After 48 Consecutive Endoscopic Gastrojejunal Revisions for Weight Gain Following Roux-en-Y Gastric Bypass: What Have We Learned?

Lava Y Patel, MD, Thomas J Stringer, BA, Craig Brown, BS, Matthew E Gitelis, BS, John G Linn, MD, Woody Denham, MD, Liz Farwell, APN, Stephen Haggerty, MD, Michael B Ujiki, MD. NorthShore University HealthSystem

Background: Endoscopic gastrojejunal revision (EGJR) is a novel procedure for patients seeking a minimally invasive treatment option for weight gain in the years following a Roux-en-Y gastric bypass (RYGB).  Several studies have demonstrated the procedure to be effective at reversing weight gain and achieving modest weight loss outcomes.  There is minimal data however regarding how to perform the procedure most effectively and what factors may predict good outcomes.  We present our experience with 48 consecutive EGJR cases using a full-thickness suturing device.

Methods: Institutional review board-approved retrospective study of 48 consecutive EGJR cases between June 2012 and September 2015.  Adjusted linear regression models were constructed to predict weight loss postoperatively.  Analyzed predictors included preoperative body mass index (BMI), percent reduction of the gastrojejunal (GJ) anastomosis, final diameter of the GJ anastomosis, endoscopic suturing technique (interrupted vs purse-string), experience level of the surgeon, and weight regain from nadir.       

Results:  All data are presented as mean ± standard deviation unless otherwise stated.  Mean age was 50.8 ± 11.1 years and 92% were female. Prior to EGJR, patients regained an average of 52.4 ± 28.8 lbs from their weight loss nadir and had a mean body mass index of 41.3 ± 6.9 kg/m2.  The average procedure time was 50 ± 25 minutes.  Three patients underwent redo EGJR at an average of 2.3 years following the original revision procedure.  A linear regression model showed that preoperative BMI (estimate ± se: 0.26 ± 0.12, p<.05), percent reduction of the GJ anastomosis (0.23 ± 0.09, p<.05), and weight regain from nadir (0.13 ± 0.05, p<.05) could significantly predict postoperative weight loss at 6 weeks postoperatively (p<.01).  At 3 months postop, only percent reduction in the GJ anastomosis (0.35 ± 0.15, p<.05) remained a significant predictor.  These relationships remained intact after controlling for patient-reported compliance with the suggested diet and exercise program.  Patients who had the interrupted suture technique reported the sensation of restriction 68% vs purse-string technique 100% at 3 weeks postop.  There were no complications.

Conclusion: Several factors contribute to increased weight loss after EGJR including the preoperative BMI profile of the patient, the amount of weight regain experienced from nadir, and the intraoperative percent reduction of the GJ anastomosis.  Purse-string suture technique demonstrated an increased sensation of restriction postoperatively.  

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