Post written by Vitor Ottoboni Brunaldi, MD, MSc, from the Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, Brazil, and the Center for Gastrointestinal Endoscopy, Surgery and Anatomy Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.

We aimed to compare APC alone to APC plus endoscopic suturing to treat weight regain following RYGB. APC alone has been reported as a safe and effective alternative to endoscopic suturing for transoral outlet reduction. However, there is a lack of controlled studies assessing APC alone. Therefore, we designed a pilot study to compare the endoscopic gold standard (APC plus suturing) to the ablation alone.

Both methods were similarly effective within 12 months of follow-up in terms of weight loss, amelioration of blood lipids panel, and improvement in QOL and eating behavior. The safety profile was also similar between groups. The pre-revisional % solid gastric retention at 1 hour positively correlated with the probability of achieving ≥10% TWL at 12 months, which is probably our most interesting finding. A ≥30% retention cut-off presented an Odds Ratio of 7.4 (95% CI, 1.4-37.9; P = .01), and each 1% increase in preprocedural percentage gastric retention correlated with a 4% increase in the probability of achieving clinical success. Actually, this information might suggest there are 2 different types of RYGB patients. The first had wide anastomosis from surgery, thus the pouch has prompt emptying; the second had calibrated anastomosis, which leads to independent pressurization and delayed pouch emptying. In time, both types may present with weight regain and a large stoma, but only the latter benefits from outlet reduction since pouch retention did not influence primary weight loss of patients with wide anastomosis from surgery.

Figure 4. Estimated probability of achieving percentage total weight loss ≥10% at 12 months according to the percentage of gastric retention for solids at preprocedural gastric emptying scintigraphy. TWL, Total weight loss.

As a pilot RCT, this is a small sample study. Therefore, further and larger studies are needed to corroborate our findings. Articles focusing pouch emptying and manometric studies should come next in order to help us better comprehend the physiopathology of weight regain, and better select patients to the endoscopic treatment through stoma size reduction.

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