Endoscopic full-thickness transoral outlet reduction with semicircumferential endoscopic submucosal dissection

Abstract

Background Endoscopic full-thickness transoral outlet reduction (efTOR) is a therapeutic option to reduce a dilated gastrojejunal anastomosis (GJA) after Roux-en-Y gastric bypass (RYGB). Mucosal ablation with argon plasma coagulation (APC) is usually performed to achieve tissue adaptation. However, rupture of sutures before scarring can lead to recurrent dilatation of the GJA. Here, we describe efTOR with a semicircumferential endoscopic submucosal dissection (ESD-efTOR) as an alternative to APC-efTOR. Methods We enrolled 41 patients with comparable baseline characteristics (APC-efTOR 26; ESD-efTOR 15). The main objectives were reduction in the GJA diameter and in ruptured sutures. Technical success, complications, total weight loss (TWL), and percentage of total and excess weight loss (%TWL and %EWL) at 3 and 12 months, were assessed. Results ESD-efTOR resulted in significantly fewer ruptured sutures (20 % vs. 69 %; P = 0.004) and a greater reduction in the GJA (major 20 % vs. 0 %; minor 54 % vs. 37 %; no reduction 13 % vs. 58 %; P = 0.02) after 3 months. Technical efficacy, examination time, and rate of complications were comparable. Conclusions ESD-efTOR resulted in a significantly greater reduction in the GJA diameter and a lower risk of ruptured sutures compared with APC-efTOR.

Efficacy of transoral outlet reduction in Roux-en-Y gastric bypass patients to promote weight loss: a systematic review and meta-analysis

“…Two studies 24 36 showed persistent weight loss and the rest of the studies demonstrated weight recidivism at 12 months. It is hypothesized that the weight loss post TORe was secondary to reduction in GJA size, improved eating habits, quicker gastric emptying times, and induction of satiety by stimulating gastric stretch receptors 11 24 27 28 . Weight recidivism was reported to be due to genetic factors, lack of dietary compliance, or due to suture breakage/migration leading to dilation of the GJA after TORe 26 27 28 36 .…”

“…Technical success of TORe procedure with full-thickness suturing device was defined in 7 studies. Four studies 12 23 24 25 considered post procedure GJA size < 10 mm and four studies 26 27 28 29 considered post-procedure GJA size < 12 mm to be technically successful.…”

“…Four studies [12, 23-25] ▶ Table 1 Quality assessment of the study with Newcastle Ottawa Scale and Jadad scale. considered post procedure GJA size < 10 mm and four studies [26][27][28][29] considered post-procedure GJA size < 12 mm to be technically successful. Absolute weight loss was calculated using the formula TORe weight-follow up weight and TWL was defined as (TORe weight-follow up weight)/TORe weight x 100 %.…”

“…Two studies have compared TORe with APC to TORe with ESD [28,41]. One study reported greater weight loss with ESD-TORe as compared to TORe with APC while the other study did not reveal any significant difference between the two groups.…”

Endoscopic Management of Weight Regain

“…For all of the aforementioned patters, mucosal ablation with argon plasma coagulation on the gastric side of the GJA is typically performed in anticipation of suture placement. Furthermore, recent studies have suggested that adding endoscopic submucosal dissection before full-thickness suturing may achieve more durable results and greater reduction in GJA aperture [18,19]. There is also some evidence to support that reinforcement suturing in the distal pouch is important, whereas suturing in the pouch with the intention of reducing pouch volume may not be as important to achieve clinical success.…”