Endoscopic Revision of Gastric Bypass: Holy Grail or Epic Fail?

Alberto S Gallo, MD, Martin A Berducci, MD, Cristopher Ducoin, MD, Hans Fuchs, MD, Moneer Almadani, MD, Ryan C Broderick, MD, Cristina Harnsberger, MD, Bryan J Sandler, MD, Santiago Horgan, MD, Garth R Jacobsen, MD. Minimally Invasive Surgery Department. University of California San Diego

INTRODUCTION

A total of 20-30% of patients who undergo bariatric surgery will fail to lose enough weight. Multiple factors have been postulated for this including anatomical abnormalities and patient compliance. Revision by open or laparoscopic means is associated with higher morbidity and mortality compared to initial operative management, and long term results in terms of weight loss have been inconsistent. Endoscopic plication has been seen as a less invasive option, with encouraging initial results. The objective is to analyze the outcomes after ROSE (Restorative Obesity Surgery, Endolumenal) procedure.

METHODS AND PROCEDURES

We retrospectively analyzed patients that underwent ROSE procedure between 5/2008 and 11/2013 at our institution. All patients had failure of weight loss or regain weight after roux en-y gastric bypass (RYGB). Demographics, time since primary procedure, operative data and follow up were recorded.

RESULTS

A total of 27 patients underwent ROSE procedure. One patient was excluded for the analysis due to lack of postoperative follow up. Twenty five (96%) patients were female. Mean time since initial RYGB was 11.9±4.3 years. Mean initial weight and BMI were 236±47 lb and 40.6±8.1 kg/m², respectively. Mean OR time was 77±30 min. Blood loss was minimal. Preoperative average pouch length and stoma diameter were 6.8±2.3 cm and 2.1±0.7 cm, respectively. A total of 81% of the stomas were centered. On average 4±1.6 stitches were placed. Final pouch length and stoma diameter were 3.4±1.6 cm (50% reduction) and 0.86±0.4 cm (61% reduction). A total of 12 (46%) and 7 (28%) patients underwent follow up upper endoscopy at 3 and 12 months postoperatively, respectively. The mean pouch length and stoma diameter were 5±1.9 cm (26.5% reduction) and 1.2±0.7 cm (42.9 % reduction) at 3 months and 6.14±1.6 cm (10% reduction) and 2.2±1.2 (4.7% increase) at 12 months, respectively. No complications were reported.

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CONCLUSION

Although endoscopic plication achieved the intended reduction of the pouch and stoma diameter at 3 months, these trend to return to preoperative diameter at 12 months. This anatomical failure and the lack of compliance may explain why most patients failed to achieve sustainable weight loss. Further investigation into the mechanism of weight regain will no doubt aid in finding a solution to this complex problem.

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