The use of endoluminal techniques in the revision of primary bariatric surgery procedures: a systematic review

Abstract

Background Weight regain following primary bariatric surgery is attributed to anatomical, behavioural and hormonal factors. Dilation of the gastrojejunal anastomosis is a possible cause of weight regain after roux-en-Y gastric bypass (RYGB). However, surgical revision has significant risks with limited benefits. Endoluminal procedures have been suggested to manage weight regain post-surgery. This systematic review aims to assess efficacy of endoluminal procedures. Methods Studies where endoluminal procedures were performed following primary bariatric surgery were identified. Main outcome measures were mean weight loss pre- and post-procedure, excess weight loss, recurrence rates, success rates and post-procedure complications. Results Twenty-six studies were included in this review. Procedures identified were (i) endoluminal plication devices (ii) other techniques e.g. sclerotherapy, mucosal ablation, and Argon Plasma Coagulation (APC) and (iii) combination therapy involving sclerotherapy/mucosal ablation/APC and endoscopic OverStitch device. Endoluminal plication devices show greatest initial weight loss within 12 months post-procedure, but not sustained at 18 months. Only one study utilising sclerotherapy showed greater sustained weight loss with peak EWL (19.9%) at 18 months follow-up. Combination therapy showed the greatest sustained EWL (36.4%) at 18 months. Endoluminal plication devices were more successfully performed in 91.8% of patients and had lower recurrence rates (5.02%) compared to sclerotherapy and APC, with 46.8% success and 21.5% recurrence rates. Both procedures demonstrate no major complications and low rates of moderate complications. Only mild complications were noted for combination therapy. Conclusions The paucity of good quality data limits our ability to demonstrate and support the long-term efficacy of endoluminal techniques in the management of weight regain following primary bariatric surgery. Future work is necessary to not only clarify the role of endoluminal plication devices, but also combination therapy in the management of weight regain following primary bariatric surgery.

Anesthesia for Advanced Endoscopic Procedures

“…Other techniques include mucosal ablation using argon plasma coagulation of the gastrojejunal anastomosis. 1 POSE uses an incisionless operating platform to create full-thickness plications in the gastric fundus, thereby reducing gastric volume, which, in turn, limits the quantity of food that can be consumed at a given time. 2 The procedure also causes antral dysmotility that prolongs satiety by inducing an earlier and longer feeling of gastric distention.…”

“…The gastric pouch can also be decreased in size, which is called tubular TORe or restorative obesity surgery endoluminal (ROSE). Other techniques include mucosal ablation using argon plasma coagulation of the gastrojejunal anastomosis [ 1 ].…”

Endoscopic therapy of weight regain after bariatric surgery

“…Another systematic review[ 40 ] analyzed 26 studies involving all endoscopic bariatric procedures for WR and their combinations (endoscopic OverStitch device and sclerotherapy, APC or mucosal ablation). Endoscopic suturing systems showed best post-procedural results in terms of initial WL at 1 year, which were not confirmed at 18 mo.…”

“…The greatest sustained EWL (36.4%) at 18 mo has been achieved by the combination therapy. Endoscopic suturing systems showed a better performance in terms of technical success (91.8%) and recurrence rate of WR (5%) compared to sclerotherapy or APC (46.8% and 21.5%, respectively)[ 40 ].…”

Gastrojejunostomy in Roux-En-Y Gastric Bypass for Morbid Obesity: Linear Stapler Length Does Not Affect Mid-term Outcomes

“…[11][12][13] Understanding the relationship between stoma size and weight loss has spurned an interest in the role of endoscopic refashioning of the gastrojejunostomy in those patients for whom enlarged stoma size is thought to be the cause of weight regain. 12,14 Such an approach is supported by evidence that suggests that by reducing the size of this stoma, patients who have suffered from postoperative weight gain can benefit from renewed weight loss. 15,16 Despite the link between stoma size and weight loss, the impact of varying the stapler diameter or length when initially forming gastrojejunostomy is less clear.…”