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Abdulla M, Mohammed N, AlQamish J, Arau RT. Efficacy and safety of endoscopic gastroplasty for treatment of obesity: An overview of comparative meta-analyses. World J Gastrointest Endosc 2025; 17:105158. [PMID: 40438714 PMCID: PMC12110147 DOI: 10.4253/wjge.v17.i5.105158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Revised: 03/10/2025] [Accepted: 04/22/2025] [Indexed: 05/12/2025] Open
Abstract
BACKGROUND There is a scarcity of evidence and systematic reviews on endoscopic gastroplasty (EG) compared to other management options for the treatment of obesity. AIM To assess the published meta-analyses through a systematic review approach and provide further insight into the current status of available evidence through a critical appraisal. METHODS PubMed/MEDLINE, Scopus, Embase and Cochrane Library were searched from inception to November 2022. The meta-analyses that compared the efficacy and safety of EG to other interventions were considered for this overview. The outcomes of interest were total body weight loss (TBWL), excessive weight loss, and average weight loss along with occurrence of adverse effects. Methodological quality, heterogeneity, and limitations were also reviewed. RESULTS A total of six meta-analyses out of 364 records were considered for this review with a major contribution from the United States. Overall methodological quality of included studies were moderate to good. EG treatments were significantly better in terms of TBWL, excessive weight loss, and average weight loss. However, there was no significant difference between endoscopic transoral outlet reduction and full-thickness suturing plus argon plasma mucosal coagulation. Lack of comparative studies and randomized trials, lack of long-term follow-up, reporting bias, selection bias, lack of control groups, and considerable level of heterogeneity were the major limitations in the available evidence. CONCLUSION Though EG was significantly effective for treatment of obesity, there is limited comparative evidence on this topic. High-quality well-controlled evidence is required to strengthen the current evidence base on EG treatment for obesity.
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Affiliation(s)
- Maheeba Abdulla
- Department of Internal Medicine, Ibn Al Nafees Hospital, Manama 54533, Bahrain
| | - Nafeesa Mohammed
- Department of Intensive Care Unit, Salmaniya Medical Complex, Manama 5616, Bahrain
| | - Jehad AlQamish
- Department of Internal Medicine, Ibn Al Nafees Hospital, Manama 54533, Bahrain
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Estrada A, Rodriguez Quintero JH, Pereira X, Zhou Y, Moran-Atkin E, Choi J, Camacho D. Addressing recurrent weight gain after Roux-en-Y gastric bypass: efficacy of a dual surgical approach-short-term results of a single-center cohort study. Surg Obes Relat Dis 2025:S1550-7289(25)00075-9. [PMID: 40087128 DOI: 10.1016/j.soard.2025.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Revised: 01/29/2025] [Accepted: 02/01/2025] [Indexed: 03/16/2025]
Abstract
BACKGROUND There is no gold standard for recurrent weight gain following Roux-en-Y gastric bypass (RYGB). Combining jejuno-jejunostomy distalization type 1 (JJD1) and sleeve resection of the gastrojejunostomy and gastric pouch (GJ-P) may be a potential approach for these patients. OBJECTIVES To describe 1-year perioperative and nutritional outcomes of patients who underwent JJD1 with sleeve resection of the GJ-P. SETTING High-volume academic bariatric center of excellence. METHODS Patients with recurrent weight gain after RYGB who underwent JJD1 with sleeve resection of the GJ-P from 2020 to 2022 were included and studied for 1 year postoperatively. During the procedure, we aimed for a total alimentary limb length (TALL) of 350-500 cm, a new common channel (CC) of 200-350 cm, and a gastrojejunostomy <2 cm in diameter. RESULTS A total of 61 patients underwent this combined revisional procedure. The median preoperative body mass index (BMI) was 42.59 kg/m2. The median lengths of the biliopancreatic limb (BPL) before and after distalizatiovn were 50 cm (interquartile range [IQR]: 42.5-75) and 175 cm (IQR: 150-200), respectively. After revision, the median new CC was 270 cm (IQR: 250-300) and the median TALL was 400 cm (interquartile range [IQR]: 362.5-450). The median total small bowel length (TSBL) was 580 cm (IQR 550-640 cm), and the median BPL/TSBL ratio was .32 (IQR .29-.34). At 1, 6, and 12 months, the median BMI of the cohort was reduced to 39.14, 35.55, and 32.9 kg/m2, respectively. At 1 year, the total weight loss (%TWL) was 22.18%. Only 3 (n = 3) patients developed major complications at 1 year. After distalization, the resolution of all obesity-related co-morbidities improved, including type 2 diabetes (3.2%), sleep apnea (13.1%), hypertension (HTN) (11.4%), and hyperlipidemia (HLD) (1.6%). CONCLUSIONS The combination of JJD1 and sleeve resection of the GJ-P for RYGB revision was safe and effective, with substantial improvement in weight loss at 1 year.
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Affiliation(s)
- Arturo Estrada
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Xavier Pereira
- Division of General Surgery, New York University Langone Medical Center, New York City, New York, USA
| | - Ya Zhou
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Erin Moran-Atkin
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jenny Choi
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Diego Camacho
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.
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Haddad A, Suter M, Greve JW, Shikora S, Prager G, Dayyeh BA, Galvao M, Grothe K, Herrera M, Kow L, Le Roux C, O'Kane M, Parmar C, Quadros LG, Ramos A, Vidal J, Cohen RV. Therapeutic Options for Recurrence of Weight and Obesity Related Complications After Metabolic and Bariatric Surgery: An IFSO Position Statement. Obes Surg 2024; 34:3944-3962. [PMID: 39400870 DOI: 10.1007/s11695-024-07489-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/16/2024] [Accepted: 08/27/2024] [Indexed: 10/15/2024]
Abstract
Obesity is a chronic disease that may require multiple interventions and escalation of therapy throughout the years. Until recently, no universal definition existed for recurrent weight gain and insufficient weight loss. Standardization of reporting is key so outcomes can be compared and data can be pooled. The recent IFSO consensus provided standard terminology and definitions that will likely resolve this in the future, and publishers will need to enforce for authors to use these definitions. This current IFSO position statement provides guidance for the management of recurrent weight gain after bariatric surgery.
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Affiliation(s)
- Ashraf Haddad
- Gastrointestinal Metabolic and Bariatric Surgery Center -GBMC- Jordan Hospital, Amman, Jordan.
| | | | | | | | | | | | - Manoel Galvao
- Orlando Health Weight Loss and Bariatric Surgery Institute, Orlando, FL, USA
| | | | - Miguel Herrera
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Lilian Kow
- Flinders University, Adelaide, Australia
| | | | - Mary O'Kane
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Almino Ramos
- GastroObesoCenter - Institute for Metabolic Optimization, São Paulo, Brazil
| | - Josep Vidal
- Hospital Clínic de Barcelona, Barcelona, Spain
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Szvarca D, Jirapinyo P. Endoscopic Management of Weight Regain After Bariatric Surgery. Gastrointest Endosc Clin N Am 2024; 34:639-654. [PMID: 39277296 DOI: 10.1016/j.giec.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
Weight regain, also known as recurrent weight gain, is common following bariatric surgeries. While anti-obesity medications and surgical revisions offer effective treatment options, they are not without their challenges and limitations. Over the last few decades, there have been significant advancements in endoscopic interventions to address weight regain following bariatric surgery. These procedures have demonstrated feasibility, safety, efficacy, and durability, offering minimally invasive treatment options for this patient population.
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Affiliation(s)
- Daniel Szvarca
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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De Luca M, Silverii A, Zese M, Galasso G, Bellini R, Carbonelli MG, Cataldo R, Cerbone M, Chianelli M, Gregoris FC, Conigliaro R, Cuttica CM, de Werra C, Di Simone M, Docimo L, Musella M, Gagliardi G, Angrisani L, Di Lorenzo N, Boskoski I, Genco A, Raffaelli M, Anderloni A, Casella G, Galloro G, Goracci A, Lorenzoni V, Manta R, Marzullo P, Medea G, Navarra G, Ortenzi M, Paolini B, Piazza L, Porri D, Rahimi F, Rugolotto S, Pontesilli G, Sarnelli G, Sessa L, Zani I, Zappa MA, Bandini G, Ragghianti B, Monami M. Upcoming Italian clinical practice guidelines on endoscopic bariatric treatment of overweight and obesity: design and methodological aspects. Updates Surg 2024; 76:1865-1877. [PMID: 38985376 DOI: 10.1007/s13304-024-01843-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/05/2024] [Indexed: 07/11/2024]
Abstract
Obesity/overweight and its complications are a growing problem in many countries. Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to develop the first Italian guidelines for the endoscopic bariatric treatment of obesity. The creation of SICOB Guidelines is based on an extended work made by a panel of 44 members and a coordinator. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide the aims, reference population, and target health professionals. Clinical questions have been created using the PICO (patient, intervention, comparison, outcome) conceptual framework. We will perform systematic reviews, formal meta-analyses, and network meta-analyses for each PICO and critical outcomes aimed at assessing and rating the efficacy and safety of endoscopic bariatric procedures in comparison with either no interventions, lifestyle interventions, or approved anti-obesity treatments in trials with a follow-up of at least 52 weeks. For PICO on temporary endoscopic bariatric treatments, we will also consider RCT with a minimum duration of 6 months. The panel proposed 8 questions, organized into four domains: A. Indication for endoscopic bariatric surgery; B. Revisional surgery; C. Temporary gastric and duodenal-jejunal procedures; D. Endoscopic diagnosis/treatment of bariatric and metabolic surgery complications. These guidelines will apply to patients aged ≥ 14 years) with body mass index (BMI) ≥ 27 kg/m2 and requiring endoscopic bariatric surgery or endoscopic diagnostic and/or therapeutic procedures. The areas covered by the clinical questions included indications of endoscopic bariatric surgery, types of surgery, revisional surgery, and management of bariatric and metabolic surgery complications.
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Affiliation(s)
- Maurizio De Luca
- Surgery Unit, Azienda ULSS5 Polesana, Ospedale di Rovigo, Rovigo, Italy
| | | | - Monica Zese
- Surgery Unit, Azienda ULSS5 Polesana, Ospedale di Rovigo, Rovigo, Italy.
| | - Giovanni Galasso
- Endoscopy Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
| | | | | | - Rita Cataldo
- Research Unit of Anesthesia and Intensive Care, Università Campus Bio Medico di Roma e Fondazione Policlinico, Rome, Italy
| | | | - Marco Chianelli
- Unit of Endocrinology, Ospedale Regina Apostolorum Albano, Rome, Italy
| | | | - Rita Conigliaro
- Gastroenterology and Digestive Endoscopy Unit_AOU-Modena, Modena, Italy
| | | | | | - Massimo Di Simone
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Ludovico Docimo
- Division of General, Oncologic, Mini-Invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Giuseppe Gagliardi
- AULSS 5 Polesana, Anesthesiology, Intensive Care and Pain Medicine, Rovigo, Italy
| | | | | | - Ivo Boskoski
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Alfredo Genco
- Department of Obesity Surgery, Policlinico Umberto I, Rome, Italy
| | - Marco Raffaelli
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Andrea Anderloni
- Department of Gastroenterology and Endoscopy, IRCCS San Matteo Pavia, Pavia, Italy
| | | | - Giuseppe Galloro
- Digestive Surgical Endoscopy Unit, University of Naples, Naples, Italy
| | - Arianna Goracci
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | | | - Raffaele Manta
- UOC di Gastroenterologia ed Endoscopia Digestiva, Ospedali Riuniti di Livorno, Livorno, Italy
| | - Paolo Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | | | - Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
| | - Monica Ortenzi
- Clinica Chirurgica Generale e d'Urgenza, AOU Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Barbara Paolini
- Dietology, UOSA Dietetical and Clinical Nutrition, Santa Maria alle Scotte Hospital, Siena, Italy
| | - Luigi Piazza
- UOC Chirurgia Generale e d'Urgenza, Arnas Garibaldi, Catania, Italy
| | | | - Farnaz Rahimi
- Clinical Nutrition Unit, Molinette University Hospital of Turin, Turin, Italy
| | | | | | - Giovanni Sarnelli
- Unit of Digestive and Nutritional Pathophysiology, Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Luca Sessa
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Iris Zani
- Amici Obesi ONLUS Milano, 20128, Milan, Italy
| | | | - Giulia Bandini
- Division of Internal Medicine, Careggi University Hospital, Florence, Italy
| | | | - Matteo Monami
- Diabetology, Careggi University Hospital, Florence, Italy
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6
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Xie J, Wang Y. Multidisciplinary combined treatment based on bariatric surgery for metabolic syndrome: a review article. Int J Surg 2024; 110:3666-3679. [PMID: 38489549 PMCID: PMC11175773 DOI: 10.1097/js9.0000000000001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
As a chronic, multifactorial disease, obesity is associated with a global social and economic burden. This condition significantly affects normal daily life and healthy social interactions, and shortens the life expectancy of patients. Compared with traditional weight-loss methods, the emergence of bariatric surgery has effectively improved the management of obesity. Furthermore, bariatric surgery can also inhibit the progression of multiple metabolic diseases. Despite its potential advantages, bariatric surgery cannot completely eliminate the possibility of weight regain and inadequate weight loss following the procedure. For super-obese patients, bariatric surgery still remains a surgical risk. In addition, the psychological problems and poor eating habits of obese patients also affect the weight loss effect and daily life. Thus, various adjuvant therapies involving multiple disciplines have attracted people's attention. Recently, it has been recognized that the combination of multiple interventions based on bariatric surgery is more advantageous than a single intervention in alleviating the complex and diverse metabolic diseases associated with obesity. The combined therapy considerably enhances the long-term efficacy of bariatric surgery and plays a positive role in the mental health and social lives of patients. In this article, the authors review this multidisciplinary combination therapy to enhance the current understanding of the treatment of obesity.
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Affiliation(s)
| | - Yong Wang
- Center of Bariatric and Metabolic Surgery, Fourth Affiliated Hospital of China Medical University, Liaoning, People’s Republic of China
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Perdomo CM, Avilés-Olmos I, Dicker D, Frühbeck G. Towards an adiposity-related disease framework for the diagnosis and management of obesities. Rev Endocr Metab Disord 2023; 24:795-807. [PMID: 37162651 PMCID: PMC10492748 DOI: 10.1007/s11154-023-09797-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 05/11/2023]
Abstract
Obesity is a complex disease that relapses frequently and associates with multiple complications that comprise a worldwide health priority because of its rising prevalence and association with numerous complications, including metabolic disorders, mechanic pathologies, and cancer, among others. Noteworthy, excess adiposity is accompanied by chronic inflammation, oxidative stress, insulin resistance, and subsequent organ dysfunction. This dysfunctional adipose tissue is initially stored in the visceral depot, overflowing subsequently to produce lipotoxicity in ectopic depots like liver, heart, muscle, and pancreas, among others. People living with obesity need a diagnostic approach that considers an exhaustive pathophysiology and complications assessment. Thus, it is essential to warrant a holistic diagnosis and management that guarantees an adequate health status, and quality of life. The present review summarizes the different complications associated with obesity, at the same time, we aim to fostering a novel framework that enhances a patient-centered approach to obesity management in the precision medicine era.
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Affiliation(s)
- Carolina M Perdomo
- Department of Endocrinology and Nutrition. Clínica, Universidad de Navarra, Pamplona, Spain
- IdiSNA (Instituto de Investigación en la Salud de Navarra), Pamplona, Spain
- CIBEROBN, Instituto de Salud Carlos III, Madrid, Spain
| | - Icíar Avilés-Olmos
- IdiSNA (Instituto de Investigación en la Salud de Navarra), Pamplona, Spain
- Department of Neurology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Dror Dicker
- Department of Internal Medicine D, Rabin Medical Center, Hasharon Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Gema Frühbeck
- Department of Endocrinology and Nutrition. Clínica, Universidad de Navarra, Pamplona, Spain.
- IdiSNA (Instituto de Investigación en la Salud de Navarra), Pamplona, Spain.
- CIBEROBN, Instituto de Salud Carlos III, Madrid, Spain.
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8
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Hany M, Zidan A, Sabry K, Ibrahim M, Agayby ASS, Aboelsoud MR, Torensma B. How Good is Stratification and Prediction Model Analysis Between Primary and Revisional Roux-en-Y Gastric Bypass Surgery? A Multi-center Study and Narrative Review. Obes Surg 2023; 33:1431-1448. [PMID: 36905504 PMCID: PMC10156787 DOI: 10.1007/s11695-023-06532-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTIONS Revision surgery because of weight recurrence is performed in 2.5-33% of primary vertical banded gastroplasty (VBG), laparoscopic sleeve gastrectomy (LSG), and gastric band (GB) cases. These cases qualify for revisional Roux-en-Y gastric bypass (RRYGB). METHODS This retrospective cohort study analyzed data from 2008 to 2019. A stratification analysis and multivariate logistic regression for prediction modeling compared the possibility of sufficient % excess weight loss (%EWL) ≥ 50 or insufficient %EWL < 50 between three different RRYGB procedures, with primary Roux-en-Y gastric bypass (PRYGB) as the control during 2 years of follow-up. A narrative review was conducted to test the presence of prediction models in the literature and their internal and external validity. RESULTS A total of 558 patients underwent PRYGB, and 338 underwent RRYGB after VBG, LSG, and GB, and completed 2 years of follow-up. Overall, 32.2% of patients after RRYGB had a sufficient %EWL ≥ 50 after 2 years, compared to 71.3% after PRYGB (p ≤ 0.001). The total %EWL after the revision surgeries for VBG, LSG, and GB was 68.5%, 74.2%, and 64.1%, respectively (p ≤ 0.001). After correcting for confounding factors, the baseline odds ratio (OR) or sufficient %EWL ≥ 50 after PRYGB, LSG, VBG, and GB was 2.4, 1.45, 0.29, and 0.32, respectively (p ≤ 0.001). Age was the only significant variable in the prediction model (p = 0.0016). It was impossible to develop a validated model after revision surgery because of the differences between stratification and the prediction model. The narrative review showed only 10.2% presence of validation in the prediction models, and 52.5% had external validation. CONCLUSION Overall, 32.2% of all patients after revisional surgery had a sufficient %EWL ≥ 50 after 2 years, compared to PRYGB. LSG had the best outcome in the revisional surgery group in the sufficient %EWL group and the best outcome in the insufficient %EWL group. The skewness between the prediction model and stratification resulted in a partially non-functional prediction model.
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Affiliation(s)
- Mohamed Hany
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt.
- Bariatric Surgery at Madina Women's Hospital (IFSO-Certified Bariatric Center), Alexandria, Egypt.
| | - Ahmed Zidan
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Karim Sabry
- Department of Surgery, Ain Shams University, Cairo, Egypt
| | - Mohamed Ibrahim
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Ann Samy Shafiq Agayby
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Moustafa R Aboelsoud
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Bart Torensma
- Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Brunaldi VO, Peixoto de Oliveira GH, Kerbage A, Ribas PH, Nunes F, Faria G, de Moura D, Riccioppo D, Santo M, de Moura E. Long-term follow-up after transoral outlet reduction following Roux-en-Y gastric bypass: Back to stage 0? Endosc Int Open 2023; 11:E538-E545. [PMID: 37251791 PMCID: PMC10219785 DOI: 10.1055/a-2075-1198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/14/2023] [Indexed: 05/31/2023] Open
Abstract
Background and study aims Significant weight regain affects up to one-third of patients after Roux-en-Y gastric bypass (RYGB) and demands treatment. Transoral outlet reduction (TORe) with argon plasma coagulation (APC) alone or APC plus full-thickness suturing TORe (APC-FTS) is effective in the short term. However, no study has investigated the course of gastrojejunostomy (GJ) or quality of life (QOL) data after the first post-procedure year. Patients and methods Patients eligible for a 36-month follow-up visit after TORe underwent upper gastrointestinal endoscopy with measurement of the GJ and answered QOL questionnaires (RAND-36). The primary aim was to evaluate the long-term outcomes of TORe, including weight loss, QOL, and GJ anastomosis (GJA) size. Comparisons between APC and APC-FTS TORe were a secondary aim. Results Among 39 eligible patients, 29 returned for the 3-year follow-up visit. There were no significant differences in demographics between APC and APC-FTS TORe groups. At 3 years, patients from both groups regained all the weight lost at 12 months, and the GJ diameter was similar to the pre-procedure assessment. As to QOL, most improvements seen at 12 months were lost at 3 years, returning to pre-procedure levels. Only the energy/fatigue domain improvement was kept between the 1- and 3-year visits. Conclusions Obesity is a chronic relapsing disease. Most effects of TORe are lost at 3 years, and redilation of the GJA occurs. Therefore, TORe should be considered iterative rather than a one-off procedure.
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Affiliation(s)
- Vitor Ottoboni Brunaldi
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
- Mayo Clinic, Gastroenterology and Hepatology Department, Rochester, Minnesota, United States
| | | | - Anthony Kerbage
- Mayo Clinic, Gastroenterology and Hepatology Department, Rochester, Minnesota, United States
| | - Pedro Henrique Ribas
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
| | - Felipe Nunes
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
| | - Galileu Faria
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
| | - Diogo de Moura
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
| | - Daniel Riccioppo
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
| | - Marco Santo
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
| | - Eduardo de Moura
- University of Sao Paulo Faculty of Medicine, Gastrointestinal Endoscopy Unit, Gastroenterology Department, Sao Paulo, Brazil
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10
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Perdomo CM, Cohen RV, Sumithran P, Clément K, Frühbeck G. Contemporary medical, device, and surgical therapies for obesity in adults. Lancet 2023; 401:1116-1130. [PMID: 36774932 DOI: 10.1016/s0140-6736(22)02403-5] [Citation(s) in RCA: 290] [Impact Index Per Article: 145.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 02/11/2023]
Abstract
The goal of obesity management is to improve health. Sustained weight loss of more than 10% overall bodyweight improves many of the complications associated with obesity (eg, prevention and control of type 2 diabetes, hypertension, fatty liver disease, and obstructive sleep apnoea), as well as quality of life. Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual's treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains. Most available anti-obesity medications act on central appetite pathways to reduce hunger and food reward. In the past 5 years, therapeutic advances have seen the development of targeted treatments for monogenic obesities and a new generation of anti-obesity medications. These highly effective anti-obesity medications are associated with weight losses of more than 10% of overall bodyweight in more than two-thirds of clinical trial participants. Long-term data on safety, efficacy, and cardiovascular outcomes are awaited. Long-term studies have shown that bariatric surgical procedures typically lead to a durable weight loss of 25% and rapid, sustained improvements in complications of obesity, although they have not yet been compared with new-generation highly effective anti-obesity medications. Further work is required to determine optimal patient-specific treatment strategies, including combinations of lifestyle interventions, anti-obesity medications, endoscopic and bariatric surgical procedures, and to ensure equitable access to effective treatments.
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Affiliation(s)
- Carolina M Perdomo
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Pamplona, Spain; Metabolic Research Laboratory, CIBEROBN, ISCIII, IdiSNA, Clínica Universidad de Navarra, Pamplona, Spain
| | - Ricardo V Cohen
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | - Priya Sumithran
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Karine Clément
- Sorbonne Université, INSERM, Nutrition and obesities: systemic approach research group, Nutriomics, Paris, France; Assistance Publique-Hôpitaux de Paris, Nutrition Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Gema Frühbeck
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Pamplona, Spain; Metabolic Research Laboratory, CIBEROBN, ISCIII, IdiSNA, Clínica Universidad de Navarra, Pamplona, Spain.
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11
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Mauro A, Lusetti F, Scalvini D, Bardone M, De Grazia F, Mazza S, Pozzi L, Ravetta V, Rovedatti L, Sgarlata C, Strada E, Torello Viera F, Veronese L, Olivo Romero DE, Anderloni A. A Comprehensive Review on Bariatric Endoscopy: Where We Are Now and Where We Are Going. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:636. [PMID: 36984637 PMCID: PMC10052707 DOI: 10.3390/medicina59030636] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023]
Abstract
Background: Obesity is a chronic disease that impairs quality of life and leads to several comorbidities. When conservative therapies fail, bariatric surgical options such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most effective therapies to induce persistent weight loss. Over the last two decades, bariatric endoscopy has become a valid alternative to surgery in specific settings. Primary bariatric endoscopic therapies: Restrictive gastric procedures, such as intragastric balloons (IGBs) and endoscopic gastroplasty, have been shown to be effective in inducing weight loss compared to diet modifications alone. Endoscopic gastroplasty is usually superior to IGBs in maintaining weight loss in the long-term period, whereas IGBs have an established role as a bridge-to-surgery approach in severely obese patients. IGBs in a minority of patients could be poorly tolerated and require early removal. More recently, novel endoscopic systems have been developed with the combined purpose of inducing weight loss and improving metabolic conditions. Duodenal mucosal resurfacing demonstrated efficacy in this field in its early trials: significant reduction from baseline of HbA1c values and a modest reduction of body weight were observed. Other endoscopic malabsorptive have been developed but need more evidence. For example, a pivotal trial on duodenojejunal bypasses was stopped due to the high rate of severe adverse events (hepatic abscesses). Optimization of these more recent malabsorptive endoscopic procedures could expand the plethora of bariatric patients that could be treated with the intention of improving their metabolic conditions. Revisional bariatric therapies: Weight regain may occur in up to one third of patients after bariatric surgery. Different endoscopic procedures are currently performed after both RYGB and SG in order to modulate post-surgical anatomy. The application of argon plasma coagulation associated with endoscopic full-thickness suturing systems (APC-TORe) and Re-EndoSleeve have shown to be the most effective endoscopic treatments after RYGB and SG, respectively. Both procedures are usually well tolerated and have a very low risk of stricture. However, APC-TORe may sometimes require more than one session to obtain adequate final results. The aim of this review is to explore all the currently available primary and revisional endoscopic bariatric therapies focusing on their efficacy and safety and their potential application in clinical practice.
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Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesca Lusetti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Specialization School of Diseases of Digestive System Pavia, University of Pavia, 27100 Pavia, Italy
| | - Davide Scalvini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Specialization School of Diseases of Digestive System Pavia, University of Pavia, 27100 Pavia, Italy
| | - Marco Bardone
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Federico De Grazia
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Lodovica Pozzi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Valentina Ravetta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Laura Rovedatti
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Carmelo Sgarlata
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Elena Strada
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesca Torello Viera
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Letizia Veronese
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Daniel Enrique Olivo Romero
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Digestive Endoscopy Unit, Hospital Nacional Zacamil, San Salvador 01120, El Salvador
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
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12
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de Moraes MB, Pereira AG, Costa NA, Pereira FWL, de Oliveira CV, Gaiolla PSA, de Paiva SAR. Endoscopic strategies for management weight regain after Roux-en-Y gastric bypass: a narrative review. NUTRIRE 2023; 48:12. [DOI: 10.1186/s41110-023-00195-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/22/2023] [Indexed: 01/03/2025]
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13
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Jarrah M, Mokadem M. Pharmaco-endoscopic therapy for weight regain post-gastric bypass: a case report. J Surg Case Rep 2023; 2023:rjad075. [PMID: 37069846 PMCID: PMC9972808 DOI: 10.1093/jscr/rjad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/30/2023] [Indexed: 03/04/2023] Open
Abstract
About 1 in every 4 patients who undergo bariatric surgery regains significant amount of weight some time along their journey, posing it as a serious problem that needs to be addressed in a pandemic of obesity. Lifestyle modification, anti-obesity medications, and bariatric endoscopy are multiple therapeutic options that can be used to support any weight loss attempt. A 53-year-old woman with morbid obesity who responded adequately to gastric-bypass regained significant weight 8 years later. We initially approached her post-operative weight regain in a behavioral, pharmacologic non-invasive manner; however, she failed to appropriately respond to several anti-obesity medications. Upper endoscopy revealed a dilated gastric pouch and gastro-jejunal anastomosis (GJA) that was reduced using argon plasma coagulation (APC), but also with a modest response. We then added liraglutide to her APC endo-therapy sessions and subsequentially patient started losing significantly more weight. For selective post-bariatric surgery weight re-gainers, endoscopic and pharmaco-therapy combined may be needed for more effective results.
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Affiliation(s)
- Mohammad Jarrah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
- Fraternal Order of Eagles Diabetes Research Center, Iowa City, IA 52242, USA
| | - Mohamad Mokadem
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
- Fraternal Order of Eagles Diabetes Research Center, Iowa City, IA 52242, USA
- Veterans Affairs Health Care System, Iowa City, IA 52242, USA
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Pontecorvi V, Matteo MV, Bove V, De Siena M, Giannetti G, Carlino G, Polidori G, Vinti L, Angelini G, Iaconelli A, Familiari P, Raffaelli M, Costamagna G, Boškoski I. Long-term Outcomes of Transoral Outlet Reduction (TORe) for Dumping Syndrome and Weight Regain After Roux-en-Y Gastric Bypass. Obes Surg 2023; 33:1032-1039. [PMID: 36702981 PMCID: PMC10079715 DOI: 10.1007/s11695-023-06466-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Both weight regain and dumping syndrome (DS) after Roux-en-Y gastric bypass (RYGB) have been related to the dilation of gastro-jejunal anastomosis. The aim of this study is to assess the safety and long-term efficacy of endoscopic transoral outlet reduction (TORe) for DS and/or weight regain after RYBG. MATERIALS AND METHODS A retrospective analysis was performed on a prospective database. Sigstad's score, early and late Arts Dumping Score (ADS) questionnaires, absolute weight loss (AWL), percentage of total body weight loss (%TBWL), and percentage of excess weight loss (%EWL) were assessed at baseline and at 6, 12, and 24 months after TORe. RESULTS Eighty-seven patients (median age 46 years, 79% female) underwent TORe. The median baseline BMI was 36.2 kg/m2. Out of 87 patients, 58 were classified as "dumpers" due to Sigstad's score ≥ 7. The resolution rate of DS (Sigstad's score < 7) was 68.9%, 66.7%, and 57.2% at 6, 12, and 24 months after TORe, respectively. A significant decrease in Sigstad's score as well as in early and late ADS questionnaires was observed (p < 0.001). The median Sigstad's score dropped from 15 (11-8.5) pre-operatively to 2 (0-12) at 24 months. The %TBWL was 10.5%, 9.9%, and 8.1% at 6, 12, and 24 months, respectively. Further, "dumpers" with resolution of DS showed better weight loss results compared with those with persistent DS (p < 0.001). The only adverse event observed was a perigastric fluid collection successfully managed conservatively. CONCLUSION TORe is a minimally invasive treatment for DS and/or weight regain after RYGB, with evidence of long-term efficacy.
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Affiliation(s)
- Valerio Pontecorvi
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Maria Valeria Matteo
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy. .,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy.
| | - Vincenzo Bove
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Martina De Siena
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Giulia Giannetti
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Giorgio Carlino
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | | | - Laila Vinti
- , Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Giulia Angelini
- , Bariatric Medicine Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Amerigo Iaconelli
- , Bariatric Medicine Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Pietro Familiari
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Marco Raffaelli
- , Endocrine and Metabolic Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Guido Costamagna
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Ivo Boškoski
- , Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, 8 00168, Rome, Italy.,, Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168, Rome, Italy
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15
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Gurian GC, Watanabe LM, Nonino CB, Barato M, Ferreira-Julio MA, Arantes FA, Sivieri T, Noronha NY, Souza DSR, Fernandes-Ferreira R, Pinhel MADS. Efficacy of the argon plasma coagulation in patients with weight regain after gastric bypass: a randomized control trial. Endosc Int Open 2023; 11:E43-E51. [PMID: 36644534 PMCID: PMC9839426 DOI: 10.1055/a-1971-6417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/25/2022] [Indexed: 01/15/2023] Open
Abstract
Background and study aims Endoscopic procedure using argon plasma coagulation (APC) promotes a progressive reduction in gastrojejunal anastomosis diameter. The present study aimed to evaluate the efficacy of the APC in patients with weight regain in the postoperative periods of gastric bypass. Patients and methods This was a randomized controlled trial conducted with 66 patients who were randomly assigned selected (using lottery method) and divided into two groups: study group (SG), 38 patients (APC treatment); and control group (CG), 28 patients (only endoscopy procedure). We considered 30 days,180 days, and one year as short-term, medium-term, and long-term, respectively. The parameters analyzed were total weight loss (TWL), excess weight loss (%EWL), total weight loss (%TWL), and reduction of weight regain (%RWR). Furthermore, a biopsy for neoplastic histological changes was carried out for the APC group. For statistical analysis, values of P < 0.05 were considered significant. Results The %TWL and %RWR were higher in the SG in short, medium, and long terms, when compared to the same periods in the CG ( P < 0.001). One year after follow-up, the final weight did not reach the statistical difference between groups. Biopsy performed in SG 1 year after APC did not reveal neoplastic histological changes. Conclusions APC effectively treats weight regain after bariatric surgery in the short and medium-term. An important "new" weight gain was observed in the long-term, showing that obesity is a chronic disease that requires multidisciplinary and family care for life. Also, APC is a safe procedure with low adverse event rates.
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Affiliation(s)
- Gustavo Carvalho Gurian
- Hospital de Base de São José do Rio Preto – Department of Endoscopy – São José do Rio Preto – SP – Brazil
| | - Lígia Moriguchi Watanabe
- Ribeirao Preto Medical School – Department of Health Sciences – University of São Paulo – Brazil
| | - Carla Barbosa Nonino
- Ribeirao Preto Medical School – Department of Health Sciences – University of São Paulo – Brazil
| | - Mariana Barato
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
| | - Maysa Araújo Ferreira-Julio
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
| | - Francisco Alves Arantes
- Hospital de Base de São José do Rio Preto – Department of Endoscopy – São José do Rio Preto – SP – Brazil
| | - Thiago Sivieri
- Sao José do Rio Preto Medical School – Department of Metabolic and Bariatric Surgery – São José do Rio Preto – SP – Brazil
| | - Natália Yumi Noronha
- Ribeirao Preto Medical School – Department of Health Sciences – University of São Paulo – Brazil
| | - Dorotéia Silva Rossi Souza
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
| | - Rafael Fernandes-Ferreira
- Sao José do Rio Preto Medical School – Department of Molecular Biology – São José do Rio Preto – SP – Brazil
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Transoral Outlet Reduction (TORe) for the Treatment of Weight Regain and Dumping Syndrome after Roux-en-Y Gastric Bypass. Medicina (B Aires) 2023; 59:medicina59010125. [PMID: 36676749 PMCID: PMC9865659 DOI: 10.3390/medicina59010125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 01/10/2023] Open
Abstract
Obesity is a chronic relapsing disease of global pandemic proportions. In this context, an increasing number of patients are undergoing bariatric surgery, which is considered the most effective weight loss treatment for long-term improvement in obesity-related comorbidities. One of the most popular bariatric surgeries is the Roux-en-Y gastric bypass (RYGB). Despite its proven short- and long-term efficacy, progressive weight regain and dumping symptoms remain a challenge. Revisional bariatric surgery is indicated when dietary and lifestyle modification, pharmaceutical agents and/or psychological therapy fail to arrest weight regain or control dumping. However, these re-interventions present greater technical difficulty and are accompanied by an increased risk of peri- and postoperative complications with substantial morbidity and mortality. The endoscopic approach to gastrojejunal anastomotic revision, transoral outlet reduction (TORe), is used as a minimally invasive treatment that aims to reduce the diameter of the gastrojejunal anastomosis, delaying gastric emptying and increasing satiety. With substantial published data supporting its use, TORe is an effective and safe bariatric endoscopic technique for addressing weight regain and dumping syndrome after RYGB.
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Zotarelli-Filho IJ, de Quadros LG, Neto MG, Rajapaksa SW, Vidanapathirana J, Filho DR, Nogueira-de-Almeida CA. Prospective Meta-analysis of Weight Loss Regained and Success Rate of Argon Plasma Coagulation to Suture and Surgery Procedures Post-bariatric Surgery: Status of the Art of Endoscopic Treatment. Rev Recent Clin Trials 2023; 18:239-250. [PMID: 37608668 DOI: 10.2174/1574887118666230822110724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/14/2023] [Accepted: 07/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND This study performed a meta-analysis to compare the safety and efficacy of argon plasma coagulation (APC) concerning suture (SUT) and surgery (SUR). METHODS The One-Way tests were applied, with p <0.05 significant. The value of R2 was analyzed (heterogeneity), and the risk of bias of articles was evaluated. RESULTS A total of 34 studies were found, eight about APC, twenty about SUT, and six about SUR. For the percentage of Weight Loss Regained (%WLR), the means for APC, SUT, and SUR were 19.39 ± 10.94, 26.06 ± 16.71, and 17.05 ± 9.85, and for success rate (%SR), the means were 89.75 ± 16.75, 86.80 ± 11.44, and 76.00 ± 21.57, respectively with p >0.05, with R2 ≥ 50%. CONCLUSION The APC proved to be efficient and safe like the other techniques.
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Affiliation(s)
- Idiberto José Zotarelli-Filho
- Faculty of Medicine of Sao Jose do Rio Preto/SP, Brazil
- Associação Brasileira de Nutrologia/Brazilian Association of Nutrology, Catanduva, Sao Paulo, Brazil
- College of Palliative Medicine of Sri Lanka, Colombo, Sri Lanka
| | - Luiz Gustavo de Quadros
- Kaiser Day Hospital, Sao Jose do Rio Preto, Sao Paulo, Brazil
- ABC Medical School, Surgery Department, Santo Andre, Sao Paulo, Brazil
| | | | | | - Janaki Vidanapathirana
- College of Palliative Medicine of Sri Lanka, Colombo, Sri Lanka
- Director of Policy Analysis & Development, Ministry of Health, Sri Lanka
| | - Durval Ribas Filho
- Faculty of Medicine of Sao Jose do Rio Preto/SP, Brazil
- Associação Brasileira de Nutrologia/Brazilian Association of Nutrology, Catanduva, Sao Paulo, Brazil
| | - Carlos Alberto Nogueira-de-Almeida
- Associação Brasileira de Nutrologia/Brazilian Association of Nutrology, Catanduva, Sao Paulo, Brazil
- Federal University of Sao Carlos, Department of Medicine, Sao Carlos, Sao Paulo, Brazil
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Courtney MJ, Carr WRJ, Mahawar K. Laparoscopic Roux-en-Y Gastric Bypass: Weight Loss Outcomes. OBESITY, BARIATRIC AND METABOLIC SURGERY 2023:377-387. [DOI: 10.1007/978-3-030-60596-4_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Ramos AC, Bastos ELDS, Carbajo MA, Antozzi L. Laparoscopic One Anastomosis Gastric Bypass/Mini Gastric Bypass: Revisional Surgery for Failure in Weight Loss and Metabolic Outcomes. OBESITY, BARIATRIC AND METABOLIC SURGERY 2023:771-783. [DOI: 10.1007/978-3-030-60596-4_96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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20
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Resizing of the Gastric Pouch for Weight Regain after Laparoscopic Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass: Is It a Valid Option? J Clin Med 2022; 11:jcm11216238. [PMID: 36362466 PMCID: PMC9659038 DOI: 10.3390/jcm11216238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction: The laparoscopic resizing of the gastric pouch (LPR) has recently been proposed as a revisional technique in the case of weight regain (WR) after gastric bypass procedures. The aim of this study was to report our experience with LPR for WR. Materials and Methods: All patients with WR ≥ 25% after gastric bypass and with a dilated gastric pouch and/or gastrojejunal anastomosis who underwent LPR between January 2017 and January 2022 were retrospectively reviewed. From a radiological point of view, a gastric pouch was considered dilated when its volume was calculated at >80 cm3 for LRYGB and >200 cm3 for OAGB upon a 3D-CT scan. The endoscopic criterion considered both the diameter of the gastrojejunal anastomosis and the gastric pouch volume. All anastomoses > 20 mm for LRYGB and >40 mm for OAGB were considered dilated, while a gastric pouch was considered endoscopically dilated when the retrovision maneuver with the gastroscope was easily performed. These selection criteria were arbitrarily established on the basis of both our personal experience and literature data. Results: Twenty-three patients had LPR after a Roux-en-Y gastric bypass or one-anastomosis gastric bypass. The mean BMI at LPR was 36.3 ± 4.7 kg/m2. All patients underwent LPR, while the resizing of the GJA was also performed in 3/23 (13%) cases, and hiatoplasty was associated with the resizing of the pouch in 6/23 cases (26.1%). The mean BMI at the last follow-up was 29.3 ± 5.8 kg/m2. The difference between the BMI before resizing and the BMI at the last follow-up visit was statistically significant (p = 0.00005). The mean %TWL at 24.2 ± 16.1 months was 19.6 ± 9%. Comorbidities had an overall resolution and/or improvement rate of 47%. The mean operative time was 71.7 ± 21.9 min. The conversion rate was nil. Postoperative complications occurred in two cases (8.7%). Conclusions: In our series, LPR for WR showed good results in weight loss and in improvement/resolution of comorbidities, with an acceptable complication rate and operative time. Only further studies with a greater cohort of patients and a longer postoperative follow-up will be able to highlight the long-term benefits of this technique.
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Distal gastric bypass revision for weight recurrence or nonresponse to primary procedure: initial experience and outcomes in an academic practice. Surg Endosc 2022:10.1007/s00464-022-09719-4. [PMID: 36261645 DOI: 10.1007/s00464-022-09719-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/11/2022] [Indexed: 10/24/2022]
Abstract
BACKGROUND Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB. METHODS Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations. RESULTS Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively). CONCLUSIONS DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined.
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Matteo MV, Gallo C, Pontecorvi V, Bove V, De Siena M, Carlino G, Costamagna G, Boškoski I. Weight Recidivism and Dumping Syndrome after Roux-En-Y Gastric Bypass: Exploring the Therapeutic Role of Transoral Outlet Reduction. J Pers Med 2022; 12:jpm12101664. [PMID: 36294803 PMCID: PMC9605651 DOI: 10.3390/jpm12101664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Obesity is a chronic, relapsing disease representing a global epidemic. To date, bariatric surgery is the most effective treatment for morbid obesity in the long-term. Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric interventions, with excellent long-term outcomes. However, about one-third of patients may experience weight regain over time, as well as dumping syndrome. Both these conditions are challenging to manage and require a multidisciplinary and personalized approach. The dilation of the gastro-jejunal anastomosis is a recognized etiological factor for both weight regain and dumping syndrome. Dietary modifications, behavioral interventions, and medications represent the first therapeutic step. Revisional surgery is the traditional approach when non-invasive treatments fail. However, re-interventions may be technically difficult and are associated with increased morbidity and mortality. Transoral outlet reduction (TORe) is an endoscopic procedure aimed at reducing the size of the anastomosis and is proposed as a minimally invasive treatment of weight regain and/or dumping syndrome refractory to conservative therapies. This review is aimed at providing a narrative overview of the role of TORe as part of the multidisciplinary therapeutic toolkit nowadays available to approach weight regain and dumping syndrome after RYGB.
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Affiliation(s)
- Maria Valeria Matteo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Correspondence:
| | - Camilla Gallo
- Division of Gastroenterology and Center for Autoimmune Liver Disease, Ospedale San Gerardo, Department of Medicine and Surgery, University of Bicocca, 20900 Monza, Italy
| | - Valerio Pontecorvi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Vincenzo Bove
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Martina De Siena
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Giorgio Carlino
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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23
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Endoscopic gastric plication for the treatment of weight regain after Roux-en-Y gastric bypass (with video). Gastrointest Endosc 2022; 96:51-56. [PMID: 35259393 PMCID: PMC9233122 DOI: 10.1016/j.gie.2022.02.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastric plication involves inverting the stomach with tissue anchor placement to achieve serosa-to-serosa apposition. One potential application of gastric plication is the treatment of weight regain after Roux-en-Y gastric bypass (RYGB), a procedure also known as plication transoral outlet reduction (P-TORe). This study aims to assess technical feasibility, safety, and efficacy of P-TORe. METHODS This was a registry study of RYGB patients who underwent P-TORe for weight regain. The primary outcome was the amount of weight loss and clinical success rate, defined as percentage of total weight loss (TWL) of at least 5% at 12 months. Secondary outcomes were technical success, adverse events (AEs), and predictors of weight loss. RESULTS One hundred eleven RYGB patients underwent P-TORe. Average body mass index (BMI) was 38.5 ± 7.5 kg/m2. Baseline gastrojejunal anastomosis (GJA) and pouch sizes were 17 ± 6 mm and 5 ± 2 cm, respectively. The primary outcome was total weight loss, defined as patients experiencing 9.5% ± 8.5% TWL at 12 months. Clinical success rate was 73%. Technical success rate was 100%. Argon plasma coagulation (APC) was performed around the GJA in all patients (100%) before plication placement. The total number of plications per case was 7 ± 3. Overall AE rate was 12.6%. These included GJA stenosis (9.9%), melena because of marginal ulceration (1.8%), and deep vein thrombosis (.9%). The severe AE rate was 0%. Predictors of weight loss were the amount of weight regain and baseline pouch length. CONCLUSIONS This novel P-TORe technique combining APC with gastric plication appears to be technically feasible, safe, and effective at treating weight regain after RYGB.
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Obesity and social representations among patients subjected to argon plasma coagulation (APC). PSICO 2022. [DOI: 10.15448/1980-8623.2022.1.37279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This study sought to identify the Social Representations of Obesity among 15 individuals who underwent bariatric surgery through the Roux-en-Y Gastric Bypass (RYGB) method and were subjected to Argon Plasma Coagulation (APC) due to weight relapse. Data were collected through interviews and analyzed via Descending Hierarchical Classification. Obesity was associated with physical limitations and difficulties in social relationships. Prejudice and difficulty in changing habits are associated with the choice to undergo surgical treatment and to weight relapse. The suffering that goes along with obesity and the difficulty in changing habits seem to be associated with the search for surgical help.
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25
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Bulajic M, Vadalà di Prampero SF, Boškoski I, Costamagna G. Endoscopic therapy of weight regain after bariatric surgery. World J Gastrointest Surg 2021; 13:1584-1596. [PMID: 35070065 PMCID: PMC8727177 DOI: 10.4240/wjgs.v13.i12.1584] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/14/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023] Open
Abstract
Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological, anatomical and metabolic factors. Surgical revision of these patients has significant risks and limited benefits. Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective, safe, less invasive and even reproducible treatment. We herein discuss the indication, selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery. Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.
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Affiliation(s)
- Milutin Bulajic
- Department of Gastroenterology and Digestive Endoscopy, Mater Olbia Hospital, Olbia 07026, Italy
| | | | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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26
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Hamed H, Ali M, Elmahdy Y. Types, Safety, and Efficacy of Limb Distalization for Inadequate Weight Loss After Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis With a Call for Standardized Terminology. Ann Surg 2021; 274:271-280. [PMID: 32941271 DOI: 10.1097/sla.0000000000004485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Comprehensive classification and evaluation of the outcome of limb distalization (LD) for inadequate weight loss after roux-en-y gastric bypass (RYGB). BACKGROUND Limb distalization is a revisional malabsorptive procedure for the management of inadequate weight loss after RYGB. Multiple studies with small sample sizes reported the outcome of LD. This meta-analysis aims to reach a higher level of evidence regarding the safety and efficacy of the procedure. METHODS A systematic search, including all studies on LD for management of inadequate weight loss after RYGB. The search engines included were PubMed, Embase, Web of Science, Cochrane Library, Scopus, and EBSCOhost. RESULTS Fourteen studies were included. The pooled estimates of the mid-term percentage of excess weight loss (%EWL), diabetic, and hypertension remission were 50.8%, 69.9%, and 59.8%, respectively. The rate of surgical revision for the management of protein-energy malnutrition (PEM) was 17.1%. The %EWL was significantly higher with older age and good response to index surgery (P = 0.01, 0.04, respectively). Less total alimentary limb length was not associated with better %EWL (P = 0.9), but it was significantly associated with severe PEM (P = 0.01). CONCLUSIONS LD has an encouraging rate of resolution of comorbidities. A judicious patient selection is essential for better weight loss after LD. Type I LD with total alimentary limb length ≥350 cm was associated with less risk of malnutrition. PEM is a life-threatening complication that may require revisional surgery years after LD. Future studies on LD, adopting standardized surgical practice and terminology, will allow a more conclusive assessment of the outcome of the procedure.
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Affiliation(s)
- Hosam Hamed
- Gastrointestinal surgical center (GISC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Kermansaravi M, DavarpanahJazi AH, ShahabiShahmiri S, Carbajo M, Vitiello A, Parmar CD, Musella M. Areas of Non-Consensus Around One Anastomosis/Mini Gastric Bypass (OAGB/MGB): A Narrative Review. Obes Surg 2021; 31:2453-2463. [PMID: 33598845 DOI: 10.1007/s11695-021-05276-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE One anastomosis/mini gastric bypass (OAGB/MGB) is now an established bariatric and metabolic surgical procedure with good outcomes. Despite two recent consensus statements around OAGB/MGB, there are some issues which are not accepted as consensus and need more long-term data and research. MATERIAL AND METHODS After identifying the topic of non-consensus from the two recent OAGB/MGB consensuses, PubMed, Scopus, and Cochrane were searched for articles published by November 2020. RESULTS In this study, we evaluated these non-consensus topics around OAGB/MGB and all related articles on these topics were assessed by authors to have an argument on these items. CONCLUSION There is enough evidence to include OAGB/MGB as an accepted standard bariatric and metabolic surgical procedure. However, long-term data and more research are needed to have a consensus in all aspects including these non-consensus topics.
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Affiliation(s)
- Mohammad Kermansaravi
- Minimally Invasive Surgery Research Center, Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Shahab ShahabiShahmiri
- Minimally Invasive Surgery Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Miguel Carbajo
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Calle Estacion, No. 12, 1, 47004, Valladolid, Spain
| | - Antonio Vitiello
- Advanced Biomedical Sciences Department, "Federico II" University, Naples, Italy
| | - Chetan D Parmar
- Whittington Hospital NHS Trust, London, UK.
- University College London Medical School, London, UK.
| | - Mario Musella
- Advanced Biomedical Sciences Department, "Federico II" University, Naples, Italy
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Khoury T, Ilan Y. Platform introducing individually tailored variability in nerve stimulations and dietary regimen to prevent weight regain following weight loss in patients with obesity. Obes Res Clin Pract 2021; 15:114-123. [PMID: 33653665 DOI: 10.1016/j.orcp.2021.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 02/09/2021] [Accepted: 02/13/2021] [Indexed: 02/07/2023]
Abstract
Prevention of weight regain following successful weight loss is a major challenge in the treatment of obesity, irrespective of the weight reduction method used. The majority of individuals regain the lost weight over time; thus, achieving long-term sustainability in weight loss remains an unresolved issue. A compensatory adaptation to the weight loss methods occurs in several body organs and partly explains the lack of sustainable effect. Variability is inherent in many biological systems, and patterns of variability constitute a body mechanism that is active at several levels, starting from the genes and cellular pathways through to the whole-organ level. This study aimed to describe a platform that introduces individually tailored variability in vagal nerve stimulation and dietary regimen to ensure prolonged and sustainable weight loss and prevent weight regain. The platform is intended to provide a method that can overcome the body's compensatory adaptation mechanisms while ensuring a prolonged beneficial effect.
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Affiliation(s)
- Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel; Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Yaron Ilan
- Department of Medicine, Hebrew University-Hadassah Medical Center, PO Box 12000, IL-91120, Jerusalem, Israel.
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29
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Cambi MPC, Baretta GAP, Magro DDO, Boguszewski CL, Ribeiro IB, Jirapinyo P, de Moura DTH. Multidisciplinary Approach for Weight Regain-how to Manage this Challenging Condition: an Expert Review. Obes Surg 2021; 31:1290-1303. [PMID: 33392999 DOI: 10.1007/s11695-020-05164-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 12/13/2022]
Abstract
Weight regain is a multifactorial condition that affects many patients following bariatric surgery. The purpose of the paper is to review the multidisciplinary approach for the management of weight regain. We performed a search in current clinical evidence regarding the causes, consequences, and treatments of weight regain. The multidisciplinary approach with periodic monitoring is of fundamental importance to prevent or treat weight regain. Several therapeutic options are ranging from nutritional to surgical options, which should be tailored according to patients' anatomy, lifestyle behavior, and compliance. Specialized multidisciplinary care is the key to achieve optimal long-term weight loss and maintenance goals following bariatric surgery.
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Affiliation(s)
| | | | - Daniéla De Oliveira Magro
- Department of Surgery, Faculty of Medical Sciences, State University of Campinas UNICAMP-SP, Campinas Sao Paulo, Brazil
| | | | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, Av. Dr Eneas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, Sao Paulo, 05403-010, Brazil.
| | - Pichamol Jirapinyo
- Division of Gasteoenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, Av. Dr Eneas de Carvalho Aguiar, 225, 6o andar, bloco 3, Cerqueira Cesar, Sao Paulo, 05403-010, Brazil
- Division of Gasteoenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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30
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Relly R, Mati S, Aviv CN, Fishman S. Endoscopic trans-oral outlet reduction after bariatric surgery is safe and effective for dumping syndrome. Surg Endosc 2021; 35:6846-6852. [PMID: 33398583 DOI: 10.1007/s00464-020-08190-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Dumping syndrome (DS) is a common complication of bariatric surgery. Treatments include dietary and behavioral changes, as well as pharmacotherapy and revision surgery. All can be costly or hard to adhere to. In recent years, evidence accumulates in favor of endoscopic trans-oral outlet reduction (TORe) as an effective treatment for DS, targeting the pathophysiology of rapid gastric clearance. The objective of this study is to assess the safety and efficacy of TORe for DS in a single referral center. METHODS Patients after bariatric surgery suffering DS were followed, and data were retrospectively analyzed. Diagnosis and post-procedural assessment of DS were made clinically using Sigstad score. During the procedure, the anastomotic rim was cauterized. Afterwards, 2 non-interrupted "8-figure" sutures were placed, resulting in imbrication of additional gastric tissue on top of the anastomosis and narrowing to <1 cm at the end of the procedure. Patients were instructed to keep a liquid diet for 14 days and follow-up continued for 6 months. RESULTS Between 8/2018 and 9/2019 TORe was carried out in 13 patients (M:F = 3:10) with mean age of 45.1 (range 25-56) and BMI of 33.5 (range 28.1-40.3). Average time since recent surgery was 5.5 years (range 1-9). Mean pre-procedure anastomosis diameter was 25.2 mm (range 15-30) and was reduced to a mean of 5.6 mm (range 5-10). Three patients (23%) were admitted overnight due to inability to drink which resolved spontaneously. No major complications were reported. At 6 months, the Sigstad score was significantly reduced (19.4 ± 3.6 vs 5.2 ± 5.5, P < 0.001), and 11/13 (85%) of patients had a complete resolution of their dumping symptoms. In addition, BMI decreased by a mean of 2.3 kg/m2 (-1 to 7.5, p = 0.002). CONCLUSION TORe is a safe and effective treatment for patients suffering dumping syndrome and should be considered early in the treatment of DS.
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Affiliation(s)
- Reicher Relly
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel
| | - Shnell Mati
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel
| | - Cohen Nathaniel Aviv
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel
| | - Sigal Fishman
- Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel.
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Ismail M, Nagaraj D, Rajagopal M, Ansari H, Iyyankutty K, Nair M, Hegde A, Rekha PD. Is weight regaining significant post laparoscopic Roux-en-Y gastric bypass surgery? - A 5-year follow-up study on Indian patients. J Minim Access Surg 2021; 17:159-164. [PMID: 33723179 PMCID: PMC8083740 DOI: 10.4103/jmas.jmas_108_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Laparoscopic Roux-en-Y gastric bypass (RYGB) has been proven to induce significant weight loss and remission of related co-morbidities in patients with morbid obesity. The long-term follow-up data show weight regain or failure to achieve complete remission of type 2 diabetes mellitus (T2DM) in some patients. In this study, we report weight loss patterns and remission of T2DM in patients with morbid obesity during a 5-year follow-up after RYGB. Objective The objective was to evaluate outcomes during the follow-up on excess weight loss (EWL) and remission of T2DM after laparoscopic RYGB among Indian patients. Setting The study was conducted in a tertiary care hospital, Kerala, India. Materials and Methods This is a retrospective study in patients who underwent surgery between 2007 and 2010. The patient demographics, pre- and post-operative body mass index (BMI), co-morbidities and EWL were recorded from the medical records. These data were compared between pre-operative and follow-up intervals till 5 years using statistical approaches. Results The study included 157 patients (91 males and 66 females) having a mean pre-operative BMI of 47.91 ± 7.01 kg/m2. A significant reduction in the BMI was observed at each follow-up point (P < 0.01) till 5 years after the surgery. The mean percentage of EWL increased from 34.57% ± 12.62% to 71.50% ± 15.41% from 3 months to 5 years after the surgery. Twelve per cent (n = 19) of patients achieved normal BMI (<25 mg/kg2) by 3rd year after the surgery. However, the remission of T2DM was achieved in >50% of patients within a year of surgery. During the 5th year, weight regain (1-22 kg) was observed in 36.70% (n = 58) patients, and recurrence of T2DM was observed in two patients. Conclusions The long-term durability of RYGB in the study population was satisfactory with significant weight loss and remission of T2DM.
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Affiliation(s)
- Mohamed Ismail
- Department of General, Laparoscopic and Bariatric Surgery, Moulana Hospital, Perinthalmanna, Kerala, India
| | - Dileep Nagaraj
- Department of General, Laparoscopic and Bariatric Surgery, Moulana Hospital, Perinthalmanna, Kerala, India
| | - Mahesh Rajagopal
- Department of General, Laparoscopic and Bariatric Surgery, Moulana Hospital, Perinthalmanna, Kerala, India
| | - Hafiz Ansari
- Department of General, Laparoscopic and Bariatric Surgery, Moulana Hospital, Perinthalmanna, Kerala, India
| | - Kingsly Iyyankutty
- Department of General, Laparoscopic and Bariatric Surgery, Moulana Hospital, Perinthalmanna, Kerala, India
| | - Megha Nair
- Yenepoya Research Centre, Yenepoya University, Mangalore, Karnataka, India
| | - Aparna Hegde
- Yenepoya Research Centre, Yenepoya University, Mangalore, Karnataka, India
| | - P D Rekha
- Yenepoya Research Centre, Yenepoya University, Mangalore, Karnataka, India
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Itani MI, Farha J, Sartoretto A, Abbarh S, Badurdeen D, de Moura DTH, Kumbhari V. Endoscopic sleeve gastroplasty with argon plasma coagulation: A novel technique. J Dig Dis 2020; 21:664-667. [PMID: 32916766 DOI: 10.1111/1751-2980.12939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/22/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure in which the anterior and posterior aspects of the greater curvature are stitched endoscopically, producing a sleeve-like anatomy mimicking that in a sleeve gastrectomy. However, suture dehiscence and enlargement of the stomach within months of the procedure have been observed. Argon plasma coagulation (APC) is widely used in gastrointestinal endoscopy and is able to induce scarring and fibrosis. We coupled ESG with APC to evaluate its potential to improve durability. METHODS A 46-year-old woman with obesity presented for ESG. Her pre-procedure weight was 117 kg with a body mass index (BMI) of 41.4 kg/m2 . After each plication was complete, APC (60 W, argon flow rate 1.2 L/min) was used to ablate the mucosal surface of the exposed plicated mucosa. APC was applied until the mucosal color was dark brown, indicating adequate and successful mucosal and submucosal ablation. RESULTS The procedure was successful, and the patient recovered without peri- or post-operative complications. The procedure time was 47 minutes. A total of seven sutures were used. At 6-month follow-up the patient had lost 17 kg (37.5 lbs), equivalent to 14.5% total weight loss and had a BMI of 35.4 kg/m2 . Endoscopic follow-up at 6 months revealed enhanced fibrosis along the plications, resulting in a superior, sleeve-like lumen. CONCLUSIONS The combination of ESG with APC may act synergistically to reduce weight without adding significant procedure time. Further investigation is needed to determine whether it should be widely recommended.
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Affiliation(s)
- Mohamad I Itani
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Jad Farha
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Shahem Abbarh
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Dilhana Badurdeen
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Diogo T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Borjas G, Marruffo M, Sanchez N, Urdaneta A, Gonzalez M, Ramos E, Maldonado A. Gastric bypass with weight regain - Biliary limb distalization plus endoscopic transjejunal A.P.C. pouch therapy in one step: Case report. Int J Surg Case Rep 2020; 76:148-152. [PMID: 33032046 PMCID: PMC7548425 DOI: 10.1016/j.ijscr.2020.09.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Abstract
Weight regain is a common problem within Bariatric Surgery and about 20% of patients who undergo Roux-en-Y gastric bypass patients may experience weight regain. Among the arsenal of alternatives to treat weight regain we have endoscopic therapies and surgical modifications of the primary technique, among others. This case represents the first report in which endoscopic therapy via transjejunal is used in conjunction with distalization of the biliopancreatic limb. Introduction In recent years there has been a significant growth in the percentage of patients with weight regain after Roux-en-Y gastric bypass (RYGB). Approximately 20% RYGB patients may experience weight regain 24 months after the intervention. Presentation of case A 53 yr male patient who underwent RYGB in 2011 with an initial weight of 140 kg and BMI of 44.19 kg/m who consults in 2019 for a weight regain of 45.9%. Transoperative endoscopy assessment revealed a gastric pouch and gastrojejunal anastomosis with a diameter of 7 cm and 2.5 cm respectively. During the procedure we found a common channel of 725 cm, it is decided to shorten it through the distalization of the biliopancreatic limb. Afterward using the same laparoscopic ports to introduce the endoscope through jejunal cane to realize the APC therapy. He was discharged on the 2nd-day, without any complaint. Discussion The purpose of this case report is to expose the viability to perform a combined surgical technique such as the distalization of the biliopancreatic limb with endoscopic techniques of argon plasma coagulation (APC) via transjejunal in the same operative course. Using this combined technique we can increase hypoabsortive and restrictive components that would represent a secure and efficient weight loss in our patient. Conclusions This innovative technique can represent a viable alternative that is secure and reproducible in revisional surgery for weight regain context.
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Affiliation(s)
- Guillermo Borjas
- Unidad Internacional de Cirugía Bariátrica y Metabólica, Grupo Médico Santa Paula, Caracas, Venezuela.
| | - Mario Marruffo
- Unidad Internacional de Cirugía Bariátrica y Metabólica, Grupo Médico Santa Paula, Caracas, Venezuela.
| | - Nestor Sanchez
- Unidad Internacional de Cirugía Bariátrica y Metabólica, Grupo Médico Santa Paula, Caracas, Venezuela.
| | - Ali Urdaneta
- Unidad Internacional de Cirugía Bariátrica y Metabólica, Grupo Médico Santa Paula, Caracas, Venezuela.
| | - María Gonzalez
- Unidad Internacional de Cirugía Bariátrica y Metabólica, Grupo Médico Santa Paula, Caracas, Venezuela.
| | - Eduardo Ramos
- Unidad Internacional de Cirugía Bariátrica y Metabólica, Grupo Médico Santa Paula, Caracas, Venezuela.
| | - Andres Maldonado
- Unidad Internacional de Cirugía Bariátrica y Metabólica, Grupo Médico Santa Paula, Caracas, Venezuela.
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Dhindsa BS, Saghir SM, Naga Y, Dhaliwal A, Ramai D, Cross C, Singh S, Bhat I, Adler DG. Efficacy of transoral outlet reduction in Roux-en-Y gastric bypass patients to promote weight loss: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1332-E1340. [PMID: 33015335 PMCID: PMC7511267 DOI: 10.1055/a-1214-5822] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/22/2020] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Transoral outlet reduction (TORe) is an endoscopic procedure used in patients with weight gain post Roux-en-Y gastric bypass (RYGB). We performed a systematic review and meta-analysis to evaluate the efficacy and safety of TORe with a full-thickness suturing device for treating patients with weight regain after RYGB. Patients and methods We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to March 2020). The primary outcomes assessed were technical success, absolute weight loss (AWL) and percent of total weight loss (% TWL) at 3, 6, and 12 months after the procedure. The secondary outcomes assessed were pooled rate of adverse events (AEs), adverse event subtypes and association of size of gastrojejunal anastomosis (GJA) and percent TWL. Results Thirteen studies on 850 patients were included. The pooled rate of technical success was 99.89 %. The absolute weight loss (kg) at 3, 6, and 12 months was 6.14, 10.15, and 7.14, respectively. The percent TWL at 3, 6, and 12 months was 6.69, 11.34, and 8.55, respectively. The pooled rate of AE was 11.4 % with abdominal pain being the most common adverse event. The correlation coefficient (r) was -0.11 between post TORe GJA size and weight loss at 12 months. Conclusion TORe is an endoscopic procedure that is safe and technically feasible for post RYGB with weight gain.
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Affiliation(s)
- Banreet Singh Dhindsa
- Department of Internal Medicine, University of Nebraska Medical Center, Las Vegas, Nevada, United States
| | - Syed Mohsin Saghir
- Department of Internal Medicine, University of Nebraska Medical Center, Las Vegas, Nevada, United States
| | - Yassin Naga
- Department of Internal Medicine, University of Nebraska Medical Center, Las Vegas, Nevada, United States
| | - Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Las Vegas, Nevada, United States
| | - Dayl Ramai
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, United States
| | - Chad Cross
- Department of Biostatistics and Epidemiology, University of Nevada Las Vegas, Las Vegas, Nevada, United States
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Las Vegas, Nevada, United States
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Las Vegas, Nevada, United States
| | - Douglas G. Adler
- Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah
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Lee Bion A, Le Roux Y, Alves A, Menahem B. Bariatric revisional surgery: What are the challenges for the patient and the practitioner? J Visc Surg 2020; 158:38-50. [PMID: 32958433 DOI: 10.1016/j.jviscsurg.2020.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric revisional surgery represents an important new issue for obese patients because of the considerable rate of failure and complications following bariatric surgery. As the frequency of bariatric procedures increases, so too does the incidence of revisional surgery, which has become becoming increasingly important. The surgeon must know the indications and the results of the various revisional procedures in order to best guide the therapeutic decision. The current challenge is to correctly select the patients for revisional surgery and to choose the appropriate procedure in each case. Multidisciplinary management is essential to patient re-assessment and to prepare the patient for a re- intervention. The objective of this update, based on data from all the most recent studies concerning revisional surgery, is to guide the surgeon in the choice of the revisional procedure, depending on patient characteristics, co-morbidities, the previously performed procedure, the type of failure or complication observed, but also on the surgeon's own habits and the center's expertise. The collected results show that revisional surgery is difficult, with higher complication rates and weight-loss results that are often lower than those of first-intent surgery. For these reasons, patient selection must be rigorous and multidisciplinary and the management in expert centers of these difficult situations must be encouraged.
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Affiliation(s)
- A Lee Bion
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France.
| | - Y Le Roux
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
| | - A Alves
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; Unicaen, Inserm, Anticipe, université de Normandie, 14000 Caen, France
| | - B Menahem
- Digestive surgery department, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; Unicaen, Inserm, Anticipe, université de Normandie, 14000 Caen, France
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Reversal of Long-Term Weight Regain After Roux-en-Y Gastric Bypass Using Liraglutide or Surgical Revision. A Prospective Study. Obes Surg 2020; 31:93-100. [PMID: 32691401 PMCID: PMC7808975 DOI: 10.1007/s11695-020-04856-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 12/24/2022]
Abstract
Purpose This study investigates whether pharmacotherapy with liraglutide is similarly effective in reversing weight regain more than 6 years after Roux-en-Y gastric bypass (RYGB) as revisional surgery aimed at restoring restriction. Methods Ninety-five consecutive patients (11 male, 84 female; mean BMI 45 ± 6 kg/m2) undergoing RYGB 9 ± 4 years ago were treated for 24 months as follows: Patients, who gained less than 10% from weight NADIR, served as controls and were provided lifestyle counseling (DC, n = 30). The others were allowed to choose between three different treatment groups: daily s.c. administration of liraglutide (LG, n = 34); endosurgery using Apollo’s Overstitch System™ (ES, n = 15), or implantation of a Fobi-ring with pouch resizing (FP, n = 16). Results Controls kept their weight stable during 24 months of study (− 0.1 ± 1.7 kg/m2). Weight loss was 4.8 ± 2.9 kg/m2 for LG and 5.5 ± 2.9 kg/m2 for FP, both losing more than 85% of regained weight from weight NADIR (p < 0.001). In contrast, weight loss in ES was 1.0 ± 0.9 kg/m2 (i.e., 20% of regained weight). Thirty-seven percent of FP experienced serious complications (p < 0.05) in contrast to the other groups. An improved prevalence of hypertension and dyslipidemia was observed in LG and FP (p < 0.02) 24 months after intervention. Conclusions Weight regain during more than 6 years after RYGB can be safely and effectively reversed with liraglutide. Compared with revisional surgery, pharmacotherapy with liraglutide was low risk and resulted in an important improvement in hypertension and dyslipidemia. Therefore, daily subcutaneous injections of liraglutide are a valid option to treat weight regain after RYGB.
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Brunaldi VO, Farias GFA, de Rezende DT, Cairo-Nunes G, Riccioppo D, de Moura DTH, Santo MA, de Moura EGH. Argon plasma coagulation alone versus argon plasma coagulation plus full-thickness endoscopic suturing to treat weight regain after Roux-en-Y gastric bypass: a prospective randomized trial (with videos). Gastrointest Endosc 2020; 92:97-107.e5. [PMID: 32217111 DOI: 10.1016/j.gie.2020.03.3757] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS A significant number of patients regain weight after Roux-en-Y gastric bypass. Ablation with argon plasma coagulation (APC) plus endoscopic full-thickness suturing (FTS-APC) and ablation alone have been reported for treating weight regain when associated with gastrojejunostomy (GJ) dilation. However, comparative controlled data are still lacking. METHODS This was a pilot single-center open-label randomized trial comparing the effectiveness and safety of APC alone versus FTS-APC for transoral outlet reduction. Patients with at least 20% weight regain from the nadir, and GJ ≥15 mm were considered eligible. The primary outcome was percentage total weight loss (%TWL) at 12 months. Secondary outcomes were the incidence of adverse events, amelioration of metabolic laboratory parameters, and improvement in quality of life and eating behavior. RESULTS Forty patients meeting the eligibility criteria were enrolled from October 2017 to July 2018. Technical and clinical success rates were similar between the groups. At 12 months, the mean %TWL was 8.3% ± 5.5% in the APC alone group versus 7.5% ± 7.7% in the FTS-APC group (P = .71). The pre-revisional % solid gastric retention at 1 hour positively correlated with the probability of achieving ≥10% TWL at 12 months. Both groups experienced significant reductions in low-density lipoprotein and triglyceride levels at 12 months, and improvement in eating behavior and quality of life at 3 months. There were 2 cases of stenoses (1 from each group), which were successfully treated with endoscopic balloon dilation. CONCLUSION APC alone is similar to FTS-APC in terms of technical and clinical outcomes within 1 year of follow-up. (Clinical trial registration number: NCT03094936.).
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Affiliation(s)
- Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil; Center for Gastrointestinal Endoscopy, Surgery and Anatomy Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Galileu Ferreira Ayala Farias
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Tavares de Rezende
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Gabriel Cairo-Nunes
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Riccioppo
- Bariatric and Metabolic Surgery Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Marco Aurelio Santo
- Bariatric and Metabolic Surgery Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil
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Vargas EJ, Abu Dayyeh BK, Storm AC, Bazerbachi F, Matar R, Vella A, Kellogg T, Stier C. Endoscopic management of dumping syndrome after Roux-en-Y gastric bypass: a large international series and proposed management strategy. Gastrointest Endosc 2020; 92:91-96. [PMID: 32112780 DOI: 10.1016/j.gie.2020.02.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Roux-en-Y gastric bypass (RYGB) is refractory to lifestyle and pharmacotherapy measures, requiring reversal of the patient's bariatric surgery. Reversal can lead to weight regain and recrudescence of their comorbidities. Our aim was to report a multicenter experience on the endoscopic management of refractory dumping syndrome with endoscopic transoral outlet reduction (TORe). METHODS A multicenter international series of consecutive patients who underwent TORe with a full-thickness endoscopic suturing device was analyzed for technical success, improvement in Sigstad scores, and weight trajectories after the procedure. Failure was defined as needing an enteral feeding tube, surgical reversal, or repeat TORe. RESULTS One hundred fifteen patients across 2 large academic centers in Germany and the United States underwent TORe for dumping syndrome. Patient age was mean 8.9 ± 1.1 years from their initial RYGB with an average percent total body weight loss of 31% ± 10.6% at the time of endoscopy. Three months postprocedure, the Sigstad score improved from a mean of 17 ± 6.1 to 2.6 ± 1.9 (paired t test P = .0001) with only 2% of patients (n = 2) experiencing weight gain. Mean weight loss and percentage of total body weight loss 3 months post-TORe were 9.47 ± 3.6 kg and 9.47% ± 2.5%, respectively. Six patients (5%) failed initial endoscopic therapy, with 50% (n = 3) successfully treated with a repeat TORe. Three patients underwent surgical reversal, indicating an overall 97% endoscopic success rate. CONCLUSIONS TORe as an adjunct to lifestyle and pharmacologic therapy for refractory dumping syndrome is safe and effective at improving dumping syndrome and reducing rates of surgical revision.
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Affiliation(s)
- Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology, Interventional Endoscopy Program, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Reem Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Vella
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd Kellogg
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine Stier
- Department of Endocrinology, University Hospital, Würzburg, Germany
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Jirapinyo P, de Moura DT, Thompson CC. Endoscopic submucosal dissection with suturing for the treatment of weight regain after gastric bypass: outcomes and comparison with traditional transoral outlet reduction (with video). Gastrointest Endosc 2020; 91:1282-1288. [PMID: 32007520 PMCID: PMC7245570 DOI: 10.1016/j.gie.2020.01.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although traditional transoral outlet reduction (TORe) involves argon plasma coagulation (APC) before endoscopic suturing, modified endoscopic submucosal dissection (ESD) has also been used. This study aims to evaluate the safety and efficacy of modified ESD-TORe in comparison with traditional APC-TORe. METHODS This was a retrospective study of prospectively collected data from patients who underwent modified ESD-TORe and APC-TORe for weight regain after Roux-en-Y gastric bypass (RYGB). Our outcomes were technical success, adverse events as categorized by the American Society for Gastrointestinal Endoscopy lexicon, and percent total weight loss (TWL) at 6 and 12 months and patients who underwent ESD-TORe were matched 1:3 based on gastrojejunal anastomosis (GJA) and pouch sizes to those who underwent APC-TORe. TWL between groups was compared. A linear regression was performed to control for any confounders. RESULTS Nineteen RYGB patients underwent ESD-TORe. Technical success rate was 100%, with no severe adverse events. At 6 and 12 months, patients experienced 13.4% ± 6.6% and 12.1% ± 9.3% TWL, respectively (P < .05 for both). Nineteen ESD-TORe patients were also matched with 57 APC-TORe patients based on GJA and pouch sizes. At 12 months, the ESD-TORe group experienced greater weight loss compared with the APC-TORe group (12.1% ± 9.3% vs 7.5% ± 3.3% TWL, respectively; P = .036). On regression analysis, ESD remained a significant predictor of percent of TWL at 12 months after controlling for age, sex, body mass index, weight regain, and years from RYGB (β = 5.99, P = .02). CONCLUSIONS Combining endoscopic tissue dissection with suturing provides greater and more durable weight loss for patients with weight regain after RYGB.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Diogo T.H. de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Gastroenterology Department, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Faul A, Chevallier JM, Poghosyan T. Dilated Gastric Pouch Resizing for Weight Loss Failure After One Anastomosis Gastric Bypass. Obes Surg 2020; 29:3406-3409. [PMID: 31115846 DOI: 10.1007/s11695-019-03972-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Some patients may experience inadequate weight loss or weight regain due to gastric pouch dilation after one anastomosis gastric bypass (OAGB). Dilated gastric pouch resizing (GPR) associated with correction of eating behavior was suggested as an option in the management of these patients. Retrospective analysis of 17 consecutives patients who underwent a GPR between 2007 and 2017 was undertaken. At revision, the mean body mass index (BMI) and percentage of total weight loss (%TWL) were 41.5 ± 11 kg/m2 and 15 ± 10, respectively. Overall morbidity rate was 6.7% (n = 1). Two years after revision, the mean BMI and %TWL were 34.1 ± 5 kg/m2 and 31 ± 13, respectively. GPR appeared to be a satisfactory option resulting in mid-term secondary weight loss in well selected patients at the expense of non-negligible morbidity rate.
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Affiliation(s)
- Adrien Faul
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and Paris Descartes University, 20 Rue Leblanc, 75015, Paris, France
| | - Jean-Marc Chevallier
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and Paris Descartes University, 20 Rue Leblanc, 75015, Paris, France
| | - Tigran Poghosyan
- Department of Digestive, Oncologic and Bariatric Surgery, AP-HP, Hôpital Européen Georges Pompidou and Paris Descartes University, 20 Rue Leblanc, 75015, Paris, France.
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Endoscopic Gastric Plication for Morbid Obesity: a Systematic Review and Meta-analysis of Published Data over Time. Obes Surg 2020; 29:3021-3029. [PMID: 31230201 DOI: 10.1007/s11695-019-04010-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic gastric plication or gastroplasty for morbid obesity is gaining worldwide recognition. Data concerning safety and efficacy are rather scarce. Furthermore, clear guidelines are yet to be established. The objective of this meta-analysis is to update the data and investigate the efficacy and safety of the procedure. An online comprehensive search using Cochrane, Google Scholar, PubMed, Web of Science, and Embase on endoscopic gastric plication was completed. The primary outcome was defined as weight loss at 6 months or more after the procedure. Secondary outcomes were defined as the occurrence of adverse events or complications including insufficient weight loss or regain. I2 statistic was used to define the heterogeneity across studies. Twenty-two cohort studies on 7 different devices met the inclusion criteria, with a total of 2475 patients. The mean baseline BMI was 37.8 ± 4.1 kg/m2 (median 37.9; range 28.0-60.2). Either a transoral endoluminal stapling or (suction based) (full-thickness) stitching and/or anchor device was used to obtain gastric volume reduction and/or alter gastric outlet. The mean follow-up was 13 months (median 12; range 6-24) for the specified outcomes of each study. Two active, FDA-approved devices were taken into account for meta-analysis: Endoscopic sleeve gastroplasty (ESG) and the primary obesity surgery endolumenal (POSE™). Average pooled %EWL at 6 months (p = 0.02) and 12 months (p = 0.04) in favor of ESG was 57.9 ± 3.8% (50.5-65.5, I2 = 0.0), 44.4 ± 2.1% (40.2-48.5, I2 = 0.0), and 68.3 ± 3.8% (60.9-75.7, I2 = 5.8), 44.9 ± 2.1% (40.9-49.0, I2 = N/A) for ESG and POSE respectively. Major adverse events without mortality were described in 25 patients (9 studies, p = 0.63). ESG and POSE are both safe and feasible procedures with good short-term weight loss. ESG seems to be superior in terms of weight loss at this point. Few major adverse events are reported and long-term results are awaited.
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Hajifathalian K, Sharaiha RZ. Revision of gastric bypass: What is on the menu? Gastrointest Endosc 2020; 91:1074-1077. [PMID: 32327118 DOI: 10.1016/j.gie.2020.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/30/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Kaveh Hajifathalian
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital, Weill Cornell Medicine
- Cornell University, New York, New York, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital, Weill Cornell Medicine
- Cornell University, New York, New York, USA
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Spota A, Laracca GG, Perretta S. Training in bariatric and metabolic endoscopy. Ther Adv Gastrointest Endosc 2020; 13:2631774520931978. [PMID: 32596663 PMCID: PMC7301653 DOI: 10.1177/2631774520931978] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/13/2020] [Indexed: 12/23/2022] Open
Abstract
The limited penetration of bariatric surgery and the scarce outcome of pharmacological therapies created a favorable space for primary bariatric endoscopic techniques. Furthermore, bariatric endoscopy is largely used to diagnose and treat surgical complications and weight regain after bariatric surgery. The increasingly essential role of endoscopy in the management of obese patients results in the need for trained professionals. Training methods are evolving, and the apprenticeship method is giving way to the simulation-based method. Existing simulation platforms include mechanical simulators, ex vivo and in vivo models, and virtual reality simulators. This review analyzes current training methods for bariatric endoscopy and available training programs with dedicated bariatric core curricula, giving a glimpse of future perspectives.
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Affiliation(s)
- Andrea Spota
- Scuola di Specializzazione in Chirurgia Generale, Università degli Studi di Milano, Milano, Italy
| | | | - Silvana Perretta
- Surgery, IRCAD, 1 place de l’hopital, hopitaux universitaires, Strasbourg 67000, France
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Barrichello S, Hourneaux de Moura DT, Hourneaux de Moura EG, Jirapinyo P, Hoff AC, Fittipaldi-Fernandez RJ, Baretta G, Felício Lima JH, Usuy EN, de Almeida LS, Ramos FM, Matz F, Galvão Neto MDP, Thompson CC. Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study. Gastrointest Endosc 2019; 90:770-780. [PMID: 31228432 DOI: 10.1016/j.gie.2019.06.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Obesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform "U" stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. This also uniquely assessed outcomes in all body mass index (BMI) categories and changes in metabolic rate, lean body mass, and adipose tissue composition. METHODS This is a multicenter analysis of prospectively collected data from 7 centers including patients with overweight and obesity who underwent ESG. Primary outcomes included absolute weight loss, percent total body weight loss (%TWL), change in BMI, and percent excess weight loss (%EWL) at 6 and 12 months in overweight and obese classes I, II, and III. Secondary outcomes included adipose tissue, lean body mass reduction, and metabolic rate analyzed by bioimpedance. Additionally, immediate or delayed adverse events (AEs) were analyzed. Clinical success was defined as achieving ≥25% EWL at 1 year with ≤5% serious AE (SAE) rate following the American Society for Gastrointestinal Endoscopy (ASGE)/American Society for Metabolic and Bariatric Surgery (ASMBS) threshold. RESULTS A total of 193 patients underwent ESG during the study period. All groups had >10% TWL and >25% EWL at 6 months of follow-up. On average, %TWL was 14.25% ± 5.26% and 15.06% ± 5.22% and the %EWL 56.15% ± 22.93% and 59.41% ± 25.69% at 6 months and 1 year of follow-up, respectively. %TWL was 8.91% ± .3%, 13.92% ± 5.76%, 16.22% ± 7.69%, and 19.01% ± .95% and %EWL 56.21% ± 2.0%, 62.03% ± 27.63%, 54.13% ± 23.46%, and 46.78% ± 2.43% for overweight and obesity classes I, II, and III, respectively, at 1 year. Male sex, age <41 years, and higher BMI were predictors of achieving a TWL ≥10% at 1-year follow-up. There was a significant reduction in adipose tissue from baseline. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery. CONCLUSIONS ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds.
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Affiliation(s)
| | - Diogo Turiani Hourneaux de Moura
- Endoscopy Unit, Department of Gastroenterology, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil; Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | - Eduardo N Usuy
- Healthme gerenciamento de perda de peso, Sao Paulo, Brazil
| | | | | | - Felipe Matz
- Endodiagnostic Clinic, Rio de Janeiro, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Jirapinyo P, de Moura DTH, Thompson CC. Sleeve in sleeve: endoscopic revision for weight regain after sleeve gastrectomy. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2019; 4:454-457. [PMID: 31709328 PMCID: PMC6831909 DOI: 10.1016/j.vgie.2019.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Diogo T H de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Moura DTHD, Sachdev AH, Lu PW, Ribeiro IB, Thompson CC. Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report. World J Clin Cases 2019; 7:2038-2043. [PMID: 31423435 PMCID: PMC6695547 DOI: 10.12998/wjcc.v7.i15.2038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/21/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication. CASE SUMMARY A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later. CONCLUSION APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
- Department of Gastroenterology, Clinics Hospital of São Paulo University, São Paulo 05403-00, Brazil
| | - Amit H Sachdev
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Po-Wen Lu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan City, 33305, Taiwan
| | - Igor Braga Ribeiro
- Department of Gastroenterology, Clinics Hospital of São Paulo University, São Paulo 05403-00, Brazil
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
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de Moura DTH, Jirapinyo P, Thompson CC. Modified-ESD Plus APC and Suturing for Treatment of Weight Regain After Gastric Bypass. Obes Surg 2019; 29:2001-2002. [PMID: 30937873 DOI: 10.1007/s11695-019-03808-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mechanisms for weight regain after gastric bypass are not fully understood and the process is likely multifactorial. The initial step in the management of weight regain is a comprehensive evaluation of contributing factors. While lifestyle modification is fundamental, it has limited efficacy which can be enhanced by medications and/or endoscopic revision. Anatomic changes such as larger pouch size and dilation of the gastrojejunal anastomosis (GJA) may contribute to increased postoperative weight gain. Endoluminal revisions offer an effective and less invasive management strategy for this population. METHODS A 55-year-old female with history of RYGB in 2006 presented with weight regain. She was referred to our unit for endoscopic evaluation. RESULTS During endoscopy, a large GJA (25 mm in diameter) was diagnosed. A novel trans-oral outlet reduction (TORe) was then performed. A modified ESD was first performed on the GJA, followed by argon plasma coagulation of the margins of the ESD. Then a purse-string TORe with suturing was performed, using a 10 mm balloon to size the GJA. On 6-month follow-up, patient lost 20 lb. and 12.26 %TBWL and EGD showed a 10 mm diameter GJA. On 1-year follow-up, patient weight loss was 14 lb. and 8.58 %TBWL. The follow-up endoscopy showed a 12 mm diameter GJA. CONCLUSION Endoluminal therapies are safe, reproducible, and effective in the treatment of weight regain and should be utilized as a first-line approach to manage this condition. This novel-combined approach is feasible and may be more effective in the treatment of weight regain.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn, Boston, MA, 1404, USA
- Departamento de Gastroenterologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn, Boston, MA, 1404, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Thorn, Boston, MA, 1404, USA.
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Hourneaux de Moura DT, Hathorn KE, Thompson CC. You Just Got Burned! What Is Wrong With This Gastric Pouch? Gastroenterology 2019; 156:2139-2141. [PMID: 30716322 DOI: 10.1053/j.gastro.2019.01.255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 12/24/2022]
Affiliation(s)
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Massachusetts
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Massachusetts
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de Moura DTH, de Moura BFBH, Manfredi MA, Hathorn KE, Bazarbashi AN, Ribeiro IB, de Moura EGH, Thompson CC. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11:329-344. [PMID: 31205594 PMCID: PMC6556487 DOI: 10.4253/wjge.v11.i5.329] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/16/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023] Open
Abstract
A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Ahmad N Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
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de Moura DTH, de Moura EGH, Thompson CC. Endoscopic sleeve gastroplasty: From whence we came and where we are going. World J Gastrointest Endosc 2019; 11:322-328. [PMID: 31205593 PMCID: PMC6556490 DOI: 10.4253/wjge.v11.i5.322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 02/06/2023] Open
Abstract
The most effective and durable treatment for obesity is bariatric surgery. However, less than 2% of eligible patients who fulfill the criteria for bariatric surgery undergo the procedure. As a result, there is a drive to develop less invasive therapies to combat obesity. Endoscopic bariatric therapies (EBT) for weight loss are important since they are more effective than pharmacological treatments and lifestyle changes and present lower adverse event rates compared to bariatric surgery. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive EBT that involves remodeling of the greater curvature. ESG demonstrated favorable outcomes in several centers, with up to 20.9% total body weight loss and 60.4% excess weight loss (EWL) on 2-year follow-up, with a low rate of severe adverse events (SAE). As such, it could be considered safe and effective in light of ASGE/ASMBS thresholds of > 25% EWL and ≤ 5% SAE, although there are no comparative trials to support this. Additionally, ESG showed improvement in diabetes mellitus type 2, hypertension, and other obesity-related comorbidities. As this procedure continues to develop there are several areas that can be addressed to improve outcomes, including device improvements, technique standardization, patient selection, personalized medicine, combination therapies, and training standardization. In this editorial we discuss the origins of the ESG, current data, and future developments.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-00, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
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