1
|
Maselli DB, Donnangelo LL, Jirapinyo P, Thompson CC, McGowan CE. Transoral Outlet Reduction: Expert Tips, Tricks, and Troubleshooting. Am J Gastroenterol 2024; 119:1047-1055. [PMID: 38634547 DOI: 10.14309/ajg.0000000000002821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/04/2024] [Indexed: 04/19/2024]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
2
|
Salazar J, Duran P, Garrido B, Parra H, Hernández M, Cano C, Añez R, García-Pacheco H, Cubillos G, Vasquez N, Chacin M, Bermúdez V. Weight Regain after Metabolic Surgery: Beyond the Surgical Failure. J Clin Med 2024; 13:1143. [PMID: 38398456 PMCID: PMC10888585 DOI: 10.3390/jcm13041143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/20/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.
Collapse
Affiliation(s)
- Juan Salazar
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Pablo Duran
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Bermary Garrido
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Heliana Parra
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Marlon Hernández
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Clímaco Cano
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela
| | - Roberto Añez
- Departamento de Endocrinología y Nutrición, Hospital Quirónsalud, 28009 Madrid, Spain
| | - Henry García-Pacheco
- Facultad de Medicina, Departamento de Cirugía, Universidad del Zulia, Hospital General del Sur, Dr. Pedro Iturbe, Maracaibo 4004, Venezuela
- Unidad de Cirugía para Obesidad y Metabolismo (UCOM), Maracaibo 4004, Venezuela
| | | | | | - Maricarmen Chacin
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
- Centro de Investigaciones en Ciencias de la Vida, Universidad Simón Bolívar, Barranquilla 080001, Colombia
| | - Valmore Bermúdez
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
- Centro de Investigaciones en Ciencias de la Vida, Universidad Simón Bolívar, Barranquilla 080001, Colombia
| |
Collapse
|
3
|
Razzak FA, Kerbage A, Brunaldi VO, Mrad R, Mahmoud T, Gala K, Vargas EJ, Storm A, Ghanem O, Dayyeh BA. Correlation Between Gastrojejunal Anastomosis Diameter, Distensibility Index, and Weight Regain After Roux-en-Y Gastric Bypass. Obes Surg 2023; 33:4042-4048. [PMID: 37922061 DOI: 10.1007/s11695-023-06918-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Gastrojejunal anastomosis (GJA) dilation is an independent predictor of weight regain (WR) after Roux-en-Y gastric bypass (RYGB). However, the role of planimetric measurements in this context remains unknown. METHODS This is a retrospective cohort study including adult RYGB patients who underwent a diagnostic endoscopy with Endoflip assessment of the GJA. We excluded patients in the early postoperative period and those with abnormal endoscopic findings (marginal ulcers and gastro-gastric fistulas). RESULTS Thirty-four patients were initially included. Endoscopic GJA diameter had a moderate positive correlation with WR (r=+0.438, p=0.011). However, after excluding the 7 patients with GJA> 30 mm, there was no significant correlation. There was a moderate agreement between the EndoFLIP-GJA diameter at 60mL and endoscopic diameter (ICC=0.576, p=0.049). The distensibility index (DI) showed a consistent moderate negative correlation with WR. Considering the maximum DI at 40 ml, we found a cutoff of DI = 7 mm2/mmHg that split the sample in two significantly different populations in terms of WR (67.4% vs. 43.2%, p=0.04). CONCLUSION Visual estimation of the GJA diameter correlates with EndoFLIP at 60mL. In the subset of patients with GJA ≤ 30 mm, more distensible GJAs are associated with lower rates of WR. Larger studies are needed to confirm this correlation and to validate its utility for clinical management.
Collapse
Affiliation(s)
- Farah Abdul Razzak
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Anthony Kerbage
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Vitor O Brunaldi
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
- Gastroenterology Department, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Rudy Mrad
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Khushboo Gala
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Andrew Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Omar Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Barham Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA.
| |
Collapse
|
4
|
Maselli DB, Chittajallu V, Wooley C, Waseem A, Lee D, Secic M, Donnangelo LL, Coan B, McGowan CE. Transoral outlet reduction: Outcomes of endoscopic Roux-en-Y gastric bypass revision in 284 patients at a community practice. World J Gastrointest Endosc 2023; 15:602-613. [PMID: 37900116 PMCID: PMC10600692 DOI: 10.4253/wjge.v15.i10.602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/28/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Daniel B Maselli
- Clinical Research, True You Weight Loss, Atlanta, GA 30342, United States
| | - Vibhu Chittajallu
- Department of Gastroenterology and Hepatology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, United States
| | - Chase Wooley
- Clinical Research, True You Weight Loss, Cary, NC 27513, United States
| | - Areebah Waseem
- Clinical Research, True You Weight Loss, Cary, NC 27513, United States
| | - Daniel Lee
- Clinical Research, True You Weight Loss, Cary, NC 27513, United States
| | - Michelle Secic
- Secic Statistical Consulting, Cleveland, OH 44106, United States
| | | | - Brian Coan
- Clinical Research, True You Weight Loss, Cary, NC 27513, United States
| | | |
Collapse
|
5
|
Franken RJ, Franken J, Sluiter NR, de Vries R, Euser S, Gerdes VEA, de Brauw M. 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. Obes Rev 2023; 24:e13607. [PMID: 37515352 DOI: 10.1111/obr.13607] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023]
Abstract
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.
Collapse
Affiliation(s)
- Rutger J Franken
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
| | - Josephine Franken
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
| | - Nina R Sluiter
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
| | | | - Sjoerd Euser
- Department of Epidemiology, Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands
| | - Victor E A Gerdes
- Department of Internal Medicine, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
- Department of Vascular Medicine, AUMC, Amsterdam, the Netherlands
| | - Maurits de Brauw
- Department of Surgery, Spaarne Gasthuis Hoofddorp, Hoofddorp, the Netherlands
| |
Collapse
|
6
|
Mauro A, Lusetti F, Scalvini D, Bardone M, De Grazia F, Mazza S, Pozzi L, Ravetta V, Rovedatti L, Sgarlata C, Strada E, Torello Viera F, Veronese L, Olivo Romero DE, Anderloni A. A Comprehensive Review on Bariatric Endoscopy: Where We Are Now and Where We Are Going. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59030636. [PMID: 36984637 PMCID: PMC10052707 DOI: 10.3390/medicina59030636] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023]
Abstract
Background: Obesity is a chronic disease that impairs quality of life and leads to several comorbidities. When conservative therapies fail, bariatric surgical options such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most effective therapies to induce persistent weight loss. Over the last two decades, bariatric endoscopy has become a valid alternative to surgery in specific settings. Primary bariatric endoscopic therapies: Restrictive gastric procedures, such as intragastric balloons (IGBs) and endoscopic gastroplasty, have been shown to be effective in inducing weight loss compared to diet modifications alone. Endoscopic gastroplasty is usually superior to IGBs in maintaining weight loss in the long-term period, whereas IGBs have an established role as a bridge-to-surgery approach in severely obese patients. IGBs in a minority of patients could be poorly tolerated and require early removal. More recently, novel endoscopic systems have been developed with the combined purpose of inducing weight loss and improving metabolic conditions. Duodenal mucosal resurfacing demonstrated efficacy in this field in its early trials: significant reduction from baseline of HbA1c values and a modest reduction of body weight were observed. Other endoscopic malabsorptive have been developed but need more evidence. For example, a pivotal trial on duodenojejunal bypasses was stopped due to the high rate of severe adverse events (hepatic abscesses). Optimization of these more recent malabsorptive endoscopic procedures could expand the plethora of bariatric patients that could be treated with the intention of improving their metabolic conditions. Revisional bariatric therapies: Weight regain may occur in up to one third of patients after bariatric surgery. Different endoscopic procedures are currently performed after both RYGB and SG in order to modulate post-surgical anatomy. The application of argon plasma coagulation associated with endoscopic full-thickness suturing systems (APC-TORe) and Re-EndoSleeve have shown to be the most effective endoscopic treatments after RYGB and SG, respectively. Both procedures are usually well tolerated and have a very low risk of stricture. However, APC-TORe may sometimes require more than one session to obtain adequate final results. The aim of this review is to explore all the currently available primary and revisional endoscopic bariatric therapies focusing on their efficacy and safety and their potential application in clinical practice.
Collapse
Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesca Lusetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Specialization School of Diseases of Digestive System Pavia, University of Pavia, 27100 Pavia, Italy
| | - Davide Scalvini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Specialization School of Diseases of Digestive System Pavia, University of Pavia, 27100 Pavia, Italy
| | - Marco Bardone
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Federico De Grazia
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Lodovica Pozzi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Valentina Ravetta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Laura Rovedatti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Carmelo Sgarlata
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Elena Strada
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesca Torello Viera
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Letizia Veronese
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Daniel Enrique Olivo Romero
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Digestive Endoscopy Unit, Hospital Nacional Zacamil, San Salvador 01120, El Salvador
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| |
Collapse
|
7
|
Dang JT, Kim GJ, Kroh M. Bariatric endoscopy: from managing complications to primary metabolic procedures. JOURNAL OF MINIMALLY INVASIVE SURGERY 2023; 26:1-8. [PMID: 36936036 PMCID: PMC10020740 DOI: 10.7602/jmis.2023.26.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/09/2023] [Indexed: 03/18/2023]
Abstract
Obesity is a worldwide epidemic and is the second leading cause of preventable death. The approach to treating obesity involves a multidisciplinary approach including lifestyle interventions, pharmacological therapies, and bariatric surgery. Endoscopic interventions are emerging as important tools in the treatment of obesity with primary and revisional bariatric endoscopic therapies. These include intragastric balloons, aspiration therapy, suturing and plication, duodenal-jejunal bypass liners, endoscopic duodenal mucosal resurfacing, and incisionless magnetic anastomosis systems. Endoscopic interventions have also demonstrated efficacy in treating complications of bariatric surgery. Approaches include stenting, endoscopic internal drainage, and endoscopic vacuum-assisted closure. This review aimed to discuss the current endoscopic procedures used as primary and revisional bariatric therapy including those used for managing bariatric surgical complications.
Collapse
Affiliation(s)
- Jerry T Dang
- Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Grace J Kim
- Digestive Disease & Surgery Institute, Cleveland Clinic - South Pointe Hospital, Warrensville Heights, OH, USA
| | - Matthew Kroh
- Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
8
|
Transoral Outlet Reduction (TORe) for the Treatment of Weight Regain and Dumping Syndrome after Roux-en-Y Gastric Bypass. Medicina (B Aires) 2023; 59:medicina59010125. [PMID: 36676749 PMCID: PMC9865659 DOI: 10.3390/medicina59010125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 01/10/2023] Open
Abstract
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.
Collapse
|
9
|
Endoscopic gastric plication for the treatment of weight regain after Roux-en-Y gastric bypass (with video). Gastrointest Endosc 2022; 96:51-56. [PMID: 35259393 PMCID: PMC9233122 DOI: 10.1016/j.gie.2022.02.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastric plication involves inverting the stomach with tissue anchor placement to achieve serosa-to-serosa apposition. One potential application of gastric plication is the treatment of weight regain after Roux-en-Y gastric bypass (RYGB), a procedure also known as plication transoral outlet reduction (P-TORe). This study aims to assess technical feasibility, safety, and efficacy of P-TORe. METHODS This was a registry study of RYGB patients who underwent P-TORe for weight regain. The primary outcome was the amount of weight loss and clinical success rate, defined as percentage of total weight loss (TWL) of at least 5% at 12 months. Secondary outcomes were technical success, adverse events (AEs), and predictors of weight loss. RESULTS One hundred eleven RYGB patients underwent P-TORe. Average body mass index (BMI) was 38.5 ± 7.5 kg/m2. Baseline gastrojejunal anastomosis (GJA) and pouch sizes were 17 ± 6 mm and 5 ± 2 cm, respectively. The primary outcome was total weight loss, defined as patients experiencing 9.5% ± 8.5% TWL at 12 months. Clinical success rate was 73%. Technical success rate was 100%. Argon plasma coagulation (APC) was performed around the GJA in all patients (100%) before plication placement. The total number of plications per case was 7 ± 3. Overall AE rate was 12.6%. These included GJA stenosis (9.9%), melena because of marginal ulceration (1.8%), and deep vein thrombosis (.9%). The severe AE rate was 0%. Predictors of weight loss were the amount of weight regain and baseline pouch length. CONCLUSIONS This novel P-TORe technique combining APC with gastric plication appears to be technically feasible, safe, and effective at treating weight regain after RYGB.
Collapse
|
10
|
Abboud DM, Yao R, Rapaka B, Ghazi R, Ghanem OM, Abu Dayyeh BK. Endoscopic Management of Weight Recurrence Following Bariatric Surgery. Front Endocrinol (Lausanne) 2022; 13:946870. [PMID: 35909531 PMCID: PMC9329792 DOI: 10.3389/fendo.2022.946870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 06/23/2022] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Donna Maria Abboud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Rebecca Yao
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Babusai Rapaka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Rabih Ghazi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Omar M. Ghanem
- Department of Surgery Mayo Clinic, Rochester, MN, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Barham K. Abu Dayyeh,
| |
Collapse
|
11
|
Bulajic M, Vadalà di Prampero SF, Boškoski I, Costamagna G. Endoscopic therapy of weight regain after bariatric surgery. World J Gastrointest Surg 2021; 13:1584-1596. [PMID: 35070065 PMCID: PMC8727177 DOI: 10.4240/wjgs.v13.i12.1584] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/14/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023] Open
Abstract
Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological, anatomical and metabolic factors. Surgical revision of these patients has significant risks and limited benefits. Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective, safe, less invasive and even reproducible treatment. We herein discuss the indication, selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery. Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.
Collapse
Affiliation(s)
- Milutin Bulajic
- Department of Gastroenterology and Digestive Endoscopy, Mater Olbia Hospital, Olbia 07026, Italy
| | | | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| |
Collapse
|
12
|
Galvao Neto M, Brunaldi VO, Grecco E, Silva LB, de Quadros LG, de Souza TF, Teixeira A, de Morais HWP, de Lima JHF, Concon Filho A, Amorim A, de Santana MF, Teixeira N, Marchesini JC. Good Clinical Practices on Argon Plasma Coagulation Treatment for Weight Regain Associated with Dilated Gastrojejunostomy Following Roux-en-Y Gastric Bypass: a Brazilian-Modified Delphi Consensus. Obes Surg 2021; 32:273-283. [PMID: 34811645 PMCID: PMC8608421 DOI: 10.1007/s11695-021-05795-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/03/2021] [Accepted: 11/10/2021] [Indexed: 12/14/2022]
Abstract
Introduction Argon plasma coagulation (APC) alone is effective and safe at treating weight regain following Roux-en-Y gastric bypass (RYGB). However, technical details of the treatment vary widely among studies. Therefore, we aimed to create good clinical practice guidelines through a modified Delphi consensus, including experts from the collaborative Bariatric Endoscopy Brazilian group. Methods Forty-one locally renowned experts were invited to the consensus by email. Experiences of > 150 APC-treated cases or authorship of relevant articles were the eligibility criteria. An initial questionnaire with short-answer questions was distributed to the experts. The organizing committee converted the responses into statements for an online 2-day voting webinar. Consensus was defined as more than 67% of positive answers. Three consecutive voting rounds were planned with discussion and statement refinements between rounds. Results Thirty-seven experts fulfilled eligibility criteria and attended the live webinar voting. The total number of patients treated by the panel was 12,349. By the third round, all 79 statements reached consensus. The recommendations include the definition of dilated gastrojejunal anastomosis as ≥ 15 mm, minimum regain of 20% of the lost weight to indicate the APC therapy, 6 to 8 weeks as the ideal interval between ablation sessions, and stopping treatment when the stoma reaches < 12 mm of breadth. Conclusions This consensus provides several recommendations based on a highly experienced panel of endoscopists. Although it covers most aspects of the treatment, the level of evidence is low for the majority of the statements. Therefore, bariatric endoscopists should be constantly attentive to new evidence on APC treatment. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05795-y.
Collapse
Affiliation(s)
- Manoel Galvao Neto
- Endovitta Institute, São Paulo, Brazil.,ABC Faculty of Medicine, Santo Andre, Brazil
| | - Vitor Ottoboni Brunaldi
- Center for Digestive Endoscopy, Ribeirão Preto Faculty of Medicine, University of São Paulo, Bandeirantes Av. 3900, Ribeirão Preto City Ribeirão Preto, São Paulo State, 14040-030, Brazil.
| | - Eduardo Grecco
- Endovitta Institute, São Paulo, Brazil.,ABC Faculty of Medicine, Santo Andre, Brazil
| | - Lyz Bezerra Silva
- Center for Obesity and Diabetes, Santa Joana Hospital, Recife, Brazil
| | - Luiz Gustavo de Quadros
- Endovitta Institute, São Paulo, Brazil.,Kaiser Day Hospital, Sao Jose Do Rio Preto, Brazil.,Faculty of Medicine, Sao Jose Do Rio Preto, Brazil
| | - Thiago Ferreira de Souza
- ABC Faculty of Medicine, Santo Andre, Brazil.,Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | | | | | - Artagnan Amorim
- Department of Surgery, University of Marilia, Marilia, Brazil
| | | | | | | | | |
Collapse
|
13
|
Abstract
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.
Collapse
Affiliation(s)
- Russell D Dolan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA;
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan 48109, USA; .,Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
| |
Collapse
|
14
|
Chua TY, Kyanam Kabir Baig KR, Leung FW, Ashat M, Jamidar PA, Mulki R, Singh A, Yu JX, Lightdale JR. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020. Gastrointest Endosc 2021; 94:441-451. [PMID: 34147512 DOI: 10.1016/j.gie.2021.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.
Collapse
Affiliation(s)
- Tiffany Y Chua
- Division of Digestive Diseases, Harbor-University of California Los Angeles, Torrance, California, USA
| | - Kondal R Kyanam Kabir Baig
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Felix W Leung
- VA Sepulveda Ambulatory Care Center, North Hills, California, USA
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ramzi Mulki
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ajaypal Singh
- Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica X Yu
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| |
Collapse
|
15
|
Cambi MPC, Baretta GAP, Magro DDO, Boguszewski CL, Ribeiro IB, Jirapinyo P, de Moura DTH. Multidisciplinary Approach for Weight Regain-how to Manage this Challenging Condition: an Expert Review. Obes Surg 2021; 31:1290-1303. [PMID: 33392999 DOI: 10.1007/s11695-020-05164-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 12/13/2022]
Abstract
Weight regain is a multifactorial condition that affects many patients following bariatric surgery. The purpose of the paper is to review the multidisciplinary approach for the management of weight regain. We performed a search in current clinical evidence regarding the causes, consequences, and treatments of weight regain. The multidisciplinary approach with periodic monitoring is of fundamental importance to prevent or treat weight regain. Several therapeutic options are ranging from nutritional to surgical options, which should be tailored according to patients' anatomy, lifestyle behavior, and compliance. Specialized multidisciplinary care is the key to achieve optimal long-term weight loss and maintenance goals following bariatric surgery.
Collapse
Affiliation(s)
| | | | - Daniéla De Oliveira Magro
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas UNICAMP-SP, Campinas Sao Paulo, Brazil
| | | | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, Av. Dr Eneas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, Sao Paulo, 05403-010, Brazil.
| | - Pichamol Jirapinyo
- Division of Gasteoenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, Av. Dr Eneas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, Sao Paulo, 05403-010, Brazil.,Division of Gasteoenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
16
|
Magdy M, Pescarus R. Comment on: Pouch volume and pouch migration after Roux-en-Y gastric bypass: a comparison of gastroscopy and 3 D-CT volumetry: is there a "migration crisis"? Surg Obes Relat Dis 2020; 16:1908-1909. [PMID: 32928681 DOI: 10.1016/j.soard.2020.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Mark Magdy
- Département de Chirurgie Bariatrique, CIUSSS Du-Nord-De-L'île-De-Montréal, Université de Montréal, Montréal, Canada
| | - Radu Pescarus
- Département de Chirurgie Bariatrique, CIUSSS Du-Nord-De-L'île-De-Montréal, Université de Montréal, Montréal, Canada
| |
Collapse
|
17
|
Brunaldi VO, Pinton GM, Brunaldi MO. Dose response for argon plasma coagulation in the treatment of weight regain after Roux-en-Y gastric bypass: Is a high dose really necessary? Gastrointest Endosc 2020; 92:455-456. [PMID: 32703373 DOI: 10.1016/j.gie.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/03/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil; Center for Gastrointestinal Endoscopy, Surgery and Anatomy Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Bariatric and Metabolic Surgery Unit, Sao Francisco Hospital, Ribeirão Preto, Brazil
| | - Gustavo Murad Pinton
- Bariatric and Metabolic Surgery Unit, Sao Francisco Hospital, Ribeirão Preto, Brazil
| | | |
Collapse
|
18
|
Brunaldi VO, Farias GFA, de Rezende DT, Cairo-Nunes G, Riccioppo D, de Moura DTH, Santo MA, de Moura EGH. 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). Gastrointest Endosc 2020; 92:97-107.e5. [PMID: 32217111 DOI: 10.1016/j.gie.2020.03.3757] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022]
Abstract
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.).
Collapse
Affiliation(s)
- Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil; Center for Gastrointestinal Endoscopy, Surgery and Anatomy Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Galileu Ferreira Ayala Farias
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Tavares de Rezende
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Gabriel Cairo-Nunes
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Riccioppo
- Bariatric and Metabolic Surgery Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Marco Aurelio Santo
- Bariatric and Metabolic Surgery Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | | |
Collapse
|