P Riva, MD1, M Galvao Neto, MD2, L Swanstrom, MD, FACS, FRCS1, D Mutter, MD, PhD, FACS3, J Marescaux, MD, FACS, Hon, FRCS, Hon, FJSES, Hon, APSA4, S Perretta, MD, PhD3. 1Institute of Image Guided Surgery, Strasbourg, France, 2Gastro Obeso Center, Sao Paulo, Brazil, 3Department of Digestive and Endocrine Surgery, University of Strasbourg, France, 4IRCAD, Institut de Recherche contre les Cancers de l’Appareil Digestif, Strasbourg (France)
Introduction: This is the case of a 33 years old morbidly obese woman who underwent a gastro-jejunal (GJ) anastomotic revision after failed Roux-y-gastric by pass (RYGB) for weight regain. The patient underwent the RYGB in 2010 presenting an initial BMI of 54. 12 months after surgery she reached her nadir weight loss of 60 kg and a BMI of 36. She then progressively regained 14 kg and a BMI of 42. In early 2015, decision was made to perform an endoscopic revision of the GJ anastomosis using the endoscopic overstitchTM suturing system (Apollo Endosurgery Inc). This intervention allowed for a 6 kg weight loss (BMI 39) over a period of 3 months with a reduced excess body weight (EWL) of 13%. Despite diet and exercise her weight loss stopped and she was scheduled for a second endoscopic revision at a 6 months interval from the first attempt.
Methods: The patient is position supine under general anesthesia. An initial endoscopy under CO2 insufflation in carried out to rule out any esophageal or gastric disease and to take the initial measurements of the size of the anastomosis and of the gastric pouch. The cinches used to secure the sutures were still apparent. After the introduction of an overtube to secure access to the proximal esophagus, the first step of the procedure consisted in ablating all the mucosa around the anastomosis using Argon plasma coagulation (APC). Then the endoscopic suturing system mounted on the tip of a double channel endoscope was used to apply two -2/0 monofilament polypropylene sutures in a figure of eight. The diameter of the anastomosis is reduced starting from the lesser curvature going towards the greater curvature to 10 mm.
Results: Endoscopic resizing of the GJ anastomosis after a previous endoscopic revision proved to be safe and effective in this patient. At a 3 months follow-up the patient lost 7 kg and reached a BMI of 37. The combined EWL% after two endoscopic revisions was 26.32.
Conclusion: This case highlights the essence of endoscopic bariatric therapy, which is being safe effective and repeatable procedures that do not alter the anatomy, but inevitably raises the question of durability overtime and cost-effectiveness.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80207
Program Number: V073
Presentation Session: Endoscopy Video Session
Presentation Type: Video