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Endoscopic pouch revision for weight gain following RYGB

Endoscopic pouch revision for weight gain following RYGB

It is generally accepted that morbid obesity is a chronic disease that can lead to multiple metabolic conditions. Bariatric surgery is a highly effective therapy that has been shown not only to reverse metabolic syndromes1, help defer the onset of Type 2 Diabetes2,3 and improve life expectancy.4  Although 10% weight regain is common in the majority of patients4 there will be a number of patients that fail to achieve enough weight loss from their primary procedure or regain a lot of weight.5  If we consider the case of roux-en-y gastric bypass (RNYGB) it has been shown that gastrojejunal stoma diameter is significantly associated with weight regain.6  Reported options to treat inadequate weight loss or excess weight regain in RNYGB patients include laparoscopic placement of adjustable or nonadjustable bands around the gastric pouch, Laparoscopic stoma resizing, and limb lengthening procedures.  As one would expect, complications such as band migration, stricture formation and anastomotic leaks have been reported.7

Christopher D Sutton MBBch MD FRCS Consultant Upper Gastrointestinal Surgeon University Hospitals of Leicester UK

There is now a commercially available endoscopic solution for pouch and stoma resizing, namely, the Apollo Overstitch Endoscopic Suturing Device (Figure 1).

Figure 1: Overstitch endoscopic suturing system

The device attaches to a double- channel Olympus endoscope (GIF-2T240 UK & Middle East or GIF-2T160 rest of world). A curved suture arm extends from one channel and an anchor exchange extends from the second. The procedure involves an endoscopy under general anaesthetic during which the enlarged stoma is marked around its circumference with the argon plasma coagulator. (Figure 2 and 3)

Figure 2: Dilated Gastro-jejunal anastomosis

Figure 3: application of argon to stoma

An overtube is then placed into the oesophagus and the Overstitch device is introduced into the pouch using the double -channel endoscope. Interrupted transmural stitches (PLY-G02-020  Overstitch 2-0 Polypropylene Suture) are inserted from right to left until the anastomotic stoma has been reduced to <12mm (Figure 4). If the pouch has become dilated, it may be reduced in size by placing transmural, interrupted sutures from distal to proximal.

Figure 4: sutured stoma

Initial reports of this technique describe average weight loss at 6 months of 11kg with a low risk of complications.8 In 2015, it was acknowledged that the Apollo Overstitch system would work with the Olympus double-channel endoscopes available in the UK (GIF-2T240).  We have recently started using the technique on patients with weight regain and increased stoma size following RNYGB. Our early results mirror those published by the Mayo clinic. 

References

  1. Buchwald H1, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysisJAMA. 2004 Oct 13;292(14):1724-37.
  2. Carlsson LM1, Peltonen M, Ahlin S, Anveden Å, Bouchard C, Carlsson B, Jacobson P, Lönroth H, Maglio C, Näslund I, Pirazzi C, Romeo S, Sjöholm K, Sjöström E, Wedel H, Svensson PA, Sjöström L. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med. 2012 Aug 23;367(8):695-704. doi: 10.1056/NEJMoa1112082.
  3. Booth H, Khan O, Prevost T, Reddy M, Dregan A, Charlton J, Ashworth M, Rudisill C, Littlejohns Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study.
  4. P, Gulliford MC. Lancet Diabetes Endocrinol. 2014 Dec;2(12):963-8.
  5. Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Agren G, Carlsson LM;  Effects of bariatric surgery on mortality in Swedish obese subjects.Swedish Obese Subjects Study. N Engl J Med. 2007 Aug 23;357(8):741-52
  6. Courcoulas AP, Christian NJ, Belle SH, Berk PD, Flum DR, Garcia L, Horlick M, Kalarchian MA, King WC, Mitchell JE, Patterson EJ, Pender JR, Pomp A, Pories WJ, Thirlby RC, Yanovski SZ, Wolfe BM Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity.; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. JAMA. 2013 Dec 11;310(22):2416-25.
  7. Abu Dayyeh BK, Lautz DB, Thompson CC. Gastrojejunal stoma diameter predicts weight regain after Roux-en-Y gastric bypass. Clin Gastroenterol Hepatol. 2011 Mar;9(3):228-33.
  8. Brethauer SA, Kothari S, Sudan R, Williams B, English WJ, Brengman M, Kurian M, Hutter M, Stegemann L, Kallies K, Nguyen NT, Ponce J, Morton JM. Surg Obes Relat Dis. Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. 2014 Sep-Oct;10(5):952-72.
  9. Jirapinyo P1, Slattery J, Ryan MB, Abu Dayyeh BK, Lautz DB, Thompson CC. Evaluation of an endoscopic suturing device for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass. Endoscopy. 2013 Jul;45(7):532-6. 

Join Mr Christopher Sutton and Apollo Endosurgery for a hands-on session at 7th BOMSS Annual Scientific Meeting on the new endoscopic suturing device. To register your interest in attending this event, please click here

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