Endoluminal Bariatric Surgery Post-Gastric Bypass

Pornthep Prathanvanich, MD, Bipan Chand, MD

LOYOLA UNIVERSITY CHICAGO STRITCH SCHOOL OF MEDICINE CHICAGO

Introduction
Revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard surgical approaches. Endoluminal revision after bariatric surgery has included stoma, gastric pouch and closure of gastro-gastric fistulas.

Methods
We present 3 cases of patients post gastric bypass with both weight regain and gastrointestinal symptoms undergoing endoluminal therapy. The first case is a 48 year-old female who had undergone gastric bypass 10 years prior with a BMI of 65.4 kg/m2 and weight of 160 kg. A nadir weight of 72 kg was achieved however, she presents with an increasing weight of 83 kg and abdominal pain.

Her work up demonstrated iron deficiency anemia and upper endoscopy demonstrated a dilated stoma and gastrogastric fistula. We describe a technique of fistula identification with closure and stoma reduction using an endoluminal suturing system.

Second case is a 49-year-old female with morbid obesity who is status post-gastric bypass 7 years previously. A nadir weight of 73 kg was achieved however she presented with weight gain to 111 kg and a BMI of 39.84 and had dumping syndrome. She had an upper endoscopy showing an enlarged gastric pouch thought to be contributing to weight gain and dumping. We performed gastrojejunostomy reduction.

Third case is a 42-year-old female who had open Roux-en-Y gastric bypass in 2002. Initial weight at that time was 186 kg and she obtained 57 kg of weight loss in the first year. Weight gain occurred at about 3 years post operation. Upper endoscopy showed a large gastric pouch and large gastogastric fistula. She had undergone first attempted laparoscopic revision in 2008 but was aborted due to dense adhesions. Laparotomy was attempted in 2012 however was aborted secondary to dense adhesions. She presented with a weight of 168 kg and BMI of 60.25. We performed closure of gastrogastric fistula and pouch reduction.

Results
All of three cases were technically successful with no perioperative complications. The operative time was 96, 48 and 110 minutes respectively. No patients had postoperative dysphagia, regurgitation or reflux. All demonstrated increased satiety and fullness with some element of weight loss in the short term.

Conclusion
We present the closure of gastrogastric fistulas, gastrojejunal and pouch reduction post gastric bypass using endoluminal therapy. We demonstrate technical success however long term results are yet to be determined.

Session: Podium Presentation

Program Number: V008