Post written by Omar M. Ghanem, MD, from the Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.

The video describes a case of a patient suffering from weight regain after open Roux-en-Y gastric bypass (RYGB) in 2003. The patient’s presenting BMI was 59. We elected to perform a novel staged endo-laparoscopic approach with transoral outlet reduction (TORe) of the gastrojejunostomy followed by a minimally invasive surgical type 1 distalization (increasing biliopancreatic limb length and shortening the common channel).

The 2 procedures were 2 months apart. The patient lost 15 points of BMI. The video displays precise and detailed technical aspects of both the endoscopic and surgical portions. 

Although RYGB is one of the most effective modalities for sustainable weight loss, up to one-third of patients might experience weight regain in the long term. TORe has shown to have promising outcomes, leading to an average BMI drop of 6 kg/m2 in RYGB patients suffering from weight recurrence.

On the other hand, type 1 distalization leads to another 8 BMI points on average in this patient group. Patients presenting with weight relapse after RYGB whose BMI is greater than 50 kg/m2 require a multimodal and specialty approach to help them regain their life back.

In these situations, this novel procedure of TORe followed by type 1 distalization of the Roux limb has led to superior additive effect and shown to decrease the patient’s BMI by a total of 15 points.

In conclusion, this approach is innovative and novel. The video showcases the technical details of how to perform both procedures (TORe and type 1 distalization) in a stepwise, organized, detailed fashion. The collaborative approach between both endoscopists and surgeons will lead to superior weight loss results than either of these procedures alone. Partnership between the different specialties is key for better outcomes, specifically in patients with weight regain after RYGB.

Roux limb.

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