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A novel approach for weight regain after Roux-en-Y gastric bypass: Staged transoral outlet reduction (TORe) followed by surgical type 1 distalization
Roux en-Y gastric bypass (RYGB) is an effective modality for substantial long-term weight loss. Although patients experience 60% to 80% excess weight loss after RYGB, about one-third of these patients experience weight regain and relapse of obesity-related pathologies over time.1,2 This subset of patients presents a treatment challenge because lifestyle modifications and pharmacologic therapies may have limited efficacy.3Objective assessment of luminal diameter and distensibility by an impedance planimetry system before and after pneumatic dilation in gastric sleeve stenosis
Sleeve gastrectomy has increased in popularity in recent years. Despite its low adverse event rate, its increased prevalence has yielded an increase in the incidence of complications.1 One such complication is gastric sleeve stenosis (GSS), which occurs in up to 4% of patients, typically at the incisura.2 Depending on the severity of the stenosis, this complication commonly causes reflux, regurgitation, and obstructive symptoms such as nausea, vomiting, and abdominal pain.If at first you don’t succeed… a complicated course of endoscopic reversal of a gastric bypass
Marginal ulcer remains a common adverse event after Roux-en-Y gastric bypass (RYGB). Despite treatment with antisecretory therapy, up to a third of patients with recalcitrant ulcers may require surgical revision.1-4 In suboptimal surgical candidates or in patients who have failed attempts at surgical intervention, endoscopic techniques may be a preferable or required approach. Case reports have described uncomplicated endoscopic bypass reversal to treat refractory marginal ulcers.5 Here, we describe a more complicated, protracted case of a refractory marginal ulceration requiring endoscopic reversal, highlighting the potential for an oscillating, yet salvageable, approach (Video 1, available online at www.giejournal.org ).Division of a long-term symptomatic tissue bridge for reversal of endoscopic sleeve gastroplasty
Endoscopic sleeve gastroplasty (ESG) induces weight loss through delayed gastric emptying through gastric remodeling.1 In the long term, this commonly manifests as tissue bridges seen on follow-up endoscopy.2,3 ESG’s clinical efficacy, long durability for weight loss,4 and minimal rate of severe adverse events5 have led to widespread adoption. Although “redo” ESG appears safe and effective,6 reversibility is not well described and is limited to the acute setting. There is a risk that cutting sutures acutely may result in microperforations that put a patient at risk for leak, perigastric fluid collection, abscess, and bleeding.A unique twist following treatment of a sleeve gastrectomy leak: a multidisciplinary approach
Sleeve gastrectomy (SG) is currently the most common bariatric surgery procedure performed.1 GI leak is a known adverse event of SG, reported in up to 3% of patients,2 and is often the result of increased intraluminal pressure exceeding the strength of tissue and/or the staple line. Although there is a growing endoscopic armamentarium to manage these adverse events, refractory leaks often require surgical intervention.3-6 We describe a complex case of a leak after SG that, despite operative management, required a multidisciplinary approach involving endoscopic and surgical treatment strategies (Video 1, available online at www.giejournal.org ).Cost-effective modified endoscopic vacuum therapy for the treatment of gastrointestinal transmural defects: step-by-step process of manufacturing and its advantages
GI transmural defects may be classified into 3 distinct categories: perforations, leaks, and fistulas. Each represents a therapeutic challenge directly affecting morbidity, mortality, and quality of life and is associated with significant healthcare costs.1,2 Endoscopic therapy has become the first-line therapy in most cases,3,4 with available treatment modalities that include closure techniques such as glues/tissue sealants, cap-mounted clips, and endoscopic suturing; cover techniques such as self-expandable metal stents (SEMSs) and cardiac septal defect occluder devices; and endoscopic draining approaches such as septotomy, endoscopic internal drainage with double-pigtail stents, and endoscopic vacuum therapy (EVT).Endoscopic sleeve gastroplasty is feasible after failed modified primary obesity surgery endoluminal procedure
Endoscopic sleeve gastroplasty (ESG) or gastric plication is a recent, minimally invasive treatment in bariatric endoscopy. The basic mechanisms of action are gastric volume reduction and alteration of gastric peristalsis.1 Currently, 3 devices are used in daily clinical practice: Apollo Overstitch (Apollo Endosurgery, Austin, Tex, USA), Endomina (Endo Tools Therapeutics, SA-ETT, Gosselies, Belgium), and an incisionless operating platform (USGI Medical, San Clemente, Calif, USA). They are used to perform the modified primary obesity surgery endoluminal (POSE-2) procedure.Switching the switch: endoscopic reversal of a biliopancreatic diversion
Biliopancreatic diversion (also known as duodenal switch) is a complex bariatric surgery that includes a sleeve gastrectomy and long Roux-en-Y intestinal bypass. The entero-enteric anastomosis is very distal, resulting in bypass of two-thirds or more of the intestine. Patients lose weight not only because nutrients bypass most of the intestine, thereby reducing the absorption area, but also because nutrients join the biliopancreatic secretions and enzymes distally, leading to reduced digestion and absorption.Endoscopic revision for weight regain after open vertical-banded gastroplasty
Vertical-banded gastroplasty (VBG) was one of the most popular restrictive bariatric procedures in the 1980s and 1990s, with excellent short- and medium-term results.1,2 Mason described the open VBG (OVBG) for the first time in 1982,3 consisting of the application of staples from above the gastric crow’s foot up to the angle of His to create a tiny pouch (<50 mL), together with the construction of a neopylorus with a polypropylene mesh collar (Fig. 1). The procedure was modified and performed laparoscopically (laparoscopic vertical-banded gastroplasty) by MacLean in 1993.Endoscopic revision of gastric bypass using plication technique: an adjustable approach
Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric surgeries worldwide.1 Despite successful weight loss after RYGB, weight regain in subsequent years is common, with nearly one-third of patients returning to their prebypass weight.2,3 Although the cause of weight regain is often multifactorial, one of the anatomic causes is dilation and increased tissue compliance of the gastrojejunal anastomosis (GJA),4 which is likely a larger contributor to weight loss than anastomosis size alone.Endoscopic sleeve gastroplasty: the “cable” technique
Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure for the treatment of obesity whereby transmural sutures are placed to reduce gastric volume. An endoscopic suturing system (OverStitch, Apollo Endosurgery, Austin, Tex, USA) is used to create a running suture pattern that imbricates the greater curvature of the stomach, resulting in a reduction in functional volume by approximately 70%, in addition to 30% foreshortening.1-3EUS-guided jejunojejunostomy to facilitate ERCP in a patient with unique Roux-en-Y gastric bypass anatomy
Lumen-apposing metal stents (LAMSs), although initially created for draining pancreatic fluid collections, are frequently used in an “off-label” fashion. They have recently gained popularity as a means to facilitate ERCP in patients with surgically altered GI anatomy. We have previously described using LAMSs to create a temporary gastroenterostomy to facilitate ERCP in a patient with duodenal switch anatomy.1 The present case describes the use of a LAMS to enable ERCP in a patient with a history of vertical sleeve gastrectomy converted to a Roux-en-Y gastric bypass.Endoscopic gastric plication for the treatment of GERD and underlying class I obesity
GERD is a common gastrointestinal disorder that affects approximately 25% of the U.S. population.1 Several studies have demonstrated a higher prevalence of GERD in patients with obesity compared to those with a normal body mass index (BMI).2 Specifically, a gain of at least 3.5 kg/m2 in BMI is associated with a 3-fold increase in rates of GERD compared with those with a stable BMI.3 Potential mechanisms include an increase in intragastric pressure, transient relaxations of the lower esophageal sphincter, prevalence of hiatal hernia, esophageal dysmotility, and a decrease in lower esophageal sphincter pressure in patients with obesity.Laparoscopic hernia repair and fundoplication with endoscopic sleeve gastroplasty for complex hernia and GERD management in morbid obesity
Symptomatic hiatal hernia (HH) and gastroesophageal reflux disease (GERD) pose a unique medical and surgical challenge in the context of morbid obesity. On one hand, morbid obesity is a strong risk factor for GERD and HH1,2 as a result of increased intra-abdominal pressure and ineffective lower esophageal sphincter.3 On the other hand, management of HH and GERD in morbid obesity is challenging because of the high risk of hernia recurrence after conventional surgical repair.4 Therefore, an optimal solution for HH and GERD in morbid obesity is one that would provide durable hernia repair and weight loss.Same-session endoscopic sleeve gastroplasty and transoral incisionless fundoplication: a possible solution to a growing problem
Obesity and GERD have not only been rising in prevalence but also are among the most common conditions seen by gastroenterologists today.1 Here, we present a 63-year-old woman with class II obesity (body mass index, 36 kg/m2; weight, 236 lb), proton pump inhibitor (PPI)-responsive GERD, and Crohn’s ileocolitis, who was referred for further management of her obesity and GERD. Despite intensive lifestyle changes, she was unable to lose significant weight. In addition, she required double-dose PPI for her reflux symptoms.Start of a new TREnD: TransRemnant Endoscopic Drainage for management of walled-off necrosis in a patient with Roux-en-Y gastric bypass
A 64-year-old woman with a history of Roux-en-Y gastric bypass (RYGB) was admitted to an outside hospital with severe necrotizing pancreatitis. Three weeks after her initial presentation, the patient was transferred to our hospital because of persistent abdominal pain and nausea, along with fever and worsening leukocytosis.Gastric overtube use to prevent duodenoscope loop formation during EUS-directed transgastric ERCP procedure
A patient with a history of Roux-en-Y gastric bypass surgery in 2003 and cholecystectomy in 2017 was transferred for evaluation of biliary-type abdominal pain and abnormal liver test results. Abdominal US scan demonstrated a dilated bile duct measuring 1.4 cm and choledocholithiasis (Fig. 1). Upper endoscopy confirmed normal Roux-en-Y anatomy, and an EUS-directed transgastric ERCP procedure was planned.Endoscopic reversal of Roux-en-Y anatomy for the treatment of recurrent marginal ulceration
Marginal ulceration is one of the most common adverse events after Roux-en-Y gastric bypass (RYGB). The incidence rate of marginal ulcer may be as high as 7%.1-3 Antisecretory therapy is the first-line treatment. However, more than one-third of patients undergo surgical revision for intractable ulcers.4,5 The surgical outcome is excellent overall, except for smokers.5,6 Smokers with intractable marginal ulcer pose an extreme management challenge to clinicians. In this video (Video 1, available online at www.VideoGIE.org ), we describe an active-smoker patient with recurrent and intractable marginal ulcer despite multiple surgical revisions and use of maximal medical therapy who was successfully treated with endoscopic reversal of RYGB.Endoscopic vacuum therapy for postoperative GI fistula
A 70-year-old man underwent laparotomy with total gastrectomy and Roux-en-Y reconstruction and esophagojejunal anastomosis for a poorly differentiated gastric adenocarcinoma on October 16, 2019. The adenocarcinoma was located in the lesser curvature and staged as pT4N0M0. Surgical margins were free, and the tumor measured 7.6 cm in its greatest axis.Gastric bypass outlet reduction by use of a single-channel endoscope
We present a case of transoral gastric outlet reduction (TORe) by use of a new endoscopic suturing system with a single-channel endoscope; to our knowledge, this is the first such description to be published. A 36-year-old woman with morbid obesity and obstructive sleep apnea had undergone Roux-en-Y gastric bypass surgery many years earlier. She lost a total of 125 pounds after surgery; however, she regained 110 pounds 1 year later. She underwent a laparoscopic adjustable gastric band placement 6 years before her current presentation, which resulted in minimal weight loss and severe nausea and vomiting.Management of adverse events of EUS-directed transgastric ERCP procedure
Accessing the pancreatobiliary region in patients with a history of Roux-en-Y gastric bypass (RYGB) can be challenging. Traditionally, techniques such as percutaneous biliary drainage, enteroscopy-assisted ERCP, and laparoscopy-assisted ERCP have been used. However, each technique has its limitations. EUS–directed transgastric ERCP (EDGE) using a lumen-apposing metal stent (LAMS) has emerged as a novel endoscopic technique for ERCP in patients who have undergone RYGB. The aim of this case series was to highlight LAMS-related shortcomings and adverse events during the periprocedural period.Endoscopic sleeve gastroplasty by use of a novel suturing pattern, which allays concerns for revisional bariatric surgery
Endoscopic sleeve gastroplasty (ESG) is a safe and effective minimally invasive procedure that has been gaining traction to treat patients with obesity.1-3 Because obesity is a chronic disease, revisional bariatric surgery may be beneficial if adverse events, inadequate weight loss, or weight regain have occurred.4Endoscopic sleeve gastroplasty in peritoneal dialysis
Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, safe, and effective weight-loss technique first described in 2013.1 The principle is to reduce the gastric capacity by creating a restrictive sleeve through an endoluminal suturing system. This is done by the placement of full-thickness sutures along the corpus of the stomach. Although bariatric surgery is recommended for obesity management, the benefits of ESG include less morbidity and mortality, shorter hospital stays, and quicker recovery times.Modified primary obesity surgery endoluminal (POSE-2) procedure for the treatment of obesity
The minimally invasive endoluminal approach has evolved to become a mainstream treatment option for obesity.1 Particularly, endoscopic remodeling of the stomach and restricting the gastric lumen by placing multiple, internal, full-thickness suture plication has been shown to affect hunger and appetite and to induce effective and sustained weight loss.2Successful closure with endoscopic suturing of a recalcitrant marginal ulcer despite Roux-en-Y gastric bypass reversion
One serious adverse event of Roux-en-Y gastric bypass (RYGBP) is bleeding. Early bleeding can occur in up to 5% of patients, with predominant early postoperative bleeding (<30 days) and bleeding from extraluminal causes. Most late RYGBP bleeding is caused by marginal ulcers, with rates reported as 0.6% to 16%. Intraluminal causes of bleeding are endoscopically diagnosed and treated. Endoscopic suturing is in the new arsenal of tools to treat bleeding marginal ulcers that are refractory to medical prophylaxis.
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