Introduction

Obesity is a global health concern with increasing prevalence, and bariatric surgery remains a prominent treatment option. One-anastomosis gastric bypass (OAGB) has gained popularity for its advantages, including significant weight loss and fewer early complications. However, concerns arise regarding nutritional deficiencies, weight regain, and other complications. This study aims to assess the effectiveness and safety of endoscopic transoral outlet reduction (TORe) as a treatment for weight regain after OAGB.

Aims & Methods

Consecutive Patients with weight regain following OAGB were evaluated. Weight regain was defined as a 10% increase in total body weight from the post-surgery weight nadir. Diagnostic gastroscopy determined anastomosis diameter, pouch dimensions and ruled out contraindications for TORe. The procedure involved circumferential argon plasma coagulation and full thickness endoscopic suturing to narrow the anastomosis. Patient data was collected, and outcomes assessed in accordance with ethical standards

Results

sixty four patients were treated during a 4 years duration and followed up for 1 a minimum of 1 year. Fourty seven percents were females, mean pre-treament BMI 35.5. Average weight loss was 7% of total body weight after 6 months and 8% after 12 months (p=0.03). A reduction of at least 5% and 10% was seen in 65% and 31%, respectively. Additional treatment was needed in 17% of patients. Major complication that required surgical intervention occurred in only one patient

Conclusion

Endoscopic transoral outlet reduction appears safe and effective fot the treatment of weight regain s/p OAGB. Sustained weight loss was seen during a 1 year follow up. Further investigation is needed to assess the long term durably of the effect.

Introduction

Obesity remains a major public health issue in developed countries. While bariatric procedures such as Roux-en-Y gastric bypass (RYGB) are effective, up to 20% of patients experience long-term weight regain. Dilation of the gastrojejunal anastomosis (GJA) may contribute to this, possibly due to faster gastric emptying. Argon plasma coagulation (APC) has been shown to reduce GJA diameter, potentially restoring satiety and promoting weight loss.

Aims & Methods

This study aimed to evaluate APC efficacy in reducing GJA diameter in patients with post-RYGB weight regain and to identify potential predictors of total weight loss (TWL).
A retrospective, single-center study included 36 RYGB patients treated with APC from 2018–2023. The primary outcome was %TWL. Secondary endpoints included reduction in anastomosis diameter (RAD), comorbidities, and adverse events (AEs). Patients were followed at 3, 6, and 12 months and categorized by TWL (≥5%, ≥10%, ≥15%). Responders were defined as those achieving ≥5% TWL at 3 months. Associations between TWL, responders to APC and demographic or clinical variables were analyzed.

Results

Total Weight Loss
Initially, all patients experienced some degree of weight loss after the APC intervention. The mean absolute TWL of 8.3%, 8%, and 8.2% at 3, 6, and 12 months.
Regarding categorical TWL, over 60% achieved ≥5% TWL throughout follow-up (Figure 1), with 61.1% at 3 months, 66.7% at 6 months, and 63.9% at 12 months. Though ≥10% and ≥15% rates were lower. No clinically significant associations were found between pre-treatment patients factors and comorbidities; and subsequent weight loss.
TWL was significantly higher in responders (14.9%, 11.7%, 11.1%) vs. non-responders (Figure 2), but no predictive baseline factors were identified (Table 1).
At 12 months (Figure 3), over 80% maintained ≥5% TWL, and more than 50% reached ≥10% . Though ≥15% was sustained in only 13.9%–16.7%, highlighting obesity’s chronic nature and APC’s limited long-term effect.
Furthermore, at 12 months, mean BMI in responders was significicantly lower (31.7kg/m²), and over a quarter (27.3%) of responders achieved a BMI <30, no longer meeting obesity criteria, which may be considered a significant clinical success.
GJA diameter
Patients presented with notably enlarged GJA diameters, with a mean pre-APC GJA of 26.61 ± 5.41 mm, and 16.4 ± 5.0 mm post-APC (p < 0.001). A small final GJA diameter (<18 mm) was achieved in 72%. The mean RAD was 10.22 ± 6.4 mm, representing a 36.9 ± 19.3% decrease. However, neither RAD nor final GJA diameter were predictive of TWL. These findings align with the hypothesis proposed by some authors, suggesting that patients with persistently larger GJA diameters (>18 mm) may benefit from alternative interventions, such as endoscopic suturing.

Variables	Non-responders: (TWL < 5% at 3m) 14/36 (39%)	Responders: (TWL ≥ 5% at 3m) 22/36 (61%)	p value
BMI before RYGB (kg/m2)	44.5 ± 5	46.2 ± 4.1	0.270
BMI before APC (kg/m2)	36.3 ± 5.2	35.9 ± 5.5	0.824
BMI 1 year post-APC (kg/m2)	34.8 ± 5.1	31.7 ± 4.1	0.049
TWL (%) 3 months	1.4 ± 0.02	14.9 ± 0.07	0.001
TWL (%) 6 months	5.4 ± 0.08	11.7 ± 0.07	0.008
TWL (%) 12 months	3.7 ± 0.08	11.1 ± 0.08	0.009
Baseline GJA diameter (mm)	26.5 ± 5	26.7 ± 5.7	0.923
Final GJA diameter (mm)	15.8 ± 4.8	16.8 ± 5.3	0.577
RAD (%) median (IQR)	-39.3 (-50,-23)	-33.8 (-54.3, -19.2)	0.808

Table 1. Variables in responders an non-responders.

Number of APC sessions, efficacy and safety
The impact of the number of APC sessions on TWL was assessed comparing patients with 1–2 sessions versus those with 3-4. Although other studies have found correlation, in our study, a weak correlation with TWL at 3 months was found with Spearman’s Rho test (ρ = 0.163).
Technical success rate was 100%. Only three mild AEs (8%) were reported: two mild stenosis that required endoscopic dilation and a GJA mild ulcer.

Conclusion

APC is a safe, non-invasive and effective option for managing weight regain after RYGB at least in the short and medium term, in 60% of patients. Despite efforts, no predictors of TWL were identified. Larger studies and a multidisciplinary approach may further improve outcomes.

References

Thompson CC, Slattery J, Bundga ME. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Surg Endosc. 2006;20(11):1744-8.
Baretta GA, Alhinho HC, Matias JE. Argon plasma coagulation of gastrojejunal anastomosis for weight regain after gastric bypass. Obes Surg. 2015;25(1):72-9.
Moon, R.C., Texeira, A.F, Neto, M.G. Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study. 2018;28(9):2737-44.

Szvarca D, Jirapinyo P. Endoscopic Management of Weight Regain After Bariatric Surgery. Gastrointest Endosc Clin N Am. octubre de 2024;34(4):639-54.

Jirapinyo, P, Moura D, Dong W. Dose response for argon plasma coagulation in the treatment of weight regain after Roux-en-Y gastric bypass. Gastrointest Endosc. 2020;91(5):1078-84.

Lopez-Nava G, Asokkumar R, Rull A, Corbelle F, Beltran L, Bautista I. Bariatric endoscopy procedure type or follow-up: What predicted success at 1 year in 962 obese patients? Endosc Int Open. diciembre de 2019;07(12):E1691-8.

Introduction

Ulceration at the gastrojejunostomy is a late complication following gastric bypass surgery, usually responsive to high dose PPI. However, in refractory cases, patients may require surgical treatment. Recently, a new technique of endoscopic jejunal flap over-suturing has been reported with exceptional success rates. We aimed to evaluate the implementation of this approach in our practice.

Aims & Methods

Consecutive patients with symptomatic marginal ulcers, who failed to response to a two-month course of high dose PPI were included. Patients were treated with endoscopic suturing of a jejunal flap over the ulcer. In case of a narrow anastomosis, a self-expandable metallic stent (SEMS) was used alone or in combination with suturing. The stent was removed after 2 months. Endoscopy was repeated 8 weeks after the procedure. Technical success was defined as a fully covered marginal ulcer. Clinical success was defined as an ulcer heal on repeat endoscopy, while persistent ulcer, perforation or need for surgical repair was considered as failure.

Results

Ten patients were included, seven after Roux-en-Y gastric bypass and after 3 single anastomosis gastric bypass. All patients were negative for Helicobacter Pylori, deny alcohol abuse or NSAIDS use, 2 patients were active smokers at the time of diagnosis. All patients were on chronic PPI at the time of diagnosis, and the average therapy duration was 27 months. Jejunal over-suturing was performed in 9 patients of them 3 in combination with a SEMS, and 1 patient was treated only with a SEMS. Overall technical success rate was 100%, and a clinical success rate was 50% with 4 patients going through surgery thereafter. No adverse events occurred during the procedure or follow up period.

Conclusion

To date, marginal ulcers remain a dreaded late adverse event necessitating prolonged PPI use, repeat endoscopies and even revisional surgery. Endoscopic treatment to promote healing of refractory marginal ulcers appears safe. Technical success was achieved in all patients while clinical success only in half. However, since the only alternative treatment is surgery the endoscopic approach should still be considered. The lower than expected clinical success might be related to a more PPI resistant population compared with previous published series. Further research is needed to determine the appropriate therapeutic algorithm.

Introduction

Endoscopic Sleeve Gastroplasty (ESG) is one of the main interventions of primary minimally invasive bariatric surgery, especially for subjects suffering from I and II class obesity^1,2. However, since obesity is a chronic, relapsing, and multifactorial disease, a second intervention may be necessary. The purpose of this study is to assess the effectiveness of endoscopic revision (Re-ESG) versus primary intervention (P-ESG).

Aims & Methods

A prospective dataset enrolling all subjects undergone ESG in a tertiary center from May 2017 to December 2023 was retrospectively analyzed. All subjects undergone Re-ESG for weight regain (WR), weight plateau (WP) or weight loss failure (WF), as defined by Lopez Nava et al.³, were enrolled. Weight loss outcomes [Absolute Weight Loss (AWL), Excess Weight Loss (EWL), Total Body Weight Loss (TBWL), Body Mass Index Loss (BMIL)] at 6-,12-,18- and 24-months after P-ESG and Re-ESG were collected and compared.

Results

Out of a total of 578 patients, 53 patients (9.2%) underwent Re-ESG: 24 for WR, 18 for WP and 12 for WF, after a mean time of 25.4 ± 11.4 months from P-ESG (35 subjects underwent revision in the first 24 months, whereas other 18 between 30 and 66 months). One subject underwent a second revision, for a total of 54 revisions.
Both P-ESG and Re-ESG were associated with significant total body weight loss and excess body weight loss up to 24 months and when compared, endoscopic revision were proven to be as effective as primary intervention, at least in the short and medium term, as showed in Table 1.

	6-months				12-months				18-months				24-months
	AWL (kg)	EWL (%)	TBWL (%)	p	AWL (kg)	EWL (%)	TBWL (%)	p	AWL (kg)	EWL (%)	TBWL (%)	p	AWL (kg)	EWL (%)	TBWL (%)	p
P-ESG	18.4 (7.9)	55.2 (24.5)	17.3 (6.7)	<0.01	17.9 (9.7)	52.9 (27.7)	16.7 (8.2)	<0.01	18.1 (10.5)	50.0 (22.7)	16.6 (8.3)	<0.01	16.3 (11.9)	45.7 (32.7)	15.1 (10.6)	<0.01
Re-ESG	15.0 (7.7)	52.9 (23.5)	14.7 (6.1)	<0.01	17.0 (8.0)	55.7 (21.8)	16.5 (7.2)	<0.01	11.9 (10.9)	41.4 (44.2)	11.4 (11.0)	<0.01	7.3 (11.8)	25.4 (25.9)	7.0 (9.2)	0.937
P	0.32	0.571	0.434		0.712	0.684	0.924		0.121	0.569	0.128		0.122	0.183	0.109
	Table 1. Comparison of weight loss outcomes between primary ESG and endoscopic revision (Re-ESG) at 6-,12-,18- and 24-months follow-up. Data are reported as mean value (standard deviation). A two sample T-Test was used to compare baseline weight and weight loss outcomes. ESG=Endoscopic Sleeve Gastroplasty; P-ESG= Primary ESG; Re-ESG= Revision of ESG; AWL=Absolute weight loss; EWL=Excess weight loss; TBWL=Total body weight loss.

Conclusion

Our study, despite the limit of a low sample, highlights how the endoscopic revision of a previous ESG is as effective as the primary intervention in the short and medium term.
These results may pave the way for an exclusively minimal-invasive multi-step treatment of chronic obesity.

References

1. Abu Dayyeh BK, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. The Lancet. 2022;400(10350):441-451. doi:10.1016/S0140-6736(22)01280-6
2. Saumoy M, Gandhi D, Buller S, et al. Cost-effectiveness of endoscopic, surgical and pharmacological obesity therapies: a microsimulation and threshold analyses. Gut. Published online August 8, 2023:gutjnl-2023-330437. doi:10.1136/GUTJNL-2023-330437
3. Lopez-Nava G, Sharaiha RZ, Vargas EJ, et al. Endoscopic Sleeve Gastroplasty for Obesity: a Multicenter Study of 248 Patients with 24 Months Follow-Up. Obesity Surgery. 2017;27(10):2649-2655. doi:10.1007/s11695-017-2693-7

Introduction

Gastric outlet obstruction (GOO) is a debilitating condition commonly caused by malignant or benign diseases, impairing gastric emptying and nutritional status. While surgical gastrojejunostomy (SGJ) has traditionally been the standard palliative approach, endoscopic ultrasound-guided gastrojejunostomy (EUSGJ) has recently emerged as a minimally invasive alternative. This systematic review and meta-analysis aimed to compare the efficacy and safety of EUSGJ versus SGJ for the management of GOO.

Aims & Methods

A systematic search of PubMed, Embase, Medline, and Cochrane Library was conducted to identify studies directly comparing EUSGJ and SGJ in adult patients with GOO. Nine retrospective studies comprising 1,086 patients (654 EUSGJ; 432 SGJ) were included. Primary outcomes included technical and clinical success, length of hospital stay (LOS), operative time, and overall complication rates. Secondary outcomes included infection, ileus, hemorrhage, perforation, and re-intervention. Meta-analyses were performed using fixed or random effects models depending on data heterogeneity.

Results

EUSGJ was significantly superior to SGJ in terms of technical success (OR = 0.16; 95% CI: 0.05–0.45; p = 0.0006), shorter operative time (MD = –96.89 minutes; 95% CI: –146.16 to –47.61; p < 0.00001), reduced postoperative LOS (MD = –4.79 days; 95% CI: –6.52 to –3.06; p < 0.0001), lower overall complication rates (OR = 0.24; 95% CI: 0.17–0.33; p < 0.00001), reduced postoperative ileus (OR = 0.07; 95% CI: 0.02–0.17; p < 0.00001), and fewer infections (OR = 0.17; 95% CI: 0.08–0.37; p < 0.00001). No statistically significant differences were found regarding clinical success, re-intervention, hemorrhage, or perforation.

Conclusion

EUSGJ demonstrates superior procedural outcomes and safety profiles compared to SGJ in the management of GOO and represents a valuable tool in expert hands. However, further prospective studies and randomized trials are necessary to validate these findings, assess long-term outcomes, and define its role within individualized patient care and clinical guidelines.

Disclosure

No conflict of interest

Clinical Case Summary

A 56-year-old male presented with postprandial vomiting and weight loss beginning three weeks after laparoscopic ulcerorraphy of a perforated pyloric ulcer. An abdominal CT showed marked gastric distension and upper GI endoscopy revealed gastric stasis and a fibrotic stenosis in the duodenal bulb in close relation with a suture stitch, only transposable with an ultra-slim gastroscope. Two sessions of balloon dilation (BD) until 20mm were performed one month apart with poor clinical/endoscopic improvement. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) was proposed to avoid surgical reintervention.
Using a standard gastroscope a 0.035´´guidewire was passed into the proximal jejunum allowing insertion of a 7-french nasobiliary drain. Jejunal distension was achieved through saline, iodate contrast and methylene blue infusion. The linear echoendoscope was used to identify a distended loop adjacent to the gastric wall and EUS-guided puncture with a 19G needle was accomplished. A 20x10mm lumen-apposing metal stent (LAMS) was deployed in distal gastric body. The flow of blue mixture to the lumen confirmed successful gastroenterostomy creation. The patient was hospitalized overnight and resumed oral feeding the day after the procedure. No symptom recurrence was observed and the gastroenterostomy remained patent during the 6 months of follow-up.
Gastric outlet obstruction (GOO) may result from several malignant and benign causes. Surgical gastroenterostomy, self-expandable metal stents (SEMS) and BD are standard therapeutic options. EUS-GE is emerging as an effective and minimally invasive alternative. EUS-GE presents high technical and clinical success with lower rates of adverse events and reduced need of reintervention when compared to surgery and other endoscopic therapies. In benign GOO, SEMS seems less adequate and BD often results in suboptimal outcomes. The authors exemplify the effectiveness of EUS-GE in a case of GOO associated with a benign condition.

References

Illustrative material:
- Endoscopic and fluoroscopic images of guidewire and nasobiliary drain passed into the proximal jejunum
- EUS image of jejunal distension previous to LAMS placement
- EUS image of LAMS placement
- Endoscopic and fluoroscopic images of LAMS in situ
- Endoscopic image of 6 months follow-up