Weight regain after Roux-en-Y gastric bypass (RYGB) is common and is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of RYGB. Endoscopic revision of dilated GJ, called transoral outlet reduction (TORe), has been proved effective in the management of weight regain and dumping syndrome post RYGB.
A 43-year-old female status post RYGB 3 years prior regained 40% of her lost weight and had symptoms of dumping syndrome. Endoscopy revealed dilated GJ anastomosis to 30mm. We performed TORe using the 2-fold running suture method. Follow-up at 12 weeks showed the patient lost 20% of her gained weight and had postprandial satiety without any symptoms of dumping syndrome. Repeat endoscopy revealed a well healed scar and maintained GJ diameter of 8 mm.
Prior to endoscopic suturing we performed aggressive argon plasma coagulation (APC) therapy to the gastric side of gastric outlet to devitalize the tissue. Eight bites were taken in a circumferential manner around the anastomosis with the initial bite travelling from the jejunal to the gastric side. T-tag was dropped without cinching. An identical suture pattern was performed without removing the scope and then T-tag was dropped. Dilation balloon was inserted through the stoma and inflated to 8mm. In a sequential manner, each suture was cinched over the balloon so the stoma was 8mm in diameter.
This video demonstrates that endoscopic suturing with the OverStitch endoscopic suturing device can be performed when there is an “inactive” suture in place (ie, a suture can remain inside the working channel of the scope whilst a second “active” suture can be used to take bites). This allows suturing of an outlet or any luminal defect to be performed whilst the defect is open. This allows preservation of anatomical landmarks during the suturing process. Furthermore, it should be noted that when 2 sutures are used, they can be cinched off individually or both sutures can be cinched using a single cinching device.
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