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.
The data supporting the use of stomal revision continues to grow with recent developments in advanced endoscopic, incisionless suturing techniques. Newer, superior closure systems provide greater durability than its predecessors
Questions that are frequently asked:
Have you started to regain weight after initial success from weight loss surgery (WLS)?
Over time, the stomach pouch or the outlet that connects it to the small intestine can stretch. As a result, patients can eat more food before feeling full. We now offer a safe and effective endoscopic procedure to reduce your enlarged pouch and outlet to their original post-operative proportions.
Why would i regain weight after WLS?
Several studies suggest the majority of patients regain significant weight after WLS. A common cause includes gradual stretching of the stomach pouch or outlet. When the standard-of-care WLS procedures are performed, the stomach and outlet are made very small to reduce the amount of food consumed and slow the passage of food through the digestive tract. Together, this helps patients feel fuller, longer after eating just a small amount. As a result, weight loss occurs from a dramatic decrease in calories. Many clinicians have shown when the stomach pouch and/or outlet gradually stretch, it takes longer for the patient to feel full. As a result, patients may begin to regain weight.
Endoscopic outlet and pouch repair
We now offer qualified patients an endoscopic suturing procedure to reduce the volume of an enlarged pouch and the diameter of the outlet. This procedure is performed using a small flexible endoscope and specialized devices that allows sutures to be placed through the endoscope. The scope and suturing devices are inserted through the mouth into the stomach pouch the same way as a standard endoscope. Sutures are then placed around the outlet to reduce the diameter, typically from the size of a silver dollar to the size of a dime. The same technique may then be used to place additional sutures in the stomach pouch to reduce its volume capacity.
What are the benefits of the endoscopic procedure?
Scarring and adhesions from the initial WLS procedure often make open or laparoscopic revision surgery very challenging, and at times impossible. Abdominal revision surgery takes longer than the original WLS and patients are three times more likely to develop complications.
Having a revision through endoscopic procedure decreases the patient’s risks when compared to abdominal revision surgery. Patients experience less pain, recover faster, and have no abdominal scarring. Typically, patients go home the same day, but each patient’s discharge will vary based on the physician’s recommendation.
What are the side effects?
It is anticipated that patients will feel little or no discomfort from the endoscopic procedure. Minor side effects may include gas pain, nausea, sore throat, swollen tongue, and lip pain from the insertion of the endoscope into the mouth.
What is the recovery process?
Patients typically return to their normal routine within 48 hours. Following endoscopic outlet and pouch repair, patients should follow the same diet and exercise regimen they did after their initial weight loss surgery.
Will it be covered by insurance?
It depends upon the patient’s insurance plan. If not, cash pay options may be available. For further information, please speak with your physician at your next appointment.
"In the evolution of natural orifice, translumenal endoscopic surgery (NOTES), transoral (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 performing endosurgery. 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. A simple upper endoscopy can make this diagnosis and you could be offered an incisionless, surgical approach to correct the problem. Of course, sound nutritional advice should be available, as well as close follow up with your medical or bariatric physician."
AA Starpoli, MD
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