoring prior and post OverStitchTM outlet revision

Those 20 patients underwent endoluminal surgery using an endoscopic suturing technique with double-lumen surgical scope and an OverStitchTM suturing device with Prolene 2/0 (OverStitchTM, Apollo). Dumping Syndrome was confirmed by elevated Sigstad score40 above 7, oral glucose tolerance test (OGTT), continuous glucose measurement for 7 days (CGM)41 and a gastric emptying scinitgraphy42-43. Indication for surgical revision was defined as simultaneous dilatation of the gastro-jejunostomy > 3.5 cm and pathological findings resulting from the above mentioned examinations, which indicate hypoglycemic hyperinsulinemia.

Figure 3: Scintigraphic findings prior and post OverStitchTM outlet revision

Endoluminal outlet revision with OverStitchTM suturing device was performed under general anesthesia. PONV (prophylaxis of nausea and vomiting) prophylaxis was administered in all cases in order to avoid postoperative vomiting which could endanger the newly-placed sutures.

Patients were operated in a left lateral position with the right arm placed alongside the body and the left arm extended at 90o. During procedure to re-evaluate anatomy, initially a gastroscopy was performed using a diagnostic single lumen endoscope. The gastral mucosa of the outlet was ablated 1 cm circularly with an argon plasma coagulator (APC) (Figure 4). Excess argon was removed by suction. Afterwards an overtube was placed into the esophagus with guidance of the scope. (OverTubeTM Endoscopic Access System, Apollo Endosurgery) Protected by the overtube the double-lumen scope equipped with OverStitchTM was inserted proximal to the gastro-enterostomy.  If procurable, anastomosis was stitched above the alimentary limb to redirect chyme, thus further extending passage time. Various suturing techniques were used, including the standard single interrupted stitches or running sutures with 4 or 5 stitches.

Figure 4: Pneumoperitoneum due to full thinkness sutures, without correlating pathological significance

In all patients the post-operative course was uneventful. Discharge from inpatient care was in all cases two days after surgery. Interestingly, none of the patients sensed post-surgical abdominal pain, except of one, who showed plenty of free intra-abdominal air after the intervention, without corresponding pathological condition. This patient described the perceived pain comparable to a laparoscopic surgery approach. The pain level in all patients was evaluated by visual analogue pain scale (range 0-10) and the medium score was 0.6. Post-operative care included blood test and contrast x-ray. Inflammation parameters (leucocytes, CrP) did not rise above standard values in any case during post-surgical hospital stay. Postoperative dietary transition, from orally administrated liquids on the first day to intake of pureed foods during the 4 weeks after surgery, was tolerated by all patients without any difficulties.

One month after endoluminal overstitch intervention all patients have been re-evaluated. The median preoperative elevated Sigstad-Dumping-Score was and showed an impressive reduction to median 3.87 (P< 0.001). Except of two patients dumping symptoms were completely resolved with the intervention. These two patients showed a remarkable improvement but no complete remission of late dumping syndrome weeks post surgery. In one case with a remaining Sigstad score of 12, dropping at least from initial 24, a reconstruction to natural anatomy with isochronal sleeve gastrectomy was performed. Even with reinstalled pyloric allocation function in this patient dumping syndrome relapsed. The other patient still showed a Sigstad score of 9, which was initially at a score of 16. In this case we added pharmacotherapy and so reached finally the symptoms resolve.

Scintigraphical re-examination demonstrated decelerated gastric emptying. Prior to surgery, after 10 minutes examination time, the scinitgraphy revealed only 12% of the tracer activity remaining in projection of the pouch area, whereas after the OverStitchTM intervention of the tracer activity in this region of interest was risen to  69% ,  showing a remarkable slower delivery of the test meal into the alimentary limb (p <0.001)41-42.

Comparing the CGM, the most impressive case showed a reduction of the overall hypoglycemic glucose values from 84% to 5% post-interventional during an evaluation of 7 days of continuous glucose monitoring.

Use of the OverstitchTM endoluminal endoscopic suturing device for revision of dilated pouch outlet following Roux-en-Y gastric bypass represents a promising novel therapeutic option involving minimal trauma and offering rapid reconvalescence. Functional results appear to compare well with established laparoscopic techniques. We were able to demonstrate that surgical gastro-enterostomy revision carried out with the OverStitchTM suturing device is a very effective therapeutic option for patients with late dumping syndrome.

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