Endoscopic post-bypass revisions

Endoscopic management of weight regain following Roux-en-Y gastric bypass

INTRODUCTION

With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population.

AREAS COVERED

We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care.

EXPERT COMMENTARY

Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.

Weight regain following RYGB can be effectively treated using a combination of endoscopic suturing and sclerotherapy

BACKGROUND

Obesity is a leading cause of morbidity and healthcare utilization. At the moment, the best treatment for obesity has shown to be laparoscopic gastric bypass. However, about a quarter of the patients experience substantial weight regain, which is difficult to treat, as revision surgery has higher risks than primary procedures. Endoscopic procedures, such as endoscopic suturing, are effective, safe and less invasive in addressing weight regain.

METHODS

We conducted a retrospective analysis on 22 consecutive patients operated between 2011 and 2013 who had a significant weight regain after RYGB (mean follow-up 22 months), in order to evaluate the long-term outcomes of endoscopic gastro-jejunal revision after weight regain post-bypass surgery. Mucosal ablation around the anastomosis was performed in all patients, and the endoscopic suturing device was used to perform suture stoma reduction. We also evaluated, in a group of 11 patients, the effect of combining sclerotherapy and endoscopic suturing.

RESULTS

We showed good efficacy of the endoluminal procedure, with 100 % of patients achieving weight loss. Maximum weight loss was noted at a mean of 18-month follow-up (average of 60.3 % excess weight loss; n = 19), while the mean weight loss regained percentage was 5 % ± 39. 4/22 patients (all four in non-sclerotherapy group, all of them had an anastomosis >10 mm) regained some of this lost weight by the time of the longest follow-up. There was an actual correlation between final stoma diameter (<10 mm) and weight loss.

CONCLUSIONS

A larger randomized sample of patients with a longer follow-up would be needed to support the effectiveness of the combination of the two therapies. Although almost 20 % of the patients regained weight during the follow-up period, the endoluminal approach offers the advantage of being repeatable after weight regain without adding morbidity risks.

Endoscopic management of bariatric surgery complications: what the gastroenterologist should know

Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.

Endoscopic management of complications after gastrointestinal weight loss surgery

As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.