The overweight epidemic is estimated to have afflicted
some 1.7 billion people world-wide. Approximately 2/3
of the United States population are overweight (BMI ≥25)
and almost half of this group are obese (BMI ≥30).
About 5% of the U.S. population is morbidly obese (BMI
≥40 or BMI≥35 in association with significant
comorbidities).1 Among children aged 6 through
19 (1992-2002), 31% were at risk for becoming overweight
and 16.0% were overweight.2 There
is a rise in the prevalence of obesity as well as obesity
related comorbidities that are responsible for more than
2.5 million deaths annually through out the world.1
Bariatric
surgery is indicated for patients with morbid obesity
and more than 90,000 obesity surgical procedures were
performed on 2003. It is estimated there will be a 3-fold
increase in the number of bariatric surgeries by 2008.3
The
most popular and effective surgical obesity procedure
is the Roux-en-Y gastric bypass (RNYGB) that is both a
restrictive procedure, by creating a small gastric pouch,
and a malabsorptive reconstruction by way of the creation
of a jejunal bypass. Studies show that following RNYGB,
weight loss is achieved in amounts of 2/3 of excess weight
at 1-2 years post-op, 3/5 at 5 years and more than half
in years 5 through 10.4 RNYBG will fail in some 10-15%
of patients for a variety of reasons that are likely multifactorial.
Weight
regain may very well be related to dietary habits, but
it has been suggested that dilation of the gastrojejunostomy
(GJ) anastomosis or stoma (the connection point between
the stomach pouch and the intestine) may play a role in
the loss of the sensation of satiety or the ability to
feel full after eating. Many patients loss the sense of
fullness and eat more. The gastric pouch may also dilate
along with an enlargement of the GJ stoma.5
However, the causal relationship between a dilated gastric
pouch and GJ stoma is unknown. The two distinct treatment
failure groups include patients with an inability to meet
their goal weight with primary RNYGB and those who achieve
a 50-60 percent of excess weight loss and then regain
weight following surgery. In this latter group, the dilated
GJ anastomosis may be contributory to weight regain. The
lack of response to gastric bypass anti-obesity surgery
is often referred to as post-gastric bypass recidivism.
Endoscopic
(using a video camera on a tube to look into the stomach
through the mouth) assessments of the gastrojejunostomy
or stoma (the connection between the gastric pouch and
intestine) following RNYGB have shown a correlation between
recidivism and GJ diameter.6 The resultant
stoma size of the GJ anastomosis (the connection between
the gastric pouch and small intestine) following RNYGB
surgery is approximately 10-12 mm. GJ diameters greater
than 2 cm appear to regain more weight.7 Open,
surgical revision of the GJ anastomosis is undesirable
because of the inherent surgical risks and the possibility
of anastomotic leakage. This observation has lead to attempts
at incisionless, endoscopic or endolumenal approaches
to reduce the diameter of the GJ anastomosis and restore
it to its immediate post-operative size.
Spaulding7
reported the use of endoscopic (through the mouth) sclerotherapy
with sodium morrhuate in 20 patients experiencing post-gastric
bypass recidivism that achieved a reduction in GJ diameter
to 9-10 mm. The average weight loss was 5.8 kg. In a longer
follow up (≥ 12 months) of 32 recidivism patients
treated with sclerotherapy for dilated GJ, 56.3% began
to lose weight, 34.4% stabilized their weight, and 9.4%
continued to gain weight.8
Catalano3
also reported the use of endoscopic sclerosant injections
into the dilated GJ stomas of 28 patients who suffered
weight gain after an initial loss following RNYGB. Stomal
size was reduced to <12mm in 18 of 28 (64%) subjects.
A mean of 2.3 sessions were performed with a mean use
of 14.5 ml of sodium morrhuate injected in divided doses
into four quadrants of the anastomosis. Of the responder
group, mean weight loss was 22.3 kg (± 9.2 kg)
at 18 months mean follow up. Larger pre-endotherapy stoma
diameters seemed to predict failure to sclerotherapy.
Stoma diameters in treatment responders decreased from
a mean of 16.1 mm before endotherapy to 10.4 mm after
endotherapy. The treatment failures had a larger pre-endotherapy
mean stoma diameter of 18.7 mm and decreased their diameters
to only 16.8 mm after therapy. Post-injection pain occurred
in 21 of 28 (75%) in the first 12-24 hours following sclerotherapy.
Schweitzer5
reported using a flexible endoscopic suturing device (ESD,
Wilson-Cook) to place three sutures across the dilated
GJ anastomosis, thereby creating 3 plications, in 4 four
Post-RNYGB recidivism patients. All 4 patients had a successful
reduction in GJ stomal size. Early on, following stomal
size reduction, these patients experienced ‘feeling
full’ more quickly and reported weight loss without
long-term follow up.
In 2005, Starpoli et al9 conducted a prospective
study of GJ anastomotic size reduction in 11 post-RNYGB
recidivism patients using the BARD EndoCinch suturing
system. Those with endoscopically measured GJ diameters
of >15mm underwent gastroplication along the anastomotic
ridge, resulting in an average size reduction of 35% or
9 mm (diameter) at a 3 month follow up. The average weight
loss recorded per patient was 10 lbs and there were no
reported operative complications or morbidity. In the
same year results were also reported using the EndoCinch
suturing system to reduce the size of the GJ anastomosis
in 8 patients who had regained an average of 24 kg from
baseline following RNYGB. At 4 months follow up, 6 of
8 patients had lost an average of 10 kg and 4 reported
significant improvements in satiety.
In
the revolution of natural orifice translumenal endoscopic
surgery (NOTES), endolumenal (through the mouth and without
incisions) suturing techniques for stomal revision of
the dilated GJ anastomosis are examples of the growing
capabilities of the gastrointestinal endoscopist. There
may be a chance that your poor weight control after gastric
bypass surgery may be the result of an expansion or stretching
of the connection between the stomach pouch and the intestine.
This can be determined by a simple endoscopy and you could
be offered a nonsurgical approach to correcting this problem.
Of course, sound nutritional advice should be available
as well as close follow up with your medical or bariatric
physician.
AA Starpoli, MD
REFERENCES
1.
Buchwald et al. Bariatric Surgery A systematic review
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2.
Hedley AA et al. Prevalence of overweight and obesity
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291:2847-2850.
3.
Catalano MF et al. Weight gain after bariatric surgery
as a result of a large gastric stoma: endotherapy with
sodium morrhuate may prevent the need for surgical revision.
Gastrointestinal Endoscopy. 2005; 66:240-245
4.
DeMaria EJ. Bariatric procedures. Chapters from ACS Surgery.
2005.
5.
Schweitzer M. Endoscopic intraluminal suture plication
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gastric bypass patients. J Laparoendosc Adv Surg Tech
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Negbenebor D.S., Roslin M., Cacciarelli A., Gualtieri
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Size in Post-Gastric Bypass Recidivism Abstract &
Poster American College of Gastroenterology October 2004.
7.
Spaulding L. Treatment of dilated gastrojejunostomy with
sclerotherapy. Obes Surg. 2003;12(2):254-7.
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Spaulding L et al. Long-term results of sclerotherapy
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Obes Relat Dis. 2007 Oct 10.
9.
Anthony Austin Starpoli, Darlene Sandra Negbenebor, Mitchell
S Roslin, Thomas Khouri Haddad, Nicholas M Gualtieri,
Grethe Stoa Birketvedt
Prospective Feasibility Study of Gastrojejunostomy Anastomotic
Size Reduction by Endoluminal Gastroplication in Patients
with Post-Gastric Bypass Recidivism Abstract
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10
Thompson CT et al. Peroral endoscopic reduction of dilated
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