Endoscopic gastric pouch plication (EGPP) is an alternative approach to surgical revision from RYGB, resulting in a relatively favourable safety profile, according to authors from Case Western Reserve University, Cleveland, OH. However, they caution that further research is required to thoroughly assess its efficacy and to draw comparisons with other surgical revision techniques.
The authors noted that that RYGB is vulnerable to complications that can require re-intervention and re-operation. The causes are multifactorial and include dilation of gastrojejunal anastomosis (GJA), elongation of the gastric pouch, and less commonly, gastro-gastric fistulas. It is estimated that 12% of patients will have some type of surgical revision following gastric bypass surgery, either for unsatisfactory weight loss or for complications.
Minimally invasive revisional procedures including EGPP, where endoscopic suturing is used to tighten the dilated gastric pouch, may involve fewer risks such as reducing operating room times and post-operative pain. This study used data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry (2020 to 2022). The primary objectives were to determine the rate of serious complications and mortality of endoscopic gastric pouch plication in the revisional setting, and to identify independent predictors of serious complications through multivariable analysis.
The authors explained that “EGPP involves endoscopic visualisation of the gastric pouch and gastrojejunal anastomosis, followed by placement of full-thickness or partial-thickness endoscopic sutures using devices such as the Apollo OverStitch or Incisionless Operating Platform (Figure 1). These sutures are placed in a continuous or interrupted fashion to reduce the pouch volume and/or outlet diameter. The procedure typically requires general anaesthesia and CO2 insufflation. Practitioners performing EGPP should have expertise in therapeutic endoscopy and typically complete dedicated training programs in bariatric endoscopy, with specific emphasis on endoscopic suturing techniques.”
Outcomes
The study population had a mean age of 50.6 years (SD ± 9.9) and the majority of patients were female (89.9%) and white (60.3%). Patients had an initial mean BMI of 40.4kg/m2 with comorbidities including hypertension (36.7%), gastroesophageal reflux disease (34.6%), sleep apnoea (19.6%) and diabetes (13.2% with 10.5% being insulin-dependent).
The primary indications for EGPP were predominantly weight-related issues:
Recurrent weight gain accounted for 71.9% of cases
Suboptimal initial weight loss 15.1%
Dumping syndrome 5.5%; and
GERD (4.14%)
Less common indications included:
Gastrointestinal tract fistula 1.0%
Persistent comorbidities 0.5%; and
Hypoglycemia (0.3%)
The average operating time for EGPP was 41.2 min (SD 35.2) and the mean hospital stay was 0.4 days with 72.1% (n=1,063) of cases performed as a same-day procedure. The rates of complications for patients undergoing EGPP were: anastomotic leak (0.3%), postoperative bleed (0.9%), reoperation (0.4%), re-intervention (2.6%), readmission (3.2%), cardiac complication (0.07%), pneumonia (0.07%), acute kidney injury (0.07%), venous thromboembolism (0.07%), deep surgical site infection (0.3%) and serious complications (3.3%).
After multivariable logistic regression, only GERD was independently predictive of serious complications (p=0.05) and patients with GERD had more than double the rate of serious complications (5.1 vs 2.4%, p=0.006).
In comparing GERD versus non-GERD patients, most complications occurred at similar rates in both groups, with no statistically significant differences for leaks, bleeding, interventions within 30 days, cardiac events, acute kidney injury, venous thromboembolism and surgical site infections. Nevertheless, significant differences were observed in reoperation rates (1.0% vs 0.01%, p=0.012), readmission within 30 days (2.4% vs 4.7%, p=0.016) and ulcer occurrence (0.2% vs 1.0%, p=0.040), with GERD patients experiencing higher rates in these categories.
The group with GERD also experienced more frequent strictures (0.0% vs 0.2%) and the overall rate of serious complications was significantly higher in the GERD group (2.4% vs 5.1%, p=0.006). The authors wrote that this suggests that patients with pre-existing GERD may be at higher risk for certain postoperative complications EGPP.
The study authors said that future research should focus on long-term efficacy data comparing EGPP to surgical revision, standardised criteria for patient selection (particularly regarding GERD status), cost-effectiveness analyses and quality of life outcomes. Moreover, researchers should examine the technical variations in EGPP techniques and their impact on outcomes to help establish best practices.
“Our results demonstrate that EGPP is an uncommon procedure, with only 1474 cases reported in this study,” the authors concluded. “... Weight recurrence emerged as the predominant indication, accounting for 71.9% of all cases. This additional data will be essential in determining the optimal role of EGPP in the management of post-bariatric surgery complications and weight-related issues.”
The findings were reported in the paper, ‘Indications and Outcomes of Endoscopic Gastric Pouch Plications After Bariatric Surgery: An Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database’, published in Obesity Surgery.
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