Transoral outlet reduction: a comparison of purse-string with interrupted stitch technique

Endobariatric systems: Strategic integration of endoscopic therapies in the management of obesity

The escalating obesity pandemic and its comorbidities necessitate adaptable and versatile treatment strategies. Endobariatric and metabolic therapies (EBMTs) can be strategically employed in a multipronged approach to obesity management, analogous to the way chess systems are employed to seize opportunities and thwart threats. In this review, we explore the spectrum of established and developing EBMTs, examining their efficacy in weight loss and metabolic improvement and their importance for a tailored, patient-centric approach. The complexity of obesity management mirrors the intricate nature of a chess game, with an array of tactics and strategies available to address the opponent's moves. Similarly, the bariatric endoscopist employs a range of EBMTs to alter the gastrointestinal tract landscape, targeting critical anatomical regions to modify physiological reactions to food consumption and nutrient assimilation. Gastric-focused EBMTs aim to reduce stomach capacity and induce satiety. Intestinal-focused EBMTs target hormonal regulation and nutrient absorption to improve metabolic profiles. EBMTs offer unique advantages of reversibility, adjustability and minimal invasiveness, allowing them to be used as primary treatments, adjuncts to pharmacotherapy or tools to address post-bariatric surgery weight recidivism. However, sub-optimal adoption of EBMTs due to lack of awareness, perceived costs and limited training opportunities hinders their integration into standard obesity management practices. By strategically integrating EBMTs into the broader landscape of obesity care, leveraging their unique advantages to enhance outcomes, clinicians can offer a more dynamic and personalized treatment paradigm. This approach, akin to employing chess systems to adapt to evolving challenges, allows for a comprehensive, patient-centric management of obesity as a chronic, complex and relapsing disease.

Endoscopic Management of Weight Regain After Bariatric Surgery

Weight regain, also known as recurrent weight gain, is common following bariatric surgeries. While anti-obesity medications and surgical revisions offer effective treatment options, they are not without their challenges and limitations. Over the last few decades, there have been significant advancements in endoscopic interventions to address weight regain following bariatric surgery. These procedures have demonstrated feasibility, safety, efficacy, and durability, offering minimally invasive treatment options for this patient population.

Transoral Outlet Reduction: Expert Tips, Tricks, and Troubleshooting

Transoral outlet reduction (TORe) is an incisionless, endoscopic procedure to address weight recurrence after Roux-en-Y gastric bypass. Given the chronic, progressive nature of obesity and the minimally invasive, anatomy preserving technique of TORe, the procedure is expected to be met with high patient acceptance and widening clinical adoption. Nevertheless, the approach to TORe has been heterogeneous. As endoscopic bariatric therapies are increasingly incorporated into the multidisciplinary management of obesity, it is crucial to have a standardized, evidence-based framework for their implementation. In this review, based on the available literature and the authors' combined experience of over 1,000 TORe procedures, we present our approach to patient selection, procedural technique, troubleshooting, and patient aftercare unique to TORe.

Prospective evaluation of transoral outlet reduction (TORe) after Roux-en-Y gastric bypass (RYGB) failure

BACKGROUND AND AIMS

Weight regain after RYGB is multifactorial including dilatation of the gastro-jejunal anastomosis. Transoral outlet reduction (TORe) procedure is a minimally invasive alternative to surgical anastomotic revision.

METHODS

We conducted a prospective, multicenter, simple blind, randomized study in patients with weight regain following RYGB, comparing the efficacy of conventional nutritional and behavioral management associated with a TORe procedure (TORe group) with conventional management alone and a Sham procedure (Sham group). The main objective of this study was to evaluate the percentage of excess weight loss (%EWL) at 12 months after endoscopy.

RESULTS

From January 2015 to January 2019, 73 subjects were randomized in four French Bariatric centers. The final analysis involved 50 subjects, 25 in each group, 44 women, 6 men, with an average BMI of 40.6 kg/m2. At 12 months, the average %EWL was significantly higher in the TORe group than in the Sham group (13.5 ± 14.1 vs. - 0.77 ± 17.1; p = 0.002). Cohen's d was 0.91, indicating a large effect size of the procedure on the %EWL. There was no significant difference between groups concerning the improvement of obesity-related comorbidities (diabetes and dyslipidemia) and quality of life at 12 months. We report frequent adverse events in the TORe group (20% had adverse events related to the procedure). Three adverse events were serious, including two perforations of the gastro-jejunal anastomosis after TORe group that led to the premature termination of the study.

CONCLUSIONS

After RYGBP failure linked to the dilatation of the gastro-jejunal anastomosis, TORe procedure with nutritional management results in significantly higher %EWL at 12 months compared to patients with nutritional management alone. As surgery, this minimally invasive endoscopic procedure can be associated with severe adverse events.

Development of a novel endoscopic suturing simulator: validation and impact on clinical learning curve (with video)

BACKGROUND AND AIMS

Endoscopic suturing is a complex skill with broad applications. The aim of this study was to develop and validate a novel endoscopic suturing simulator and scoring system for the purse-string suture pattern.

METHODS

This was a prospective study of an endoscopic suturing simulator that consists of a circular opening representing a dilated gastrojejunal anastomosis of Roux-en-Y gastric bypass with 12 small target holes around its circumference. Purse-string suturing is performed in a counterclockwise fashion. Time allotted is 5 minutes, and each successful bite is awarded 10 points. Participants were divided into the novice, intermediate, and experienced groups. Validity evidence based on content, validity evidence based on other variables, and validity evidence based on consequences of testing were assessed.

RESULTS

Seventeen subjects (3 novice, 7 intermediate, and 7 experienced) participated in the study. Validity evidence based on content: The content validity index for realism, relevance, and representativeness was 0.89, 1.00, and 1.00, respectively. Validity evidence based on other variables: The novice, intermediate, and experienced groups scored 30.0 ± 8.2, 57.1 ± 28.1, and 131.2 ± 51.7 (P = .001). Validity evidence based on consequences of testing: The simulator group required 5 ± 5 transoral outlet reduction cases before being able to independently complete an entire purse-string, whereas the non-simulator group required 38 ± 11 clinical cases (P < .0001).

CONCLUSIONS

This novel endoscopic suturing simulator seems realistic, relevant, and representative of the clinical suturing experience. In addition, it seems effective at objectively assessing suturing skills and shortening the clinical learning curve.

Transoral outlet reduction: Outcomes of endoscopic Roux-en-Y gastric bypass revision in 284 patients at a community practice

BACKGROUND

Transoral outlet reduction (TORe) is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass (RYGB) for weight recurrence; however, little has been published on its clinical implementation in the community setting.

AIM

To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB.

METHODS

This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022. Patients were provided longitudinal nutritional support via virtual visits. The primary outcome was total body weight loss (TBWL) at twelve months from TORe. Secondary outcomes included TBWL at three months and six months; excess weight loss (EWL) at three, six, and twelve months; twelve-month TBWL by obesity class; predictors of twelve-month TBWL; rates of post-TORe stenosis; and serious adverse events (SAE). Outcomes were reported with descriptive statistics.

RESULTS

Two hundred eighty-four adults (91.9% female, age 51.3 years, body mass index 39.3 kg/m2) underwent TORe an average of 13.3 years after RYGB. Median pre- and post-TORe outlet diameter was 35 mm and 8 mm, respectively. TBWL was 11.7% ± 4.6% at three months, 14.3% ± 6.3% at six months, and 17.3% ± 7.9% at twelve months. EWL was 38.4% ± 28.2% at three months, 46.5% ± 35.4% at six months, and 53.5% ± 39.2% at twelve months. The number of follow-up visits attended was the strongest predictor of TBWL at twelve months (R2 = 0.0139, P = 0.0005). Outlet stenosis occurred in 11 patients (3.9%) and was successfully managed with endoscopic dilation. There was one instance of post-procedural nausea requiring overnight observation (SAE rate 0.4%).

CONCLUSION

When performed by an experienced endoscopist and combined with longitudinal nutritional support, purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB.

Efficacy and safety of revisional treatments for weight regain or insufficient weight loss after Roux-en-Y gastric bypass: A systematic review and meta-analysis

Weight regain or inadequate weight loss following Roux-en-Y gastric bypass poses a significant clinical challenge. Our objective was to evaluate various revisional techniques for addressing weight regain and insufficient weight loss after Roux-en-Y gastric bypass through a systematic review and meta-analysis. We performed a literature search (in PubMed and Embase) on revisional interventions in collaboration with a medical information specialist. Measured outcomes included body mass index at intervention, total weight loss during follow-up, and complications. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals. Thirty-nine studies were included: four studies reported on argon plasma coagulation, four studies on transoral outlet reduction, nine studies on transoral outlet reduction + argon plasma coagulation, four studies on pouch/gastrojejunal anastomosis revision, five on laparoscopic gastric banding, two studies on laparoscopic gastric banding + pouch resizing, 10 on distalization-RYGB, and one on duodenal switch. All techniques resulted in short-term clinically relevant weight loss. Endoscopic procedures had a short follow-up and resulted in modest and temporary weight loss. Surgical revision techniques were successful for weight loss in longer term follow-up, at the expense of high complication rates.

Metabolic and Bariatric Endoscopy: A Mini-Review

We are currently in a worldwide obesity pandemic, which is one of the most significant health problems of the 21st century. As the prevalence of obesity continues to rise, new and innovate treatments are becoming available. Metabolic and bariatric endoscopic procedures are exciting new areas of gastroenterology that have been developed as a direct response to the obesity crisis. These novel interventions offer a potentially reversible, less invasive, safer, and more cost-effective method of tackling obesity compared to traditional bariatric surgery. Minimally invasive endoscopic treatments are not entirely novel, but as technology has rapidly improved, many of the procedures have been proven to be extremely effective for weight loss and metabolic health, based on high-quality clinical trial data. This mini-review examines the existing evidence for the most prominent metabolic and bariatric procedures, followed by a discussion on the future trajectory of this emerging subspecialty.

Factors Associated with Weight Loss After Endoscopic Transoral Outlet Reduction (TORe)

INTRODUCTION

Endoscopic transoral outlet reduction (TORe) has emerged as a safe and effective treatment option for weight regain after Roux-en-Y Gastric Bypass (RYGB). Factors that predict successful weight loss after TORe are incompletely understood. The aims of this study were to evaluate procedural factors and patient factors that may affect percent total body weight loss (%TBWL) after TORe.

METHODS

A retrospective cohort study was performed on patients after TORe. The primary outcomes were %TBWL at 6 and 12 months based on four procedural factors: purse-string (PS) vs. non-purse-string (NPS) suture pattern, gastric pouch sutures (N), change in the diameter of the gastrojejunal anastomosis, and change in the length of the gastric pouch. Secondary outcomes included patient factors that affected weight loss.

RESULTS

Fifty-one patients underwent TORe. Weight loss for completers was 11.3 ± 7.6% and 12.2 ± 9.2% at 6 and 12 months. There was a correlation between %TBWL and change in pouch length at 6 and 12 months and number of sutures in the pouch at 6 months. The difference in %TBWL between PS and NPS groups at 6 months (PS, n=21, 12.3 ± 8.5% and NPS, n=8, 8.7 ± 3.7%) and 12 months (PS, n=21, 13.5 ± 9.2% and NPS, n=5, 7.0 ± 7.9%) did not reach statistical significance. For secondary outcomes, depression was associated with %TBWL.

CONCLUSION

Change in pouch length and number of sutures in the pouch correlated positively while depression correlated negatively with weight loss after TORe. Further studies are needed to understand these effects.

Advances in endobariatrics: past, present, and future

The obesity epidemic in the USA and worldwide is well documented and continues to grow. Endoscopic metabolic and bariatric therapies may offer a less invasive approach than surgical intervention. This article will review advances in endobariatrics over the last several decades, addressing the past and current state of bariatric and metabolic endoscopy. Food and Drug Administration-cleared devices and interventions currently under investigation are described including gastric devices, gastric remodeling procedures, small-bowel devices, duodenal ablation, as well as procedures to address weight regain after bariatric surgery. Future studies evaluating gastric and duodenal combination therapy, adjunctive pharmacotherapy, as well as individualized precision-health algorithms are underway.

Transoral Outlet Reduction (TORe) for the Treatment of Weight Regain and Dumping Syndrome after Roux-en-Y Gastric Bypass

Obesity is a chronic relapsing disease of global pandemic proportions. In this context, an increasing number of patients are undergoing bariatric surgery, which is considered the most effective weight loss treatment for long-term improvement in obesity-related comorbidities. One of the most popular bariatric surgeries is the Roux-en-Y gastric bypass (RYGB). Despite its proven short- and long-term efficacy, progressive weight regain and dumping symptoms remain a challenge. Revisional bariatric surgery is indicated when dietary and lifestyle modification, pharmaceutical agents and/or psychological therapy fail to arrest weight regain or control dumping. However, these re-interventions present greater technical difficulty and are accompanied by an increased risk of peri- and postoperative complications with substantial morbidity and mortality. The endoscopic approach to gastrojejunal anastomotic revision, transoral outlet reduction (TORe), is used as a minimally invasive treatment that aims to reduce the diameter of the gastrojejunal anastomosis, delaying gastric emptying and increasing satiety. With substantial published data supporting its use, TORe is an effective and safe bariatric endoscopic technique for addressing weight regain and dumping syndrome after RYGB.

Endoscopic Gastric Bypass Revision

This article describes endoscopic revision of gastric bypass to address weight regain.

Endoscopic revision of one-anastomosis gastric bypass (ER-OAGB) for weight recurrence: a case series of 17 adults

Weight recurrence after one-anastomosis gastric bypass (OAGB), the third most common metabolic and bariatric surgery performed worldwide, is observed in a subset of patients due to the chronic, progressive nature of obesity. Endoscopic revision of the OAGB (ER-OAGB) through full-thickness suturing to reduce the gastrojejunal anastomosis and gastric pouch is a potential alternative to surgical revision. Here, we present a case series of ER-OAGB and long-term nutritional support at two international centers with expertise in bariatric endoscopy. Data were retrospectively evaluated from a prospectively maintained database. The primary outcome was total body weight loss (TBWL) at 12 months. Secondary outcomes included TBWL at 3, 6, and 15 months; excess weight loss (EWL) at 3, 6, 12, and 15 months; frequency of new/worsening symptoms of gastroesophageal reflux disease (GERD); and the frequency of serious adverse events. In this series, 17 adults (70.6% female, mean age 46.8 years, mean BMI 39.1 kg/m2) successfully underwent ER-OAGB an average of 8 years (range 2-21 years) after OAGB for a mean weight recurrence of 43.2% (range 10.9-86.9%). TBWL from ER-OAGB was 9.7 ± 1.8% at 3 months, 13.4 ± 3.5% at 6 months, 18.5 ± 2.1% at 12 months, and 18.1 ± 2.2% at 15 months. EWL from ER-OAGB was 30.5 ± 14.7% at 3 months, 42.6 ± 16.2% at 6 months, 54.2 ± 11.3% at 12 months, and 54.2 ± 11.7% at 15 months. There were no instances of new/worsening GERD symptoms or serious adverse events. In this small series of adults who experienced weight recurrence after OAGB, ER-OAGB facilitated safe and clinically meaningful weight loss, without new or worsening GERD symptoms, when performed by experienced bariatric endoscopists in concert with longitudinal nutritional support.

Weight Recidivism and Dumping Syndrome after Roux-En-Y Gastric Bypass: Exploring the Therapeutic Role of Transoral Outlet Reduction

Obesity is a chronic, relapsing disease representing a global epidemic. To date, bariatric surgery is the most effective treatment for morbid obesity in the long-term. Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric interventions, with excellent long-term outcomes. However, about one-third of patients may experience weight regain over time, as well as dumping syndrome. Both these conditions are challenging to manage and require a multidisciplinary and personalized approach. The dilation of the gastro-jejunal anastomosis is a recognized etiological factor for both weight regain and dumping syndrome. Dietary modifications, behavioral interventions, and medications represent the first therapeutic step. Revisional surgery is the traditional approach when non-invasive treatments fail. However, re-interventions may be technically difficult and are associated with increased morbidity and mortality. Transoral outlet reduction (TORe) is an endoscopic procedure aimed at reducing the size of the anastomosis and is proposed as a minimally invasive treatment of weight regain and/or dumping syndrome refractory to conservative therapies. This review is aimed at providing a narrative overview of the role of TORe as part of the multidisciplinary therapeutic toolkit nowadays available to approach weight regain and dumping syndrome after RYGB.

Endoscopic Management of Weight Recurrence Following Bariatric Surgery

Metabolic and bariatric surgery is the most effective therapy for weight loss and improving obesity-related comorbidities, comprising the Roux-en-Y gastric bypass (RYGB), gastric banding, sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch. While the effectiveness of weight loss surgery is well-rooted in existing literature, weight recurrence (WR) following bariatric surgery is a concern. Endoscopic bariatric therapy presents an anatomy-preserving and minimally invasive option for managing WR in select cases. In this review article, we will highlight the endoscopic management techniques for WR for the most commonly performed bariatric surgeries in the United States -RYGB and SG. For each endoscopic technique, we will review weight loss outcomes in the short and mid-terms and discuss safety and known adverse events. While there are multiple endoscopic options to help address anatomical issues, patients should be managed in a multidisciplinary approach to address anatomical, nutritional, psychological, and social factors contributing to WR.

Endoscopic revision of gastrojejunal anastomosis for the treatment of dumping syndrome in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis

BACKGROUND

Dumping syndrome is a known complication of Roux-en-Y gastric bypass (RYGB). Recently, endoscopic gastrojejunal anastomosis (GJA) revision has been employed as a treatment option. The primary aim of this study was to perform a systematic review and meta-analysis for the role of endoscopic GJA revision in patients with RYGB for the treatment of dumping syndrome.

METHODS

Search strategies were developed for PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception through December 2020 in accordance with PRISMA and MOOSE guidelines. Pooled proportions with rates estimated using random effects models were used. Outcomes included pooled technical success, clinical success, adverse events, and rate of reintervention. Heterogeneity was assessed with I² statistics and publication bias by funnel plot using Egger and Begg tests.

RESULTS

Six studies (n = 263 patients; 60.25% female) were included (1 prospective and 5 retrospective). Mean age was 46.27 ± 2.54 years. Average patient weight was 95.59 ± 4.78 kg, BMI of 41.43 ± 3.07 kg/m², and pre-procedure GJA size of 32.23 ± 8.68 mm. Pooled technical and clinical success was 98.15% and 89.5%. Among studies reporting Sigstad scores, endoscopic GJA revision resulted in a significant improvement [mean Sigstad score difference of - 9.96 (95% CI, - 19.951 to - 0.975); P < 0.03]. Mean procedure time was 37.12 ± 10.40 min with an intra-procedural adverse event rate of 2.42%. Over a mean follow-up of 8.03 ± 6.87 months, post-procedure adverse events occurred in 2.96% of patients with a reintervention rate of 11.54%.

CONCLUSION

This systematic review and meta-analysis suggests that endoscopic GJA revision appears an effective and safe treatment for dumping syndrome.

Revision Bariatric Procedures and Management of Complications from Bariatric Surgery

Bariatric surgery is effective, but may be associated with adverse events. A multi-disciplinary approach including endoscopic interventions can be effective to manage these. Endoscopists should familiarize themselves with gastrointestinal pathology which can occur after bariatric surgery, including nutritional deficiencies, acid reflux, anastomotic stenosis, gallstone disease, leaks, fistulas, and weight regain. Endoscopic interventions including anastomotic stricture dilation, control of bleeding, endoscopic ultrasound-guided approach for endoscopic retrograde cholangiopancreatography, leak or fistula closure via endoscopic suturing or stent placement, and transoral outlet reduction (TORe) or revision obesity surgery endoluminal (ROSE) to address weight regain are among the endoscopic tools which have demonstrated safety and efficacy in the management of adverse events after bariatric surgery.

Therapeutic endoscopy for the treatment of post-bariatric surgery complications

Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.

Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison

BACKGROUND AND AIMS

An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y gastric bypass (RYGB) and can be corrected with endoscopic or surgical revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (AE) rates and weight loss profiles between endoscopic and surgical revisional techniques over a 5-year period.

METHODS

This is a retrospective matched cohort study of RYGB patients who underwent endoscopic or surgical revision for weight regain with an enlarged GJA (>12 mm). Patients who underwent endoscopic revision (ENDO group) were matched 1:1 to those undergoing surgical revision (SURG group) based on completion of 5-year follow-up, age, sex, body mass index, initial weight loss, and weight regain. Demographics, GJA size, serious AEs, and weight profiles were collected. The primary outcome was comparison of serious AE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the serious AE rate, and a Student t test was used for weight comparisons.

RESULTS

Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The AE rate in the ENDO group (6.5%) was lower than the SURG group (29.0%, P = .043). Zero and 6 (19.4%) serious (severe) AEs occurred in the ENDO and SURG groups, respectively (P = .02). There was no significant difference in weight loss at 1, 3, and 5 years.

CONCLUSIONS

Endoscopic revision of the GJA is associated with significantly fewer total and serious AEs and similar long-term weight loss when compared with surgical revision.

Transoral outlet reduction: could additional sutures cause more harm?

BACKGROUND

The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastrojejunal anastomosis (GJA). However, there is a paucity of literature pertaining to post-TORe stenosis as an adverse event. Our aim was to determine the rate of stenosis, its potential predictors, and other complications of DPSP TORe.

METHODS

We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019.

RESULTS

The adverse event rate of TORe was 17.1 % (n = 22), with a 13.3 % (n = 17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter pre- and post-TORe, the difference between these values, and procedure duration were not predictive of stenosis. Of patients who developed stenosis, 10 (58.8 %) responded to endoscopic balloon dilation and 7 (41.2 %) required stent placement.

CONCLUSION

As the DPSP technique is a challenging procedure, with high complication rate and limited benefit, it should not be used for TORe.

Endoscopic Approaches to Obesity Management

The field of endoscopic bariatric and metabolic therapy has rapidly evolved from offering endoscopic treatment of weight regain following bariatric surgery to providing primary weight loss options as alternatives to pharmacologic and surgical interventions. Gastric devices and remodeling procedures were initially designed to work through a mechanism of volume restriction, leading to earlier satiety and reduced caloric intake. As the field continues to grow, small bowel interventions are evolving that may have some effect on weight loss but focus on the treatment of obesity-related comorbidities. Future implementation of combination therapy that utilizes both gastric and small bowel interventions offers an exciting option to further augment weight loss and alleviate metabolic disease. This review considers gastric devices and techniques including space-occupying intragastric balloons, aspiration therapy, endoscopic tissue suturing, and plication interventions, followed by a review of small bowel interventions including endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically delivered devices to create incisionless anastomoses. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos)

BACKGROUND AND AIMS

As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type.

METHODS

The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized.

RESULTS

Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving.

CONCLUSIONS

Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.

Argon plasma coagulation alone versus argon plasma coagulation plus full-thickness endoscopic suturing to treat weight regain after Roux-en-Y gastric bypass: a prospective randomized trial (with videos)

BACKGROUND AND AIMS

A significant number of patients regain weight after Roux-en-Y gastric bypass. Ablation with argon plasma coagulation (APC) plus endoscopic full-thickness suturing (FTS-APC) and ablation alone have been reported for treating weight regain when associated with gastrojejunostomy (GJ) dilation. However, comparative controlled data are still lacking.

METHODS

This was a pilot single-center open-label randomized trial comparing the effectiveness and safety of APC alone versus FTS-APC for transoral outlet reduction. Patients with at least 20% weight regain from the nadir, and GJ ≥15 mm were considered eligible. The primary outcome was percentage total weight loss (%TWL) at 12 months. Secondary outcomes were the incidence of adverse events, amelioration of metabolic laboratory parameters, and improvement in quality of life and eating behavior.

RESULTS

Forty patients meeting the eligibility criteria were enrolled from October 2017 to July 2018. Technical and clinical success rates were similar between the groups. At 12 months, the mean %TWL was 8.3% ± 5.5% in the APC alone group versus 7.5% ± 7.7% in the FTS-APC group (P = .71). The pre-revisional % solid gastric retention at 1 hour positively correlated with the probability of achieving ≥10% TWL at 12 months. Both groups experienced significant reductions in low-density lipoprotein and triglyceride levels at 12 months, and improvement in eating behavior and quality of life at 3 months. There were 2 cases of stenoses (1 from each group), which were successfully treated with endoscopic balloon dilation.

CONCLUSION

APC alone is similar to FTS-APC in terms of technical and clinical outcomes within 1 year of follow-up. (Clinical trial registration number: NCT03094936.).

Endoscopic submucosal dissection with suturing for the treatment of weight regain after gastric bypass: outcomes and comparison with traditional transoral outlet reduction (with video)

BACKGROUND AND AIMS

Although traditional transoral outlet reduction (TORe) involves argon plasma coagulation (APC) before endoscopic suturing, modified endoscopic submucosal dissection (ESD) has also been used. This study aims to evaluate the safety and efficacy of modified ESD-TORe in comparison with traditional APC-TORe.

METHODS

This was a retrospective study of prospectively collected data from patients who underwent modified ESD-TORe and APC-TORe for weight regain after Roux-en-Y gastric bypass (RYGB). Our outcomes were technical success, adverse events as categorized by the American Society for Gastrointestinal Endoscopy lexicon, and percent total weight loss (TWL) at 6 and 12 months and patients who underwent ESD-TORe were matched 1:3 based on gastrojejunal anastomosis (GJA) and pouch sizes to those who underwent APC-TORe. TWL between groups was compared. A linear regression was performed to control for any confounders.

RESULTS

Nineteen RYGB patients underwent ESD-TORe. Technical success rate was 100%, with no severe adverse events. At 6 and 12 months, patients experienced 13.4% ± 6.6% and 12.1% ± 9.3% TWL, respectively (P < .05 for both). Nineteen ESD-TORe patients were also matched with 57 APC-TORe patients based on GJA and pouch sizes. At 12 months, the ESD-TORe group experienced greater weight loss compared with the APC-TORe group (12.1% ± 9.3% vs 7.5% ± 3.3% TWL, respectively; P = .036). On regression analysis, ESD remained a significant predictor of percent of TWL at 12 months after controlling for age, sex, body mass index, weight regain, and years from RYGB (β = 5.99, P = .02).

CONCLUSIONS

Combining endoscopic tissue dissection with suturing provides greater and more durable weight loss for patients with weight regain after RYGB.

Five-year outcomes of transoral outlet reduction for the treatment of weight regain after Roux-en-Y gastric bypass

BACKGROUND AND AIMS

Transoral outlet reduction (TORe) is a common endoscopic treatment for patients with weight regain after Roux-en-Y gastric bypass (RYGB) with a dilated gastrojejunal anastomosis (GJA). This study aims to assess long-term efficacy of TORe.

METHODS

This was a retrospective review of prospectively collected data on RYGB patients who underwent TORe for weight regain or inadequate weight loss. The primary outcome was efficacy of TORe at 1, 3, and 5 years. Secondary outcomes were procedure details, safety profile, and predictors of long-term weight loss after TORe.

RESULTS

Three hundred thirty-one RYGB patients underwent 342 TORe procedures and met inclusion criteria. Of these, 331, 258, and 123 patients were eligible for 1-, 3- and 5-year follow-ups, respectively. Mean body mass index was 40 ± 9 kg/m². Pre-TORe GJA size was 23.4 ± 6.0 mm, which decreased to 8.4 ± 1.6 mm after TORe. Patients experienced 8.5% ± 8.5%, 6.9% ± 10.1%, and 8.8% ± 12.5% total weight loss (TWL) at 1, 3, and 5 years with follow-up rates of 83.3%, 81.8%, and 82.9%, respectively. Of 342 TORe procedures, 76%, 17.5%, 4.4%, and 2.1% were performed using single purse-string, interrupted, double purse-string, and running suture patterns, respectively, with an average of 9 ± 4 stitches per GJA. Pouch reinforcement suturing was performed in 57.3%, with an average of 3 ± 2 stitches per pouch. There were no severe adverse events. Some patients (39.3%) had additional weight loss therapy (pharmacotherapy or procedure), with 3.6% getting repeat TORe. Amount of weight loss at 1 year (β = .43, P = .01) and an additional endoscopic weight loss procedure (β = 8.52, P = .01) were predictors of percentage of TWL at 5 years.

CONCLUSIONS

TORe appears to be safe, effective, and durable at treating weight regain after RYGB.

The Use of the Overstitch for Bariatric Weight Loss

Obesity is a public health pandemic and leading contributor to morbidity and mortality. Endoscopic bariatric therapies have emerged as a viable minimally invasive treatment option to fill the therapeutic gap between conservative and surgical approaches. The ability to reliably place full-thickness sutures throughout the gastrointestinal tract has opened the door to novel endoscopic gastric restrictive procedures. A growing body of literature supports endoscopic sleeve gastroplasty as a safe, effective, and reproducible endoscopic treatment of obesity and metabolic syndrome. In addition, endoscopic sutured revision procedures following gastric bypass and sleeve gastrectomy are now first-line with demonstrable safety and long-term efficacy.

Endoscopic Management of Recalcitrant Marginal Ulcers by Covering the Ulcer Bed

BACKGROUND

Management options for marginal ulcers (MU) vary from medical therapy to revision surgery. Medical therapy is often ineffective and revision surgery is associated with a high morbidity and possible recurrence.

AIMS

To evaluate technical feasibility, efficacy, and safety of endoscopic management of MU by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent (FCSEMS).

METHODS

Medical records of consecutive patients who underwent endoscopic suturing and/or FCSEMS deployment for recalcitrant MU between August 2016 and June 2017 at a single academic center were reviewed. Recalcitrant MU was defined as an ulcer that persists after 6 to 8 weeks despite maximal medical therapy (open capsule PPI, 40 mg bid as well as sucralfate qid), cessation of smoking and nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori eradication.

RESULTS

Eleven patients (age range 31-60; all females) with mean BMI of 27.72 ± 5.93 kg/m² underwent endoscopic suturing and/or stent deployment for recalcitrant MU with abdominal pain at a median of 50 months (range 3-120) post-Roux-en-Y gastric bypass (RYGB). Seven patients were managed by oversewing, two were managed by FCSEMS, and two patients required both. Technical success was 100%. All patients reported resolution of abdominal pain at 1 week. Surveillance endoscopy performed in 10/11 (90.9%) patients at 8 weeks revealed complete ulcer healing in 9/10 (90%). No adverse events were reported.

CONCLUSION

Endoscopic management is an effective and safe method to treat MU and should be considered an alternative to surgical revision. It appears effective for perforated and recalcitrant MU.

Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.

Endoscopic bariatric and metabolic therapies: Another tool for the management of diabetes and obesity

Endoscopic bariatric and metabolic therapies (EBMTs) have sparked significant interest as minimally invasive therapeutic options for weight loss. Although bariatric surgery remains an effective option for sustained weight loss and improvement in the metabolic syndrome, access and utilization are limited. Various EBMTs have been designed to emulate the physiologic effects of established surgical interventions, including space-occupying and non-space-occupying gastric therapies, gastric remodeling procedures, and small bowel therapies. This review discusses the safety and efficacy of available US Food and Drug Administration-approved minimally invasive endoscopic bariatric interventions, as well as those currently under investigation. In addition, the role of endoscopic revision after failed surgical intervention is discussed.

Endoscopic management of weight regain following Roux-en-Y gastric bypass

INTRODUCTION

With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population.

AREAS COVERED

We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care.

EXPERT COMMENTARY

Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.

Training in Bariatric and Metabolic Endoscopic Therapies

Bariatric endoscopy is an emerging subspecialty for gastroenterologists encompassing a broad array of procedures including primary endoscopic bariatric and metabolic therapies and the treatment of complications of bariatric surgery. In addition, comprehensive understanding of lifestyle intervention and pharmacotherapy are essential to successful outcomes. This review summarizes goals and steps of training for this emerging field.