Endoscopic Revision of Gastrojejunostomy for Weight Regain
Surgery has certainly changed over the years. We used to make big incisions to perform surgery all over the body. These cuts or incisions got dramatically smaller with minimally invasive surgery, which encompasses laparoscopy (operations in the belly), arthroscopy (operations in the joints and endoscopy which includes operations in other parts of the body such as axilla, neck, and the gastrointestinal or bronchial tract.
Since the introduction of minimally invasive surgery, our incisions continue to get smaller (<1cm) as the tools we use to see and to perform the surgery improve. The field of gastrointestinal endoscopic surgery is just starting to expand the possibilities as the instruments we use start to improve. The endoscope, for those of you have not had the dubious pleasure of ever needing one, is a long flexible tube with a lighted camera on it. The endoscope can also have channels to pass special instruments down to assist with diagnosis, biopsies, brushings or even surgery. Endoscopic surgery of the gastrointestinal tract, in certain cases, can mean no abdominal or chest wall incisions. No cuts! For example, many people have had a polyp removed endoscopically on either upper or lower endoscopy. As the instruments we use in endoscopy improve, larger polyps or tumors can be removed. This does not mean ALL tumors. It means some tumors or polyps are amenable to an endoscopic resection based on size, depth of tissue involvement and location.
But this post is about endoscopic revision of prior laparoscopic or open surgery. Endoscopic techniques have evolved to allow us to place the same sutures that we use in open and laparoscopic surgery, with the endoscope. We have been looking at reasons that gastric bypass patients regain weight, and patients and studies have documented a loss of restriction, meaning that the gastric bypass patient can eat normal portions again. So hang on- didn’t I make the pouch so small it can only hold 1-2 oz? Yes, I did. But over time, in some patients, the pouch and the stoma (hookup of new small stomach to the jejunum or intestine- AKA gastrojejunostomy) can dilate or stretch out.
Not all gastric bypass patients regain weight. When a comparison was made between Roux-en-Y gastric bypass patients who did and did not regain weight, stoma size and pouch length were noted to be bigger and longer in those who regained weight1. Other methods to reduce the size of the stoma have been tried. Stomaphyx used anchors instead of sutures and these anchors were not usually full thickness through the stomach tissue. Because the anchors were not full thickness, the reduction in stoma size has not been as durable as we would have liked. I did some procedures using Stomaphyx and was not happy with the results long-term. The ROSE procedure was another endoscopic method to reduce stoma size that currently is not widely available here in the United States. There is a newer device to suture from Apollo Endosurgery that is currently being used in the United States, Latin America and Europe. Some of my international colleagues have published their 12 month data, and it shows that the sutures used to reduce the stoma are durable and that the stoma size remains small at one year out from the endoscopic stoma reduction. Endoscopic suturing of the stoma and pouch results in 20-25% of excess weight loss or 60-65% of weight regained loss. These results have been documented from 3-12 months out.
Patients want to regain the restriction they had right after the Roux-en-Y gastric bypass surgery. Endoscopic reduction of the pouch and stoma will increase the restriction patients’ experience, and their weight loss can be maximized with dietary changes and behavior modification. Endoscopic pouch and stoma reduction should be done in conjunction with the bariatric surgeon and a dietitian well versed in weight loss surgery. This will give the patient the best chance for success. When weight regain happens, patients often feel like they failed. Having contact with the bariatric surgeon and dietitian is the best way to get the motivation, encouragement and support they need for success. Many studies have shown that attending follow up visits after weight loss surgery results in better weight loss.
1. Influence of pouch and stoma size on weight loss after gastric bypass. Helen M. Heneghan, M.D., Panot Yimcharoen, M.D., Stacy A. Brethauer, M.D., Matthew Kroh, M.D., Bipan Chand, M.D. Surgery for Obesity and Related Diseases 8 (2012) 408–415.