You Just Got Burned! What Is Wrong With This Gastric Pouch?

Endoscopic transoral outlet reduction induces enterohormonal changes in patients with weight regain after Roux-en-Y gastric bypass

Background and study aims Transoral outlet reduction (TORe) has long been employed in treating weight regain after Roux-en-Y gastric bypass. However, its impact on gut hormones and their relationship with weight loss remains unknown. Patients and methods This was a substudy of a previous randomized clinical trial. Adults with significant weight regain and dilated gastrojejunostomy underwent TORe with argon plasma coagulation (APC) alone or APC plus endoscopic suturing (APC-suture). Serum levels of ghrelin, GLP-1, and PYY were assessed at fasting, 30, 60, 90, and 120 minutes after a standardized liquid meal. Results were compared according to allocation group, clinical success, and history of cholecystectomy. Results Thirty-six patients (19 APC vs. 17 APC-suture) were enrolled. There were no significant baseline differences between groups. In all analyses, the typical postprandial decrease in ghrelin levels was delayed by 30 minutes, but no other changes were noted. GLP-1 levels significantly decreased at 12 months in both allocation groups. Similar findings were noted after dividing groups according to the history of cholecystectomy and clinical success. The APC cohort presented an increase in PYY levels at 90 minutes, while the APC-suture group did not. Naïve patients had significantly lower PYY levels at baseline ( P = 0.01) compared with cholecystectomized individuals. This latter group experienced a significant increase in area under the curve (AUC) for PYY levels, while naïve patients did not, leading to a higher AUC at 12 months ( P = 0.0001). Conclusions TORe interferes with the dynamics of gut hormones. APC triggers a more pronounced enteroendocrine response than APC-suture, especially in cholecystectomized patients.

Status of bariatric endoscopy-what does the surgeon need to know? A review

BACKGROUND

Obesity is a chronic and multifactorial disease with a variety of potential treatment options available. Currently, there are several multidisciplinary therapeutic options for its management, including conservative, endoscopic, and surgical treatment.

AIM

To clarify indications, technical aspects, and outcomes of bariatric endoscopy.

METHODS

Narrative review of current literature based on electronic databases including MEDLINE (PubMed), Cochrane Library, and SciELO.

RESULTS

Bariatric endoscopy is in constant development and comprises primary and revisional treatment options as well as management of surgical complications. Various devices act upon different mechanisms of action, which may be individualized to each patient. Despite favorable results for the endoscopic treatment of obesity, prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies. Regarding the management of bariatric surgery complications, endoscopic therapy may be considered the procedure of choice in a variety of situations. Still, as there is no standardized algorithm, local experience should be considered in decision-making.

CONCLUSION

The treatment of patients with obesity is complex, and a multidisciplinary approach is essential. Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications, and therefore, must be part of the armamentarium in the fight against this disease.

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.).

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication.

CASE SUMMARY

A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later.

CONCLUSION

APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.