Endoscopic gastric plication for the treatment of weight regain after Roux-en-Y gastric bypass (with video)

  • Pichamol Jirapinyo
    Affiliations
    Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Harvard Medical School, Boston, Massachusetts, USA
    Search for articles by this author
  • Christopher C. Thompson
    Correspondence
    Reprint requests: Christopher C. Thompson, MD, MSc, Brigham and Women’s Hospital, Division of Gastroenterology, Hepatology and Endoscopy, 75 Francis St, Boston, MA 02115.
    Affiliations
    Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Harvard Medical School, Boston, Massachusetts, USA
    Search for articles by this author
Published:March 05, 2022DOI:https://doi.org/10.1016/j.gie.2022.02.051

      Background and Aims

      Gastric plication involves inverting the stomach with tissue anchor placement to achieve serosa-to-serosa apposition. One potential application of gastric plication is the treatment of weight regain after Roux-en-Y gastric bypass (RYGB), a procedure also known as plication transoral outlet reduction (P-TORe). This study aims to assess technical feasibility, safety, and efficacy of P-TORe.

      Methods

      This was a registry study of RYGB patients who underwent P-TORe for weight regain. The primary outcome was the amount of weight loss and clinical success rate, defined as percentage of total weight loss (TWL) of at least 5% at 12 months. Secondary outcomes were technical success, adverse events (AEs), and predictors of weight loss.

      Results

      One hundred eleven RYGB patients underwent P-TORe. Average body mass index (BMI) was 38.5 ± 7.5 kg/m2. Baseline gastrojejunal anastomosis (GJA) and pouch sizes were 17 ± 6 mm and 5 ± 2 cm, respectively. The primary outcome was total weight loss, defined as patients experiencing 9.5% ± 8.5% TWL at 12 months. Clinical success rate was 73%. Technical success rate was 100%. Argon plasma coagulation (APC) was performed around the GJA in all patients (100%) before plication placement. The total number of plications per case was 7 ± 3. Overall AE rate was 12.6%. These included GJA stenosis (9.9%), melena because of marginal ulceration (1.8%), and deep vein thrombosis (.9%). The severe AE rate was 0%. Predictors of weight loss were the amount of weight regain and baseline pouch length.

      Conclusions

      This novel P-TORe technique combining APC with gastric plication appears to be technically feasible, safe, and effective at treating weight regain after RYGB.

      Graphical abstract

      Abbreviations:

      AE (adverse event), APC (argon plasma coagulation), EWL (excess weight loss), GJA (gastrojejunal anastomosis), IOP (Incisionless Operating Platform), P-TORe (plication transoral outlet reduction), RYGB (Roux-en-Y gastric bypass), TORe (transoral outlet reduction), TWL (total weight loss)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sjöström L.
        • Narbro K.
        • Sjöström C.D.
        • et al.
        Effects of bariatric surgery on mortality in Swedish obese subjects.
        N Engl J Med. 2007; 357: 741-752
        • Adams T.D.
        • Davidson L.E.
        • Hunt S.C.
        Weight and metabolic outcomes 12 years after gastric bypass.
        N Engl J Med. 2018; 378: 93-96
        • Abu Dayyeh B.K.
        • Lautz D.B.
        • Thompson C.C.
        Gastrojejunal stoma diameter predicts weight regain after Roux-en-Y gastric bypass.
        Clin Gastroenterol Hepatol. 2011; 9: 228-233
        • Heneghan H.M.
        • Yimcharoen P.
        • Brethauer S.A.
        • et al.
        Influence of pouch and stoma size on weight loss after gastric bypass.
        Surg Obes Relat Dis. 2012; 8: 408-415
        • Thompson C.C.
        • Chand B.
        • Chen Y.K.
        • et al.
        Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery.
        Gastroenterology. 2013; 145: 129-137
        • Kumar N.
        • Thompson C.C.
        Comparison of a superficial suturing device with a full-thickness suturing device for transoral outlet reduction (with videos).
        Gastrointest Endosc. 2014; 79: 984-989
        • Jirapinyo P.
        • Kumar N.
        • AlSamman M.A.
        • et al.
        Five-year outcomes of transoral outlet reduction for the treatment of weight regain after Roux-en-Y gastric bypass.
        Gastrointest Endosc. 2020; 91: 1067-1073
        • Horgan S.
        • Jacobsen G.
        • Weiss G.D.
        • et al.
        Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.
        Surg Obes Relat Dis. 2010; 6: 290-295
        • Brunaldi V.O.
        • Jirapinyo P.
        • de Moura D.T.H.
        • et al.
        Endoscopic treatment of weight regain following Roux-en-Y gastric bypass: a systematic review and meta-analysis.
        Obes Surg. 2018; 28: 266-276
        • Jensen M.D.
        • Ryan D.H.
        • Apovian C.M.
        • et al.
        2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.
        Circulation. 2014; 129: S102-S138
        • Magkos F.
        • Fraterrigo G.
        • Yoshino J.
        • et al.
        Effects of moderate and subsequent progressive weight loss on metabolic function and adipose tissue biology in humans with obesity.
        Cell Metab. 2016; 23: 591-601
        • Cotton P.B.
        • Eisen G.M.
        • Aabakken L.
        • et al.
        A lexicon for endoscopic adverse events: report of an ASGE workshop.
        Gastrointest Endosc. 2010; 71: 446-454
        • Jirapinyo P.
        • Kröner P.T.
        • Thompson C.C.
        Purse-string transoral outlet reduction (TORe) is effective at inducing weight loss and improvement in metabolic comorbidities after Roux-en-Y gastric bypass.
        Endoscopy. 2018; 50: 371-377
        • Jirapinyo P.
        • de Moura D.T.H.
        • Dong W.Y.
        • et al.
        Dose response for argon plasma coagulation in the treatment of weight regain after Roux-en-Y gastric bypass.
        Gastrointest Endosc. 2020; 91: 1078-1084
        • Thompson C.C.
        • Jacobsen G.R.
        • Schroder G.L.
        • et al.
        Stoma size critical to 12-month outcomes in endoscopic suturing for gastric bypass repair.
        Surg Obes Relat Dis. 2012; 8: 282-287