Skip to main content

Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis

Abstract

Background and aims

Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature.

Methods

Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used.

Results

130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4  kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5–10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported.

Conclusion

When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Flegal KM, Carroll MD, Ogden CL, Curtin LR (2010) Prevalence and trends in obesity among US adults, 1999-2008. JAMA 303(3):235–241. doi:10.1001/jama.2009.2014

    CAS  Article  PubMed  Google Scholar 

  2. Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE et al (2012) Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 366(17):1567–1576. doi:10.1056/NEJMoa1200225

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. Yanovski SZ, Yanovski JA (2014) Long-term drug treatment for obesity: a systematic and clinical review. JAMA 311(1):74–86. doi:10.1001/jama.2013.281361

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. Anderson JW, Konz EC, Frederich RC, Wood CL (2001) Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr 74(5):579–584

    CAS  PubMed  Google Scholar 

  5. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K et al (2004) Bariatric surgery: a systematic review and meta-analysis. JAMA 292(14):1724–1737. doi:10.1001/jama.292.14.1724

    CAS  Article  PubMed  Google Scholar 

  6. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ et al (2009) Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 122(3):248–256, e5. doi:10.1016/j.amjmed.2008.09.041

    Article  PubMed  Google Scholar 

  7. Sjostrom L (2013) Review of the key results from the Swedish Obese Subjects (SOS) trial—A prospective controlled intervention study of bariatric surgery. J Intern Med 273(3):219–234. doi:10.1111/joim.12012

    CAS  Article  PubMed  Google Scholar 

  8. Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC (2008) Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg 18(6):648–651. doi:10.1007/s11695-007-9265-1

    Article  PubMed  Google Scholar 

  9. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA et al (2017) Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. N Engl J Med 376(7):641–651. doi:10.1056/NEJMoa1600869

    Article  PubMed  PubMed Central  Google Scholar 

  10. Abu Dayyeh BK, Lautz DB, Thompson CC (2011) Gastrojejunal stoma diameter predicts weight regain after Roux-en-Y gastric bypass. Clin Gastroenterol Hepatol 9(3):228–233. doi:10.1016/j.cgh.2010.11.004

    Article  PubMed  Google Scholar 

  11. Heneghan HM, Yimcharoen P, Brethauer SA, Kroh M, Chand B (2012) Influence of pouch and stoma size on weight loss after gastric bypass. Surg Obes Relat Dis 8(4):408–415. doi:10.1016/j.soard.2011.09.010

    Article  PubMed  Google Scholar 

  12. Koball AM, Himes SM, Sim L, Clark MM, Collazo-Clavell ML, Mundi M et al (2016) Distress tolerance and psychological comorbidity in patients seeking bariatric surgery. Obes Surg 26(7):1559–1564. doi:10.1007/s11695-015-1926-x

    Article  PubMed  Google Scholar 

  13. Clark MM, Hanna BK, Mai JL, Graszer KM, Krochta JG, McAlpine DE et al (2007) Sexual abuse survivors and psychiatric hospitalization after bariatric surgery. Obes Surg 17(4):465–469. doi:10.1007/s11695-007-9084-4

    Article  PubMed  Google Scholar 

  14. Coakley BA, Deveney CW, Spight DH, Thompson SK, Le D, Jobe BA et al (2008) Revisional bariatric surgery for failed restrictive procedures. Surg Obes Relat Dis 4(5):581–586. doi:10.1016/j.soard.2007.10.004

    Article  PubMed  Google Scholar 

  15. Parikh M, Heacock L, Gagner M (2011) Laparoscopic, “gastrojejunal sleeve reduction” as a revision procedure for weight loss failure after Roux-en-Y gastric bypass. Obes Surg 21(5):650–654

    Article  PubMed  Google Scholar 

  16. Cardeal Mde A, Faria SL, Faria OP, Facundes M, Ito MK (2016) Diet-induced thermogenesis in postoperatve Roux-en-Y gastric bypass patients with weight regain. Surg Obes Relat Dis 12(5):1098–1107. doi:10.1016/j.soard.2016.01.019

    Article  PubMed  Google Scholar 

  17. Jirapinyo P, Slattery J, Ryan MB, Abu Dayyeh BK, Lautz DB, Thompson CC (2013) Evaluation of an endoscopic suturing device for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass. Endoscopy 45(7):532–536. doi:10.1055/s-0032-1326638

    CAS  Article  PubMed  Google Scholar 

  18. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available from http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 2017

  19. Kumar N, Thompson CC (2016) Transoral outlet reduction for weight regain after gastric bypass: long-term follow-up. Gastrointest Endosc 83(4):776–779. doi:10.1016/j.gie.2015.08.039

  20. Patel LY, Lapin B, Brown CS, Stringer T, Gitelis ME, Linn JG et al (2016) Outcomes following 50 consecutive endoscopic gastrojejunal revisions for weight gain following Roux-en-Y gastric bypass: a comparison of endoscopic suturing techniques for stoma reduction. Surg Endosc 2016:1–11. doi:10.1007/s00464-016-5281-3

  21. Estimates of Bariatric Surgery Numbers (2016) Available from https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed 03 May 2017

  22. Elnahas AI, Jackson TD, Hong D (2014) Management of Failed Laparoscopic Roux-en-Y Gastric Bypass. Bariatr Surg Pract Patient Care 9(1):36–40. doi:10.1089/bari.2013.0012

    Article  PubMed  PubMed Central  Google Scholar 

  23. Gobble RM, Parikh MS, Greives MR, Ren CJ, Fielding GA (2008) Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass. Surg Endosc 22(4):1019–1022. doi:10.1007/s00464-007-9609-x

    Article  PubMed  Google Scholar 

  24. Thompson CC, Chand B, Chen YK, Demarco DC, Miller L, Schweitzer M et al (2013) Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery. Gastroenterology 145(1):129–137, e3. doi:10.1053/j.gastro.2013.04.002

    Article  PubMed  Google Scholar 

  25. Kumar N, Thompson CC (2014) Comparison of a superficial suturing device with a full-thickness suturing device for transoral outlet reduction (with videos). Gastrointest Endosc 79(6):984–989. doi:10.1016/j.gie.2014.02.006

    Article  PubMed  PubMed Central  Google Scholar 

  26. Abu Dayyeh BK, Jirapinyo P, Thompson CC (2017) Plasma ghrelin levels and weight regain after Roux-en-Y Gastric bypass surgery. Obes Surg 27(4):1031–1036. doi:10.1007/s11695-016-2418-3

    Article  PubMed  Google Scholar 

  27. Jirapinyo P, Dayyeh BK, Thompson CC (2016) Gastrojejunal anastomotic reduction for weight regain in roux-en-y gastric bypass patients: physiological, behavioral, and anatomical effects of endoscopic suturing and sclerotherapy. Surg Obes Relat Dis 12(10):1810–1816. doi:10.1016/j.soard.2016.09.036

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chakravartty S, Tassinari D, Salerno A, Giorgakis E, Rubino F (2015) What is the mechanism behind weight loss maintenance with gastric bypass? Curr Obes Rep 4(2):262–268. doi:10.1007/s13679-015-0158-7

    Article  PubMed  Google Scholar 

  29. le Roux CW, Welbourn R, Werling M, Osborne A, Kokkinos A, Laurenius A et al (2007) Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg 246(5):780–785. doi:10.1097/SLA.0b013e3180caa3e3

    Article  PubMed  Google Scholar 

  30. Laurenius A, Larsson I, Bueter M, Melanson KJ, Bosaeus I, Forslund HB et al (2012) Changes in eating behaviour and meal pattern following Roux-en-Y gastric bypass. Int J Obes 36(3):348–355

    CAS  Article  Google Scholar 

  31. Mathes CM, Spector AC (2012) Food selection and taste changes in humans after Roux-en-Y gastric bypass surgery: a direct-measures approach. Physiol Behav 107(4):476–483. doi:10.1016/j.physbeh.2012.02.013

    CAS  Article  PubMed  Google Scholar 

  32. Banerjee A, Ding Y, Mikami DJ, Needleman BJ (2013) The role of dumping syndrome in weight loss after gastric bypass surgery. Surg Endosc 27(5):1573–1578. doi:10.1007/s00464-012-2629-1

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Barham K. Abu Dayyeh.

Ethics declarations

Disclosures

Dr. Todd Wilson has served as consultant for Bard, Olympus, and EndoEvolution. Dr. Erik B. Wilson has served as a consultant to Intuitive Surgical, Ethicon, Gore, and Apollo Endosurgery, and Olympus. Dr. Manoel Galvao Neto has served as a consultant to ALACER Biomedica, SCI Tech/CMS, MI Tech, Ethicon EndoSurgery, GI Dynamics, Apollo EndoSurgery, Fractyl Labs, GI Windows, and Alacer Biomedica. Dr. Natan Zundel is on the advisory board for Apollo Endosurgery and Olympus. Dr. Christopher J. Gostout is chief medical officer for Apollo Endosurgery. Dr. Barham K. Abu Dayyeh has served as a consultant for Apollo Endosurgery, Boston Scientific, and Metamodix. He received research support from GI dynamics, Aspire Bariatrics, and Spatz. Drs. Eric J.Vargas, Fateh Bazerbachi, Andres Acosta, Manpreet S. Mundi, Maria L. Collazo-Clavell, Shah Meera, H. S. Abu-Lebdeh, Todd A. Kellogg, Travis J. McKenzie, Michael L. Kendrick, Mark D. Topazian, Mrs. Monika Rizk and Mr. Paul A. Lorentz have no conflicts of interest or financial ties to disclose.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Vargas, E.J., Bazerbachi, F., Rizk, M. et al. Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis. Surg Endosc 32, 252–259 (2018). https://doi.org/10.1007/s00464-017-5671-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-017-5671-1

Keywords

  • Endoscopic
  • Bariatric surgery
  • Revision