Endoscopic Findings and Outcomes of Revisional Procedures in Patients with Weight Recidivism After Gastric Bypass

Panot Yimcharoen, Manish Singh, Stacy Brethauer, Philip Schauer, Tomasz Rogula, Matthew Kroh, Bipan Chand. Cleveland Clinic Foundation

BACKGROUND: Significant long-term weight regain occurs in 10-20% patients after gastric bypass (RYGB). Treatment of this chronic disease requires an understanding of why some patients regain weight years after surgery. Enlargement of the gastric pouch or gastrojejunostomy (GJ) over time are possible causative factors for weight regain, but there is little published data on the long term anatomic findings after gastric bypass. The aim of this study is to describe the endoscopic findings in patients referred to our practice for weight regain. We also attempt to correlate the duration of patient’s weight regain and response to revisional therapy.

METHODS: Patients referred for weight regain underwent upper endoscopy to evaluate their pouch and stoma size. Weight history and demographic data were obtained at the time of the initial evaluation. An articulating endoscopic measuring device was used for all procedures. We defined an enlarged GJ as >2 cm in diameter in any dimension and an enlarged pouch as >6 cm long or >5 cm wide. Patients who underwent revisional procedures were categorized into three groups based on their interval from primary RYGB to endoscopic evaluation (Group 1; <5 years, group 2; 5 to10 years and group 3; greater than 10 years). Regained weight (RW) is defined as weight gained after reaching weight nadir after primary RYGB. The percent of regained weight lost after revision is reported as %RWL.

RESULTS: Two-hundred and five patients are included in this study (176 female). At the time of EGD, mean age was 47+10 years, mean BMI (kg/m²) was 43.4+8.4, and time interval from primary RYGB to EGD was 6.9+3.7 years. BMI regain from nadir was 9.78+5.80 (kg/m²). Based on our definitions, abnormal endoscopic findings (n= 146, 71.2%) included large GJ (n= 86, 58.9%), large pouch (n= 43, 29.5%) or both (n=17, 11.6%). Fifty-four patients (26.3%) underwent a revisional surgical or endoluminal procedure. In group 1 (n=13) the mean %RWL was 65% (20-120%) and 62% of patients lost all their regained weight. In group 2 (n=32), the mean % RWL was 64% (9-232 %). In group 3 (n=9) the mean %RWL was 40% (5-107%). Mean follow up after revision was 19, 11 and 12 months for each group, respectively.

CONCLUSION: Endoscopy is an essential tool for evaluation of weight regain after bariatric surgery. Based on our criteria, the majority of patients were found to have an enlarged pouch and/or stoma. In this study, patients undergoing intervention for weight regain within 5 years of their primary procedure had the best outcome in terms of % RWL. Longitudinal studies designed to correlate anatomic abnormalities with long-term weight outcomes are needed.