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Endoscopic trans-oral outlet reduction after bariatric surgery is safe and effective for dumping syndrome

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Abstract

Background

Dumping syndrome (DS) is a common complication of bariatric surgery. Treatments include dietary and behavioral changes, as well as pharmacotherapy and revision surgery. All can be costly or hard to adhere to. In recent years, evidence accumulates in favor of endoscopic trans-oral outlet reduction (TORe) as an effective treatment for DS, targeting the pathophysiology of rapid gastric clearance. The objective of this study is to assess the safety and efficacy of TORe for DS in a single referral center.

Methods

Patients after bariatric surgery suffering DS were followed, and data were retrospectively analyzed. Diagnosis and post-procedural assessment of DS were made clinically using Sigstad score. During the procedure, the anastomotic rim was cauterized. Afterwards, 2 non-interrupted “8-figure” sutures were placed, resulting in imbrication of additional gastric tissue on top of the anastomosis and narrowing to <1 cm at the end of the procedure. Patients were instructed to keep a liquid diet for 14 days and follow-up continued for 6 months.

Results

Between 8/2018 and 9/2019 TORe was carried out in 13 patients (M:F = 3:10) with mean age of 45.1 (range 25–56) and BMI of 33.5 (range 28.1–40.3). Average time since recent surgery was 5.5 years (range 1–9). Mean pre-procedure anastomosis diameter was 25.2 mm (range 15–30) and was reduced to a mean of 5.6 mm (range 5–10). Three patients (23%) were admitted overnight due to inability to drink which resolved spontaneously. No major complications were reported.

At 6 months, the Sigstad score was significantly reduced (19.4 ± 3.6 vs 5.2 ± 5.5, P < 0.001), and 11/13 (85%) of patients had a complete resolution of their dumping symptoms. In addition, BMI decreased by a mean of 2.3 kg/m2 (−1 to 7.5, p = 0.002).

Conclusion

TORe is a safe and effective treatment for patients suffering dumping syndrome and should be considered early in the treatment of DS.

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Fig. 1
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© device, D end result with tight anastomosis <1 cm

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References

  1. Flegal KM, Carroll MD, Ogden CL, Curtin LR (2010) Prevalence and trends in obesity among US adults, 1999–2008. JAMA J Am Med Assoc. https://doi.org/10.1001/jama.2009.2014

    Article  Google Scholar 

  2. Arroyo-Johnson C, Mincey KD (2016) Obesity epidemiology worldwide. Gastroenterol Clin North Am 45(4):571–579

    Article  Google Scholar 

  3. Santry HP, Gillen DL, Lauderdale DS (2005) Trends in bariatric surgical procedures. J Am Med Assoc. https://doi.org/10.1001/jama.294.15.1909

    Article  Google Scholar 

  4. Bruzzi M, Rau C, Voron T, Guenzi M, Berger A, Chevallier JM (2015) Single anastomosis or mini-gastric bypass: long-term results and quality of life after a 5-year follow-up. SurgObesRelat Dis. https://doi.org/10.1016/j.soard.2014.09.004

    Article  Google Scholar 

  5. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, Navaneethan SD, Singh RP, Pothier CE, Nissen SE, Kashyap SR (2017) Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. N Engl J Med. https://doi.org/10.1056/NEJMoa1600869

    Article  PubMed  PubMed Central  Google Scholar 

  6. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K (2004) Bariatric surgery: a systematic review and meta-analysis. J Am Med Assoc 292(14):1724–1737

    Article  CAS  Google Scholar 

  7. Buchwald H, Oien DM (2013) Metabolic/bariatric surgery worldwide 2011. ObesSurg. https://doi.org/10.1007/s11695-012-0864-0

    Article  Google Scholar 

  8. Stenberg E, Szabo E, Ågren G, Näslund E, Boman L, Bylund A, Hedenbro J, Laurenius A, Lundegårdh G, Lönroth H, Möller P, Sundbom M, Ottosson J, Näslund I (2014) Early complications after laparoscopic gastric bypass surgery: results from the scandinavian obesity surgery registry. Ann Surg. https://doi.org/10.1097/SLA.0000000000000431

    Article  PubMed  Google Scholar 

  9. Lancaster RT, Hutter MM (2008) Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. SurgEndosc Other Interv Tech. https://doi.org/10.1007/s00464-008-0074-y

    Article  Google Scholar 

  10. Flum DR, Belle SH, King WC, Wahed AS, Berk P, Chapman W, Pories W, Courcoulas A, McCloskey C, Mitchell J, Patterson E, Pomp A, Staten MA, Yanovski SZ, Thirlby R, Wolfe B (2009) Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. https://doi.org/10.1056/NEJMoa0901836

    Article  PubMed  Google Scholar 

  11. Encinosa WE, Bernard DM, Du D, Steiner CA (2009) Recent improvements in bariatric surgery outcomes. Med Care. https://doi.org/10.1097/MLR.0b013e31819434c6

    Article  PubMed  Google Scholar 

  12. Van Beek AP, Emous M, Laville M, Tack J (2017) Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management. Obes Rev 18(1):68–85

    Article  Google Scholar 

  13. Berg P, McCallum R (2016) Dumping syndrome: a review of the current concepts of pathophysiology, diagnosis, and treatment. Dig Dis Sci 61(1):11–18

    Article  Google Scholar 

  14. Schulman AR, Thompson CC (2017) Complications of bariatric surgery: what you can expect to see in your GI practice. Am J Gastroenterol 112(11):1640–1655

    Article  Google Scholar 

  15. Fujioka K (2005) Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care 28(2):481–484

    Article  Google Scholar 

  16. Vecht J, Masclee AA, Lamers CB (1997) The dumping syndrome. Current insights into pathophysiology, diagnosis and treatment. Scand J Gastroenterol Suppl 223:21

    CAS  PubMed  Google Scholar 

  17. Berg P, McCallum R, Hall M, Sarosiek I (2014) Dumping syndrome: updated perspectives on etiologies and diagnosis. Pract Gastroenterol 38:30–38

    Google Scholar 

  18. Tack J, Arts J, Caenepeel P, De Wulf D, Bisschops R (2009) Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nat Rev Gastroenterol Hepatol 6(10):583

    Article  Google Scholar 

  19. Tack J, Deloose E (2014) Complications of bariatric surgery: dumping syndrome, reflux and vitamin deficiencies. Best Pract Res Clin Gastroenterol 28(4):741–749

    Article  CAS  Google Scholar 

  20. Thompson CC, Jacobsen GR, Schroder GL, Horgan S (2012) Stoma size critical to 12-month outcomes in endoscopic suturing for gastric bypass repair. SurgObesRelat Dis. https://doi.org/10.1016/j.soard.2011.03.014

    Article  Google Scholar 

  21. Horgan S, Jacobsen G, Weiss GD, Oldham JS, Denk PM, Borao F, Gorcey S, Watkins B, Mobley J, Thompson K, Spivack A, Voellinger D, Thompson C, Swanstrom L, Shah P, Haber G, Brengman M, Schroder G (2010) Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results. SurgObesRelat Dis. https://doi.org/10.1016/j.soard.2009.12.011

    Article  Google Scholar 

  22. Tran DD, Nwokeabia ID, Purnell S, Zafar SN, Ortega G, Hughes K, Fullum TM (2016) Revision of Roux-En-Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg 26(7):1627–1634

    Article  Google Scholar 

  23. Abu Dayyeh BK, Lautz DB, Thompson CC (2011) Gastrojejunal stoma diameter predicts weight regain after Roux-en-Y gastric bypass. ClinGastroenterolHepatol. https://doi.org/10.1016/j.cgh.2010.11.004

    Article  Google Scholar 

  24. Thompson CC, Chand B, Chen YK, Demarco DC, Miller L, Schweitzer M, Rothstein RI, Lautz DB, Slattery J, Ryan MB, Brethauer S, Schauer P, Mitchell MC, Starpoli A, Haber GB, Catalano MF, Edmundowicz S, Fagnant AM, Kaplan LM, Roslin MS (2013) Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery. Gastroenterology. https://doi.org/10.1053/j.gastro.2013.04.002

    Article  PubMed  Google Scholar 

  25. Craig CM, Liu LF, Deacon CF, Holst JJ, McLaughlin TL (2017) Critical role for GLP-1 in symptomatic post-bariatric hypoglycaemia. Diabetologia. https://doi.org/10.1007/s00125-016-4179-x

    Article  PubMed  Google Scholar 

  26. Craig CM, Liu LF, Nguyen T, Price C, Bingham J, McLaughlin TL (2018) Efficacy and pharmacokinetics of subcutaneous exendin (9–39) in patients with post-bariatric hypoglycaemia. Diabetes ObesMetab. https://doi.org/10.1111/dom.13078

    Article  Google Scholar 

  27. Brunaldi VO, Ayala Farias GF, Tavares de Rezende D, Cairo-Nunes G, Riccioppo D, Hourneaux de Moura DT, Santo MA, Hourneaux de Moura EG (2020) Argon plasma coagulation alone versus endoscopic suturing plus argon plasma coagulation to treat weight regain after Roux-en-Y gastric bypass: a prospective randomized trial (with videos). GastrointestEndosc. https://doi.org/10.1016/j.gie.2020.03.3757

    Article  Google Scholar 

  28. Moon RC, Teixeira AF, Neto MG, Zundel N, Sander BQ, Ramos FM, Matz F, Baretta GA, de Quadros LG, Grecco E, Souza T, Barrichello SA, Filho AC, Usuy EN, de Amorim AMB, Jawad MA (2018) Efficacy of utilizing argon plasma coagulation for weight regain in Roux-en-Y gastric bypass patients: a multi-center study. ObesSurg. https://doi.org/10.1007/s11695-018-3229-5

    Article  Google Scholar 

  29. Brunaldi VO, Jirapinyo P, de Moura DTH, Okazaki O, Bernardo WM, Galvão Neto M, Campos JM, Santo MA, de Moura EG (2018) Endoscopic treatment of weight regain following Roux-en-Y gastric bypass: a systematic review and meta-analysis. Obes Surg 28(1):266–276

    Article  Google Scholar 

  30. Fernández-Esparrach G, Lautz DB, Thompson CC (2010) Peroral endoscopic anastomotic reduction improves intractable dumping syndrome in Roux-en-Y gastric bypass patients. SurgObesRelat Dis. https://doi.org/10.1016/j.soard.2009.04.002

    Article  Google Scholar 

  31. Stier C, Chiappetta S (2016) Endoluminal revision (OverStitch TM, Apollo Endosurgery) of the dilated gastroenterostomy in patients with late dumping syndrome after proximal Roux-en-Y gastric bypass. ObesSurg. https://doi.org/10.1007/s11695-016-2266-1

    Article  Google Scholar 

  32. Tsai C, Steffen R, Kessler U, Merki H, Zehetner J (2019) Short-term outcomes of endoscopic gastro-jejunal revisions for treatment of dumping syndrome after Roux-En-Y gastric bypass. SurgEndosc. https://doi.org/10.1007/s00464-019-07137-7

    Article  Google Scholar 

  33. Vargas EJ, Bazerbachi F, Rizk M, Rustagi T, Acosta A, Wilson EB, Wilson T, Neto MG, Zundel N, Mundi MS, Collazo-Clavell ML, Meera S, Abu-Lebdeh HS, Lorentz PA, Grothe KB, Clark MM, Kellogg TA, McKenzie TJ, Kendrick ML, Topazian MD, Gostout CJ, Abu Dayyeh BK (2018) Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis. SurgEndosc. https://doi.org/10.1007/s00464-017-5671-1

    Article  Google Scholar 

  34. Vargas EJ, Abu Dayyeh BK, Storm AC, Bazerbachi F, Matar R, Vella A, Kellogg T, Stier C (2020) Endoscopic management of dumping syndrome after Roux-en-Y gastric bypass: a large international series and proposed management strategy. GastrointestEndosc. https://doi.org/10.1016/j.gie.2020.02.029

    Article  Google Scholar 

  35. Sigstad H (1970) A clinical diagnostic index in the diagnosis of the dumping syndrome: changes in plasma volume and blood sugar after a test meal. Acta Med Scand. https://doi.org/10.1111/j.0954-6820.1970.tb08072.x

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Bariatric Endoscopy Service, Department of Gastroenterology and Liver Disease, Tel Aviv Sourasky Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Weizman 6 st., 6423906, Tel Aviv, Israel

    Reicher Relly, Shnell Mati, Cohen Nathaniel Aviv & Sigal Fishman

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Relly, R., Mati, S., Aviv, C.N. et al. Endoscopic trans-oral outlet reduction after bariatric surgery is safe and effective for dumping syndrome. Surg Endosc 35, 6846–6852 (2021). https://doi.org/10.1007/s00464-020-08190-3

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