Endoscopic Treatments Following Bariatric Surgery

Abstract

Weight regain after bariatric surgery is common and can be managed with surgical interventions or less morbid endoscopic techniques. These endoscopic approaches target structural postoperative changes that are associated with weight regain, most notably dilation of the gastrojejunal anastomosis aperture. Purse string suture placement, as well as argon plasma coagulation application to the anastomosis, may result in significant and durable weight loss. Furthermore, various endoscopic approaches may be used to safely and effectively manage other complications of bariatric surgery that may result in poor weight loss or weight regain after surgery, including fistula formation.

Keywords: Bariatric endoscopy; Endoscopic surgery; Endoscopic suturing; Fistula; Gastric bypass; Surgical complications; Therapeutic endoscopy; Weight regain.

Copyright © 2017 Elsevier Inc. All rights reserved.

Figures

Figure 1

APC (argon plasma coagulation) resurfacing of the gastrojejunal anastomosis. A; Dilated gastrojejunal anastomosis with aperture of approximately 15mm, B; APC treatment applied to the gastric side of the stoma, C; In rare cases, overtreatment may result in stenosis requiring dilation.

Figure 1

APC (argon plasma coagulation) resurfacing of the gastrojejunal anastomosis. A; Dilated gastrojejunal anastomosis with aperture of approximately 15mm, B; APC treatment applied to the gastric side of the stoma, C; In rare cases, overtreatment may result in stenosis requiring dilation.

Figure 1

APC (argon plasma coagulation) resurfacing of the gastrojejunal anastomosis. A; Dilated gastrojejunal anastomosis with aperture of approximately 15mm, B; APC treatment applied to the gastric side of the stoma, C; In rare cases, overtreatment may result in stenosis requiring dilation.

Figure 2

The Overstitch endoscopic suturing device. A; Handle to drive the needle and needle exchange catheter are attached to a double channel therapeutic endoscope, B; The distal attachement with needle and suture attached to the needle driver arm with helical tissue grabbing tool through the second working channel.

Figure 2

The Overstitch endoscopic suturing device. A; Handle to drive the needle and needle exchange catheter are attached to a double channel therapeutic endoscope, B; The distal attachement with needle and suture attached to the needle driver arm with helical tissue grabbing tool through the second working channel.

Figure 3

The TORe (transoral outlet revision) procedure. A; Dilated stoma of approximately 25mm is examined B; APC cautery is applied to the gastric musoca around the stoma, C; Full-thickness purse-string suture is then placed around the stoma, D; Final aperture is sized using an 8mm balloon.

Figure 3

The TORe (transoral outlet revision) procedure. A; Dilated stoma of approximately 25mm is examined B; APC cautery is applied to the gastric musoca around the stoma, C; Full-thickness purse-string suture is then placed around the stoma, D; Final aperture is sized using an 8mm balloon.

Figure 3

The TORe (transoral outlet revision) procedure. A; Dilated stoma of approximately 25mm is examined B; APC cautery is applied to the gastric musoca around the stoma, C; Full-thickness purse-string suture is then placed around the stoma, D; Final aperture is sized using an 8mm balloon.

Figure 3

The TORe (transoral outlet revision) procedure. A; Dilated stoma of approximately 25mm is examined B; APC cautery is applied to the gastric musoca around the stoma, C; Full-thickness purse-string suture is then placed around the stoma, D; Final aperture is sized using an 8mm balloon.

Figure 4

The IOP (Incisionless Operating Platform). This disposable one-time use platform employs use of a slim gastroscope through one channel for visualization (not shown), and includes a tissue plication device (shown) through the main operating channel.

Figure 5

Extruded suture and staple material at the gastrojejunal anastomosis. This may lead to ulcers, pain and intermittent partial obstruction when foodstuff becomes impacted and tangled in the suture material.

Figure 6

Tools used for removal of the suture and staple material. From left to right; biopsy forceps, reusable scissors, and loop cutters.

Figure 7

Closure of a gastro-gastric fistula through ESD and endoscopic suturing of the fistula. A; The fistula is shown here to the left of the gastrojejunal anastomosis, B; ESD is performed around the fistula opening to expose the muscular layer and then APC used to ablate any remaining mucosa, C; Running suture placed to close the defect, D; Fistula now fully closed on final inspection.

Figure 7

Closure of a gastro-gastric fistula through ESD and endoscopic suturing of the fistula. A; The fistula is shown here to the left of the gastrojejunal anastomosis, B; ESD is performed around the fistula opening to expose the muscular layer and then APC used to ablate any remaining mucosa, C; Running suture placed to close the defect, D; Fistula now fully closed on final inspection.

Figure 7

Closure of a gastro-gastric fistula through ESD and endoscopic suturing of the fistula. A; The fistula is shown here to the left of the gastrojejunal anastomosis, B; ESD is performed around the fistula opening to expose the muscular layer and then APC used to ablate any remaining mucosa, C; Running suture placed to close the defect, D; Fistula now fully closed on final inspection.

Figure 7

Closure of a gastro-gastric fistula through ESD and endoscopic suturing of the fistula. A; The fistula is shown here to the left of the gastrojejunal anastomosis, B; ESD is performed around the fistula opening to expose the muscular layer and then APC used to ablate any remaining mucosa, C; Running suture placed to close the defect, D; Fistula now fully closed on final inspection.