UCLA

Introduction: Enlargement of the remnant gastric pouch and gastro-jejunal (GJ) stoma are associated with weight regain after RYGB surgery. Current evidence suggests an excess weight loss (%EWL) of 12-25% with GJ outlet reduction (TORe) alone. However, the efficacy of a combined approach using endoscopic trans-oral outlet reduction (TORe) in combination with Gastroplasty of the entire gastric pouch from the gastro-esophageal (GE) junction to the GJ stoma (TORe-G) is unknown.

Methods: Patients who experienced inadequate weight loss (<50% EWL) or weight regain (>25% EWL from nadir) post-RYGB along with evidence of dilated GJ stoma and gastric pouch underwent a combined GJ stoma reduction and gastroplasty. The procedure involved ablation of the peristomal mucosa and gastric pouch using APC and placement of interrupted and running full-thickness plications (Overstitch, Apollo Endosurgery, Austin Tx) for a targeted GJ diameter of ~5-8 mm and significant reduction of gastric pouch volume.

Results: 40 patients (78% females) with age 53?10 years, BMI 41?9 kg/m2, and time since RYGB 10?4 years were prospectively studied. Significant weight loss (>5% TBWL) was seen in 90% patients. Post Tore-G, mean (95% CI) %TBWL observed at 1, 3, 6, 9 and 12 months follow up was 7.6 (5-10.1), 10.4 (8.1-12.8), 12.3 (9.6-14.9), 13.3 (10.4-16.2), and 14.1 (10.9-17.2) respectively. Corresponding %EWL was 24.1 (15.9-32.3), 31.3 (23.7-38.9), 35.9 27.3-44.4), 38.5 (29.1-47.9), and 40.4 (30.2-50.6); and %RWL was 39.6 (22.1-57), 52.1 (35.5 -68.8), 60.1 (41.9-78.3), 64.7 (45-84.5), and 68 (47-89) respectively. No covariates including age, sex, interval time since RYGB, % weight regained were significantly associated with weight loss over time. No serious adverse events were observed.

Conclusions: We demonstrate for the first time the efficacy and safety of TORe-G to re-establish weight loss in patients with failed RYGB using a full thickness endoscopic suturing device. TORe-G resulted in robust weight loss and superior outcomes compared with published data with TORe alone.