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Nassani N, Bazerbachi F, Abu Dayyeh BK. Endobariatric systems: Strategic integration of endoscopic therapies in the management of obesity. Indian J Gastroenterol 2024:10.1007/s12664-024-01632-z. [PMID: 39126598 DOI: 10.1007/s12664-024-01632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/11/2024] [Indexed: 08/12/2024]
Abstract
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.
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Affiliation(s)
- Najib Nassani
- CentraCare, Interventional Endoscopy Program, St. Cloud Hospital, 1406 6th Ave N, St. Cloud, MN, 56303, USA
| | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St. Cloud Hospital, 1406 6th Ave N, St. Cloud, MN, 56303, USA
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Lovis J, Fischli S, Mongelli F, Mühlhäusser J, Aepli P, Sykora M, Scheiwiller A, Metzger J, Gass JM. Long-term results after transoral outlet reduction (TORe) of the gastrojejunal anastomosis for secondary weight regain and dumping syndrome after Roux-en-Y gastric bypass. Surg Endosc 2024; 38:4496-4504. [PMID: 38914888 PMCID: PMC11289335 DOI: 10.1007/s00464-024-10989-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/08/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Bariatric surgery has been proven to be the most effective therapy for obesity and Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedure. However, weight regain and dumping syndrome occur over time. The transoral outlet reduction (TORe) procedure using an endoscopic suturing device may be an option to treat these conditions. We aimed to analyze outcome parameters and long-term results for this endoscopic technique. METHODS A retrospective data analysis of patients who underwent TORe using an endoscopic suturing system at our institution from January 2015 to December 2020 was performed. A total of 71 subjects were included. Forty-five patients received the intervention for weight regain, 9 for dumping syndrome and 17 for both. The primary endpoint was weight stabilization or weight loss for subjects with weight regain, and resolution of symptoms for those with dumping syndrome. Secondary endpoints were intraoperative complications, procedure time, length of hospital stay and diameter of gastrojejunal anastomosis 1 year post-intervention. RESULTS The median size of the gastrojejunal anastomosis was estimated at 30 mm before intervention, and after performing a median of 3 endoscopic sutures, the median estimated gastrojejunal anastomosis width was reduced to 9.5 mm. Eight perioperative complications occurred. Overall mean follow-up was 26.5 months. All interventions achieved weight stabilization or weight loss or resolution of dumping symptoms within the first 3 months, 98.2% at 12 months, 91.4% at 24 months and 75.0% at 48 months. In 22/26 subjects a persisting improvement of dumping syndrome was achieved. CONCLUSIONS TORe is a safe and effective procedure in the treatment of patients with dumping syndrome after laparoscopic RYGB, the effect on weight stabilization is less significant. A prospective randomized trial should be conducted to compare the effects of TORe with other surgical methods like banding the gastrojejunal anastomosis.
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Affiliation(s)
- Jonathan Lovis
- Department of General Surgery, Cantonal Hospital of Lucerne, Spitalstrasse , 6000, Lucerne 16, Switzerland
| | - Stefan Fischli
- Department of Endocrinology, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Francesco Mongelli
- Department of Surgery, Regional Hospital of Lugano, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Julia Mühlhäusser
- Department of General Surgery, Cantonal Hospital of Lucerne, Spitalstrasse , 6000, Lucerne 16, Switzerland
| | - Patrick Aepli
- Department of Gastroenterology, Cantonal Hospital of Lucerne, Spitalstrasse , 6000, Lucerne 16, Switzerland
| | - Martin Sykora
- Department of General Surgery, Cantonal Hospital of Nidwalden, Ennetmooserstrasse 19, 6370, Stans, Switzerland
| | - Andreas Scheiwiller
- Department of General Surgery, Cantonal Hospital of Lucerne, Spitalstrasse , 6000, Lucerne 16, Switzerland
| | - Jürg Metzger
- Department of General Surgery, Cantonal Hospital of Lucerne, Spitalstrasse , 6000, Lucerne 16, Switzerland
| | - Jörn-Markus Gass
- Department of General Surgery, Cantonal Hospital of Lucerne, Spitalstrasse , 6000, Lucerne 16, Switzerland.
- Department of Health Sciences and Medicine, University of Lucerne, 6002, Lucerne, Switzerland.
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3
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De Luca M, Silverii A, Zese M, Galasso G, Bellini R, Carbonelli MG, Cataldo R, Cerbone M, Chianelli M, Gregoris FC, Conigliaro R, Cuttica CM, de Werra C, Di Simone M, Docimo L, Musella M, Gagliardi G, Angrisani L, Di Lorenzo N, Boskoski I, Genco A, Raffaelli M, Anderloni A, Casella G, Galloro G, Goracci A, Lorenzoni V, Manta R, Marzullo P, Medea G, Navarra G, Ortenzi M, Paolini B, Piazza L, Porri D, Rahimi F, Rugolotto S, Pontesilli G, Sarnelli G, Sessa L, Zani I, Zappa MA, Bandini G, Ragghianti B, Monami M. Upcoming Italian clinical practice guidelines on endoscopic bariatric treatment of overweight and obesity: design and methodological aspects. Updates Surg 2024:10.1007/s13304-024-01843-1. [PMID: 38985376 DOI: 10.1007/s13304-024-01843-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/05/2024] [Indexed: 07/11/2024]
Abstract
Obesity/overweight and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to develop the first Italian guidelines for the endoscopic bariatric treatment of obesity. The creation of SICOB Guidelines is based on an extended work made by a panel of 44 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (patient, intervention, comparison, outcome) conceptual framework. We will perform systematic reviews, formal meta-analyses, and network meta-analyses for each PICO and critical outcomes aimed at assessing and rating the efficacy and safety of endoscopic bariatric procedures in comparison with either no interventions, lifestyle interventions, or approved anti-obesity treatments in trials with a follow-up of at least 52 weeks. For PICO on temporary endoscopic bariatric treatments, we will also consider RCT with a minimum duration of 6 months. The panel proposed 8 questions, organized into four domains: A. Indication for endoscopic bariatric surgery; B. Revisional surgery; C. Temporary gastric and duodenal-jejunal procedures; D. Endoscopic diagnosis/treatment of bariatric and metabolic surgery complications. These guidelines will apply to patients aged ≥ 14 years) with body mass index (BMI) ≥ 27 kg/m2 and requiring endoscopic bariatric surgery or endoscopic diagnostic and/or therapeutic procedures. The areas covered by the clinical questions included indications of endoscopic bariatric surgery, types of surgery, revisional surgery, and management of bariatric and metabolic surgery complications.
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Affiliation(s)
- Maurizio De Luca
- Surgery Unit, Azienda ULSS5 Polesana, Ospedale di Rovigo, Rovigo, Italy
| | | | - Monica Zese
- Surgery Unit, Azienda ULSS5 Polesana, Ospedale di Rovigo, Rovigo, Italy.
| | - Giovanni Galasso
- Endoscopy Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | | | | | - Rita Cataldo
- Research Unit of Anesthesia and Intensive Care, Università Campus Bio Medico di Roma e Fondazione Policlinico, Rome, Italy
| | | | - Marco Chianelli
- Unit of Endocrinology, Ospedale Regina Apostolorum Albano, Rome, Italy
| | | | - Rita Conigliaro
- Gastroenterology and Digestive Endoscopy Unit_AOU-Modena, Modena, Italy
| | | | | | - Massimo Di Simone
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Ludovico Docimo
- Division of General, Oncologic, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Giuseppe Gagliardi
- AULSS 5 Polesana, Anesthesiology, Intensive Care and Pain Medicine, Rovigo, Italy
| | | | | | - Ivo Boskoski
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Alfredo Genco
- Department of Obesity Surgery, Policlinico Umberto I, Rome, Italy
| | - Marco Raffaelli
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Andrea Anderloni
- Department of Gastroenterology and Endoscopy, IRCCS San Matteo Pavia, Pavia, Italy
| | | | - Giuseppe Galloro
- Digestive Surgical Endoscopy Unit, University of Naples, Naples, Italy
| | - Arianna Goracci
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | | | - Raffaele Manta
- UOC di Gastroenterologia ed Endoscopia Digestiva, Ospedali Riuniti di Livorno, Livorno, Italy
| | - Paolo Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | | | - Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
| | - Monica Ortenzi
- Clinica Chirurgica Generale e d'Urgenza, AOU Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Barbara Paolini
- Dietology, UOSA Dietetical and Clinical Nutrition, Santa Maria alle Scotte Hospital, Siena, Italy
| | - Luigi Piazza
- UOC Chirurgia Generale e d'Urgenza, Arnas Garibaldi, Catania, Italy
| | | | - Farnaz Rahimi
- Clinical Nutrition Unit, Molinette University Hospital of Turin, Turin, Italy
| | | | | | - Giovanni Sarnelli
- Unit of Digestive and Nutritional Pathophysiology, Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Luca Sessa
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Iris Zani
- Amici Obesi ONLUS Milano, 20128, Milan, Italy
| | | | - Giulia Bandini
- Division of Internal Medicine, Careggi University Hospital, Florence, Italy
| | | | - Matteo Monami
- Diabetology, Careggi University Hospital, Florence, Italy
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4
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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.
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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
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Valats JC, Perreta S, Swanstrom L, Dargent J, Branche J, Picot MC, Currie A, Georgescu V, Macioce V, Nedelcu M, Rudler F, Nocca D. Prospective evaluation of transoral outlet reduction (TORe) after Roux-en-Y gastric bypass (RYGB) failure. Surg Endosc 2024; 38:1454-1464. [PMID: 38216748 DOI: 10.1007/s00464-023-10650-5] [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: 06/23/2023] [Accepted: 12/17/2023] [Indexed: 01/14/2024]
Abstract
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.
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Affiliation(s)
| | - Silvana Perreta
- Digestive Surgery, IRCAD Strasbourg Hospital, Strasbourg, France
| | - Lee Swanstrom
- Digestive Surgery, IRCAD Strasbourg Hospital, Strasbourg, France
| | - Jérôme Dargent
- Digestive Surgery, Polyclinic Lyon-Nord Rillieux-La-Pape, Rillieux-La-Pape, France
| | - Julien Branche
- Hepato-Gastro-Enterology, Lille University Hospital, Lille, France
| | - Marie-Christine Picot
- Clinical Research and Epidemiology Unit, INSERM, Centre d'Investigation Clinique 1411, CHU Montpellier, Univ Montpellier, 34 295, Montpellier Cedex 5, France
| | - Andrew Currie
- Digestive Surgery, Montpellier University Hospital, Montpellier, France
| | - Vera Georgescu
- Department of Biostatistics and Medical Information, Montpellier University Hospital, Montpellier, France
| | - Valérie Macioce
- Clinical Research and Epidemiology Unit, Montpellier University Hospital, Montpellier, France
| | - Marius Nedelcu
- Digestive Surgery, Montpellier University Hospital, Montpellier, France
| | - Franz Rudler
- Hepato-Gastro-Enterology, Montpellier University Hospital, Montpellier, France
| | - David Nocca
- Digestive Surgery, Montpellier University Hospital, Montpellier, France
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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.
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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
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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.
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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
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8
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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.
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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
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9
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Reicher R, Cohen NA, Fishman S, Shnell M. Endoscopic Transoral Outlet Reduction for the Treatment of Biliary Reflux Symptoms in Patients After One-Anastomosis Gastric Bypass-a Case Series. Obes Surg 2023; 33:870-878. [PMID: 36689142 DOI: 10.1007/s11695-023-06463-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
PURPOSE OAGB is the third most common bariatric surgery. Biliary reflux (BR) is an inherent complication of this unique anatomy, although there is still controversy regarding its significance and long-term risks including carcinogenesis. To date, there is no effective treatment for BR with conversion to RYGB reserved for refractory patients. TORe is an effective treatment for weight-regain and dumping syndrome after RYGB. We hypothesized that narrowing the anastomosis would decrease the amount of bile refluxate entering the stomach and esophagus in patients with BR symptoms after OAGB and alleviate symptoms. The purpose of this study is to evaluate the efficacy of TORe for the treatment of BR symptoms after OAGB. MATERIALS AND METHODS BR was diagnosed clinically in patients after OAGB using the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) instrument after treatment with high-dose proton pump inhibitor (PPI) excluded possible acid reflux. TORe was carried out using a suture pattern that narrowed and elongated the anastomosis. All patients were prospectively followed. RESULTS Twelve patients, post-OAGB, underwent TORe for BR. Symptoms resolved in 9 (75%) patients. GERD-HRQL score at 6 months declined from an average of 33.7 (SD 1.9) before the procedure to 16.1 (SD 10, p < 0.001). In one case, a small perforation was identified during the procedure and was immediately sutured with no further sequela. DISCUSSION TORe appears a safe and effective treatment for BR symptoms after OAGB, at least in the short term. Accurate tools for BR diagnosis, a larger cohort, and longer follow-up periods are needed to better show the effectiveness and durability of this treatment option.
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Affiliation(s)
- Relly Reicher
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel.
| | - Nathaniel A Cohen
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Sigal Fishman
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Mati Shnell
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
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10
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Gala K, Ghusn W, Fansa S, Abu Dayyeh BK, Ghanem OM, Kellogg T, Acosta A. Effects of Heterozygous Variants in the Leptin-Melanocortin Pathway on Transoral Outlet Reduction After Roux-en-Y Gastric Bypass: A Case-Control Study and Review of Literature. Obes Surg 2023; 33:1284-1288. [PMID: 36708466 DOI: 10.1007/s11695-023-06462-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Transoral outlet reduction (TORe) is a safe and effective technique for management of weight regain (WR) after Roux-en-Y Gastric Bypass (RYGB). Carriers of a heterozygous variant in the leptin melanocortin pathway (LMP) have been shown to be at high risk for WR in the mid- and long-term after RYGB. Our case series includes four patients with heterozygous LMP variants and presents novel data on their weight loss after TORe. METHODS We performed a retrospective study of the Mayo Clinic Biobank and identified adult participants who had been genotyped and found to have or do not have a heterozygous variant in the LMP ("carriers" vs "non-carriers", respectively) and had undergone a TORe procedure. TBWL% at 1, 3, 6, 9, and 12 months ± 15 days were calculated based on baseline weight at TORe procedure. RESULTS A total of 14 patients were included in the analysis: four patients (mean age 51.0 [5.2] years, 100% females, body mass index [BMI] 40.5 [8.7] kg/m2) with LMP variant and 10 non-carriers (age 55.4 [15.3] years, 90% females, BMI 37.3 [7.7] kg/m2). There were no baseline differences between carriers and non-carriers at time of TORe procedure. After TORE, carriers lost less weight when compared to non-carriers at 3, 6, 9, and 12 months. The difference at 12 months was statistically significant (1.6 vs 12.3%; p = 0.03). CONCLUSIONS Patients with a LMP variant and that underwent RYGB showed decreased weight loss after undergoing TORe. Further and larger studies are needed to comprehend the effect of TORe on patients with LMP variants.
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Affiliation(s)
- Khushboo Gala
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Charlton 8-142, 200 First St. S. W, Rochester, MN, 55902, USA
| | - Wissam Ghusn
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Charlton 8-142, 200 First St. S. W, Rochester, MN, 55902, USA.,Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55902, USA
| | - Sima Fansa
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Charlton 8-142, 200 First St. S. W, Rochester, MN, 55902, USA.,Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55902, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Charlton 8-142, 200 First St. S. W, Rochester, MN, 55902, USA.,Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55902, USA
| | - Omar M Ghanem
- Division of Endocrine & Metabolic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, 55902, USA
| | - Todd Kellogg
- Division of Endocrine & Metabolic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, 55902, USA
| | - Andres Acosta
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Charlton 8-142, 200 First St. S. W, Rochester, MN, 55902, USA. .,Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55902, USA.
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11
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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.
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12
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Resizing of the Gastric Pouch for Weight Regain after Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: Is It a Valid Option? J Clin Med 2022; 11:jcm11216238. [PMID: 36362466 PMCID: PMC9659038 DOI: 10.3390/jcm11216238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction: The laparoscopic resizing of the gastric pouch (LPR) has recently been proposed as a revisional technique in the case of weight regain (WR) after gastric bypass procedures. The aim of this study was to report our experience with LPR for WR. Materials and Methods: All patients with WR ≥ 25% after gastric bypass and with a dilated gastric pouch and/or gastrojejunal anastomosis who underwent LPR between January 2017 and January 2022 were retrospectively reviewed. From a radiological point of view, a gastric pouch was considered dilated when its volume was calculated at >80 cm3 for LRYGB and >200 cm3 for OAGB upon a 3D-CT scan. The endoscopic criterion considered both the diameter of the gastrojejunal anastomosis and the gastric pouch volume. All anastomoses > 20 mm for LRYGB and >40 mm for OAGB were considered dilated, while a gastric pouch was considered endoscopically dilated when the retrovision maneuver with the gastroscope was easily performed. These selection criteria were arbitrarily established on the basis of both our personal experience and literature data. Results: Twenty-three patients had LPR after a Roux-en-Y gastric bypass or one-anastomosis gastric bypass. The mean BMI at LPR was 36.3 ± 4.7 kg/m2. All patients underwent LPR, while the resizing of the GJA was also performed in 3/23 (13%) cases, and hiatoplasty was associated with the resizing of the pouch in 6/23 cases (26.1%). The mean BMI at the last follow-up was 29.3 ± 5.8 kg/m2. The difference between the BMI before resizing and the BMI at the last follow-up visit was statistically significant (p = 0.00005). The mean %TWL at 24.2 ± 16.1 months was 19.6 ± 9%. Comorbidities had an overall resolution and/or improvement rate of 47%. The mean operative time was 71.7 ± 21.9 min. The conversion rate was nil. Postoperative complications occurred in two cases (8.7%). Conclusions: In our series, LPR for WR showed good results in weight loss and in improvement/resolution of comorbidities, with an acceptable complication rate and operative time. Only further studies with a greater cohort of patients and a longer postoperative follow-up will be able to highlight the long-term benefits of this technique.
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13
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Matteo MV, Gallo C, Pontecorvi V, Bove V, De Siena M, Carlino G, Costamagna G, Boškoski I. Weight Recidivism and Dumping Syndrome after Roux-En-Y Gastric Bypass: Exploring the Therapeutic Role of Transoral Outlet Reduction. J Pers Med 2022; 12:jpm12101664. [PMID: 36294803 PMCID: PMC9605651 DOI: 10.3390/jpm12101664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Maria Valeria Matteo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Correspondence:
| | - Camilla Gallo
- Division of Gastroenterology and Center for Autoimmune Liver Disease, Ospedale San Gerardo, Department of Medicine and Surgery, University of Bicocca, 20900 Monza, Italy
| | - Valerio Pontecorvi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Vincenzo Bove
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Martina De Siena
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Giorgio Carlino
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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14
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Badurdeen DS, Kumbhari V, Gómez V. "Fast and furious": Endoscopic gastrojejunostomy revision for treatment of dumping syndrome? Gastrointest Endosc 2022; 96:645-647. [PMID: 35985859 DOI: 10.1016/j.gie.2022.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Dilhana S Badurdeen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Victoria Gómez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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15
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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.
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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
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16
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McCarty TR, Kumar N. Revision Bariatric Procedures and Management of Complications from Bariatric Surgery. Dig Dis Sci 2022; 67:1688-1701. [PMID: 35347535 DOI: 10.1007/s10620-022-07397-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Nitin Kumar
- HSHS Medical Group, Springfield, IL, 62704, USA.
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17
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de Moura DTH, Dantas ACB, Ribeiro IB, McCarty TR, Takeda FR, Santo MA, Nahas SC, de Moura EGH. Status of bariatric endoscopy–what does the surgeon need to know? A review. World J Gastrointest Surg 2022; 14:185-199. [PMID: 35317547 PMCID: PMC8908340 DOI: 10.4240/wjgs.v14.i2.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/14/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - Anna Carolina Batista Dantas
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Cirurgia Bariátrica e Metabólica, Disciplina de Cirurgia do Aparelho Digestivo e Coloproctologia, Sao Paulo 05403-010, Brazil
| | - Igor Braga Ribeiro
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA 021115, United States
| | - Flávio Roberto Takeda
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Cirurgia Bariátrica e Metabólica, Disciplina de Cirurgia do Aparelho Digestivo e Coloproctologia, Sao Paulo 05403-010, Brazil
| | - Marco Aurelio Santo
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Cirurgia Bariátrica e Metabólica, Disciplina de Cirurgia do Aparelho Digestivo e Coloproctologia, Sao Paulo 05403-010, Brazil
| | - Sergio Carlos Nahas
- Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Cirurgia Bariátrica e Metabólica, Disciplina de Cirurgia do Aparelho Digestivo e Coloproctologia, Sao Paulo 05403-010, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
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18
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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.
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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
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19
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Dolan RD, Jirapinyo P, Thompson CC. Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison. Gastrointest Endosc 2021; 94:945-950. [PMID: 34126065 PMCID: PMC8908793 DOI: 10.1016/j.gie.2021.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/05/2021] [Indexed: 02/08/2023]
Abstract
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.
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20
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Elhence A, Kulkarni A, Ghoshal UC. Metabobariatric Endoscopy: Deflating the Balloons of Myth. Clin Transl Gastroenterol 2021; 12:e00413. [PMID: 34620800 PMCID: PMC8500567 DOI: 10.14309/ctg.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Anshuman Elhence
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
| | - Akshay Kulkarni
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
| | - Uday C. Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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