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One-Year Outcomes Following Endoscopic Gastrojejunal Revision
Matthew E. Gitelis*, John G. Linn, Woody Denham, Liz Farwell, Stephen P. Haggerty, Joann Carbray, Kimberly Miller, Christine Sula, Yalini Vigneswaran, Michael B. Ujiki
NorthShore University HealthSystem, Chicago, IL
Background: Patients presenting with weight gain after Roux-en-Y gastric bypass (RYGB) are a difficult cohort to treat. Surgical revision may be effective for some patients; however, it is typically characterized by a higher procedural risk as compared to primary weight reduction surgery. A minimally invasive and safe endoscopic treatment alternative may provide the appropriate risk-reward balance for many patients. The long-term efficacy of endoscopic gastrojejunal revision (EGJR) is unknown, however. We present our one-year outcomes following EGJR using a full-thickness suturing device.
Methods: Institutional review board-approved retrospective study of 35 consecutive patients who underwent EGJR between June 2012 and October 2014. All patients were at least two years from original RYGB, had a dilated gastrojejunal anastomosis greater than 15mm, and presented with weight gain. An endoscopic suturing device (OverStitchä, Apollo Endosurgery, Austin TX) was used to narrow the anastomosis. All clinically available data including weight loss outcomes, comorbidity resolution, and complications were captured in the study. Pairwise comparisons using Students t-test were made between time points. Statistical significance was established using 2-sided alpha level less than .05.
Results: Mean age was 50.3 ± 10.3 years and 91% were female. Prior to EGJR, patients regained an average of 24.8 ± 13.3 kg from their weight loss nadir and had a mean body mass index of 41.6 ± 6.3 kg/m2. The average procedure time was 42 ± 17 minutes. A median of three sutures were placed per patient and the stoma diameter was reduced from 30.1 ± 6.8 mm to 6.4 ± 2.2 mm for an average 78.5% reduction. At six months, 96% of patients had weight loss (average 5.4 ± 5.9 kg; p <0.001). At one year, 75% of available cases maintained weight loss (average 3.7 ± 9.3 kg; p=0.133). Percent excess weight loss was 14.4 ± 15.0%, and 7.0 ± 20.7% at six months and one year, respectively. Reducing the gastrojejunal stoma diameter by 75% or more resulted in significantly more weight loss at one year (11% vs. -9%; p=0.02). With weight loss, several patients reported no longer requiring treatment for GERD (4), hyperlipidemia (2), hypertension (1), and sleep apnea (2). One patient experienced post-operative bleeding due to a marginal ulcer at the gastrojejunal anastomosis which required a second endoscopic intervention to manage.
Conclusion: EGJR appears to be successful in reversing the trend of weight gain for many patients. At one year following the procedure, there was considerable variability in weight loss outcomes. Many factors likely contribute to the success of the procedure including the percent reduction of the gastrojejunal stoma diameter.
Weight Loss Outcomes
| Postoperative clinic visit | 6 weeks (n=24) | 3 months (n=23) | 6 months (n=23) | 1 year (n=16) | | Weight loss form baseline, kg | 6.4 ± 5.3 | 6.7 ± 5.9 | 5.4 ± 5.9 | 3.7 ± 9.3 | | p-value (a) | <0.001 | <0.001 | <0.001 | 0.133 | | Excess weight loss (b), % | 14.0 ± 11.6 | 16.1 ± 13.1 | 14.4 ± 15.0 | 7.0 ± 20.7 | | Weight stabilization / weight loss (c), n (%) | 23 (95.8) | 22 (95.7) | 22 (95.7) | 12 (75.0) | | Achieved ≥ 10% EWL | 16 (66.7) | 15 (65.2) | 12 (52.2) | 6 (37.5) | | Achieved ≥ 15% EWL | 11 (45.8) | 11 (47.8) | 10 (43.5) | 6 (37.5) | | Achieved ≥ 20% EWL | 7 (29.2) | 9 (39.1) | 7 (30.4) | 4 (25.0) |
*Plus minus values are presented as mean ± standard deviation. (a) P-value from paired sample Student's t-test assuming unequal variances, two-tailed (b) Percentage EWL is computed as follows: ([weight at baseline - weight at postoperative clinic visit]/[weight at baseline - ideal weight at body mass index of 25]) * 100 (c) Weight stabilization defined as +/- 2% of weight at baseline
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