M Gitelis, M Ujiki, L Farwell, J Linn, K Miller, C Burnett, J Carbray, S Haggerty, W Denham. NorthShore University HealthSystem.
Background and Objective: Weight gain after Roux-en-Y gastric bypass (RYGB) occurs in approximately 25% of cases and this may lead to redevelopment of comorbid conditions. Currently, adequate treatment strategies for this group of patients are lacking. Endoscopic narrowing of the gastrojejunal anastomosis may result in a low-risk, minimally invasive treatment alternative compared to standard surgical revision. We aimed to assess short-term outcomes in patients undergoing endoscopic gastrojejunal revisions (EGJR) using an endoluminal suturing device.
Methods: Institutional review board-approved retrospective analysis of 20 consecutive patients who underwent EGJR. Patients pre-operatively presented with a dilated gastrojejunal anastomosis and weight gain. An endoluminal suturing device (Overstitch™, Apollo Endosurgery, Austin TX) was used to narrow the anastomosis. Study includes all clinically available data for cases beginning in June 2012.
Results: Prior to EGJR, patients regained an average of 24.4 ± 11.7 kg from their weight loss nadir and had a mean body mass index (BMI) of 42.1 ± 6.9 kg/m2. In total, 23 revisions were performed on 20 patients. Two patients underwent gastrogastric fistula closure as well as stoma reduction. One patient required more than one session to fully close a fistula and stoma. The average procedure time was 43 ± 17 minutes. An average of 3.2 ± 1.1 sutures were placed per patient and the stoma diameter was reduced from 28.7 ± 6.4 mm to 6.2 ± 2.0 mm for an average of a 77.9% reduction. At six weeks, 100% of patients experienced weight loss (average 6.9 ± 5.0 kg; p-value .011). At three months, 80.0% maintained weight loss (average 9.9 ± 5.6 kg; p-value .002). At six months, 100% of available cases maintained weight loss (average 7.5 ± 6.2 kg; p-value .032). Percent excess weight loss was 11.9% ± 7.9%, 18.5% ± 10.5%, and 12.1% ± 11.4% at six weeks, three months, and six months, respectively. Lastly, BMI decreased at six weeks (average 2.6 ± 1.9 kg/m2; p-value .012), three months (average 3.6 ± 2.0 kg/m2; p-value .001), and six months (average 2.6 ± 2.1 kg/m2; p-value .027). There were no complications.
| Weight Loss (kg) | Excess Weight Loss (%) | BMI Loss (kg/m2) | |||||||
| 6 wks. | 3 mos. | 6 mos. | 6 wks. | 3 mos. | 6 mos. | 6 wks. | 3 mos. | 6 mos. | |
| Mean | 6.9 | 9.9 | 7.5 | 11.9% | 18.5% | 12.1% | 2.6 | 3.6 | 2.6 |
| Std. Dev. | 5.0 | 5.6 | 6.2 | 7.9% | 10.5% | 11.4% | 1.9 | 2.0 | 2.1 |
| p-value | 0.011 | 0.002 | 0.032 | — | — | — | 0.012 | 0.001 | 0.027 |
Conclusion: Six month outcomes for EGJR patients demonstrated a low-risk, minimally invasive treatment option to reverse weight gain subsequent to a failed gastric bypass. Procedures presented no complications and may provide an attractive alternative to standard surgical revision.