Endoscopic Revision of RYGB With a Suturing Device. First Ous Series

Manoel Galvao, MD, Leonardo Rodriguez, MD, Juan Carlos Ayala, MD, Almino Ramos, MD, Josemberg Campos, MD, Natan Zundel, MD. Gastro Obeso Center – Sao paulo, Brazil. Centro de Cirugia de Obesidad – Santiago, Chile.Clinica Santa fe, Bogota, Colombia

Background: The Roux-en-Y gastric bypass (RYGB) is among the most-performed bariatric procedures. Despite very good results, this procedure can fail in maintaining long-term weight loss with failure rates over 20 percent. Among possible causes of RYGB procedure failure is dilation of the gastro-jejunostomy (GJ), and/or gastric pouch enlargement (6). The development of endoluminal therapies and devices for stoma revision can fulfill the need for a less-invasive approach that maintains some of the principles of surgical outlet revision while avoiding intra-abdominal surgery.
Methods: This video presents a case of endoscopic GJ stomal reduction in a RYGB patient with significant weigh regain (over 50%EWL). The device used, The OverStitch™, is a cap-based suturing system that is mounted on a double-channel endoscope (GIF-2T160; Olympus Medical Systems Corporation, Tokyo, Japan). The curved needle arm mounts to the tip of the endoscope. The anchor is passed through the primary channel and acts like a needle that is passed back and forth between the needle arm and the anchor exchange . When the handle is closed, the tissue anchor is advanced through the tissue into the anchor exchange . When suturing is complete the tissue anchor is released. The proximal end of the suture is then secured by advancing a Cinch device which is used to securely lock and cut suture. The procedure is done under general anesthesia with the patient intubated. An esophageal overtube (US Endoscopy, Mentor, OH) is positioned to grant safe access. The pouch and stoma size were measured and the operating surgeon applied sutures at the level of the GJ, moving from the lesser to the greater curvature, measuring its size at the end. The video also compare before and after images of the GJ.
Results: From 15 RYGB patients presenting with weight regain, a mean of 61%RWL (Regain weight loss measured from their nadir weight after surgery) on 12m follow-up were obtained with no intra or post-operative complication besides two cases of transient sore throat. Additionally one patient were submitted to a redo due to poor weight loss at 8m demonstrating the sutures intact and could easily be summited to endoscopic calibration with good results.
Conclusion: Endoscopic RYGB GJ revision can be done safely and effectively on short term evaluation