General and Abdominal Surgery Department, AZ Delta Hospital, Deltalaan 1, 8800, Roeselare/Torhout, Belgium.
Abdominal Surgery, Sint-Andries Hospital, Tielt, Belgium.
Obes Surg. 2023 Jun;33(6):1646-1651. doi: 10.1007/s11695-023-06580-9. Epub 2023 Apr 17.
Long-term failure after Roux-en-Y gastric bypass (RYGB) is well known and occurs in 10-15% of patients according to the literature. Causes are multifactorial and dilatation of the gastro-jejunal anastomosis (GJA) is only one of these. A transoral outlet reduction (TORe) with endoscopic sutures to reinstall more restriction could be a valid and safe alternative to reduce regained weight after failed gastric bypass surgery. The objective of this article is to describe our single-center experience and discuss the adverse events of the technique.
To describe our single-center case series and adverse events after TORe for weight regain after RYGB.
We report a case series of 20 patients referred due to weight regain after RYGB with a dilated GJA. TORe was performed using an endoscopic full-thickness suture device (Apollo OverStitch®) to reduce the diameter of the GJA and the volume of the gastric reservoir. Prospectively collected data on technical feasibility, safety and efficacy are described with a median follow-up of 22 (6-38) months.
Mean BMI was 44.5 kg/m at the time of RYGB. Postoperative nadir BMI was 27,7 kg/m. The average time to TORe was 12.1 years after initial RYGB. Patients regained a mean 45.9% of excess body weight loss (EWL) before TORe and had a mean preprocedural BMI of 35.3 kg/m. The aim was to reduce the aperture of the GJA to 5 mm which was done with a mean of 1.7 sutures and 3.5 stitches. The mean absolute weight loss was 13 kg and BMI reduction was 3.9 kg/m after 6 months. After a median follow-up of 22 months, a BMI of 31.4 kg/m was observed. Dumping symptoms resolved in four of our patients 6 weeks after TORe. Procedural adverse events were nausea and vomiting, sore throat, mild transient abdominal pain, diarrhea and constipation. All of them were treated conservatively. Due to a lack of weight loss, a suture failure was assumed in two of our patients. We describe one case of postprocedural mediastinitis, presumably due to a distal esophageal perforation, treated with a laparoscopic drainage without clinical evidence for perforation.
Endoscopic TORe by narrowing the dilated GJA appears to be an efficient and safe minimal invasive option to tackle weight regain after RYGB and should be more used in clinical practice.
文献报道，Roux-en-Y 胃旁路术（RYGB）后长期失败的发生率为 10-15%。其病因是多因素的，胃空肠吻合口（GJA）扩张只是其中之一。通过内镜缝线进行经口输出缩小术（TORe）以重新安装更多限制，可能是治疗 RYGB 术后体重反弹的有效且安全的替代方法。本文的目的是描述我们的单中心经验，并讨论该技术的不良事件。
描述我们单中心的病例系列以及 RYGB 后因 GJA 扩张导致体重反弹后进行 TORe 的不良事件。
我们报告了 20 例因 RYGB 后体重反弹而转诊的病例，这些患者的 GJA 扩张。使用内镜全层缝线装置（Apollo OverStitch®）进行 TORe，以缩小 GJA 的直径和胃储存器的体积。描述了前瞻性收集的技术可行性、安全性和疗效数据，中位随访时间为 22（6-38）个月。
RYGB 时平均 BMI 为 44.5kg/m2。术后体重最低 BMI 为 27.7kg/m2。TORe 与初次 RYGB 的平均时间间隔为 12.1 年。患者在 TORe 前平均体重恢复了 45.9%的多余体重减轻（EWL），术前 BMI 平均为 35.3kg/m2。目的是将 GJA 的孔径缩小至 5mm，使用 1.7 个缝线和 3.5 个缝线完成。6 个月后平均绝对体重减轻 13kg，BMI 降低 3.9kg/m。中位随访 22 个月后，观察到 BMI 为 31.4kg/m。4 例患者在 TORe 后 6 周缓解了倾倒综合征症状。手术相关不良事件包括恶心和呕吐、咽喉痛、轻度短暂腹痛、腹泻和便秘。所有不良事件均保守治疗。由于缺乏减重效果，我们假设 2 例患者的缝线失败。我们描述了 1 例术后纵隔炎病例，推测是由于远端食管穿孔，采用腹腔镜引流治疗，但没有临床证据表明穿孔。
通过缩小扩张的 GJA 进行内镜 TORe 似乎是一种有效的、安全的微创选择，可用于治疗 RYGB 后体重反弹，应更多地用于临床实践。
