Treatment of the Dilated Gastrojejunostomy Using a Collagen Biomatrix

| April 1, 2015

by Mathew W. Severidt, DO; Nicholas J. Kuiper, DO; and David D. Coster, MD

Mathew W. Severidt, DO; Nicholas J. Kuiper, DO; and David D. Coster, MD, are from the Grinnell Institute for Robotic and Minimally Invasive Surgery, Grinnell Bariatrics, Surgical Associates, LLP, Grinnell, Iowa.

Bariatric Times. 2015;12(4):20–22.


ABSTRACT
Objective: The increasing population of post-gastric bypass patients over time has created a difficult subset of individuals presenting with late weight gain despite early success. Lack of restriction caused by a dilated gastrojejunostomy is a relatively common finding in this subgroup. Given the rate of complications following gastrojejunosotmy revision with or without gastric pouch reduction, a safer and simpler alternative to reduce the size of the dilated gastrojejunostomy is needed.
Design: This retrospective case series from a long established Bariatric Center of Excellence in a community hospital describes three gastric bypass patients with significant late post-surgical weight gain who underwent gastrojejunostomy “revision” by placement of a collagen graft around the dilated gastric outlet, using a 32 French sizer and either a collagen matrix band or donor fascia lata tendon.
Results: All patients noted immediate return of restriction with meals. Short-term follow up demonstrated a percent of excess weight loss of 17, 27, and 46 percent. There were no complications.
Conclusion: This novel technique potentially offers the bariatric surgeon a safer alternative to a complete reconstruction of a dilated gastrojejunosotmy. In this limited case series, early results are encouraging. Further study with a larger cohort and extended follow up is warranted.

Introduction
More than 100,000 bariatric procedures are performed annually in the United States.[1] Refinement of surgical technique has allowed the majority of patients to enjoy sustainable weight loss, but up to 20 percent of bariatric patients assessed with long-term follow up will demonstrate weight regain.[2] Failure is typically due to inadequate patient lifestyle modification, but may also be due to suboptimal post-surgical anatomy such as a large gastric pouch or patulous gastrojejunostomy defined by anastomotic dilation to 2.0cm or more, causing reduced restriction and loss of satiety.

Numerous techniques for anastomotic revision are described in the literature. Complete recreation of the gastric pouch and gastrojejunostomy, although efficacious, carries a risk of leak or other complications. Endoscopic suturing, gastric band placement, and submucosal injections of sodium morrhuate are lower risk but are known to be less effective.[3–5]  The technique described in this case series represents a novel approach to revision of the dilated gastrojejunostomy, which if applied to the appropriate patient offers a low-risk alternative to traditional revisional approaches.

Methods
The three patients included in this retrospective review presented with weight recidivism and loss of restriction. All three underwent a detailed dietary history, physical examination, psychological assessment, upper gastrointestinal (UGI) series, and upper endoscopy.  All patients participated in a dedicated medical weight loss program, dietary counseling, and an exercise program several months prior to the decision to intervene surgically. Patients with a dilated gastrojejunostomy diagnosed by upper endoscopy were deemed appropriate candidates for revision if psychological evaluation failed to demonstrate issues or behaviors affecting compliance. Each candidate was counseled by a registered dietitian, was started on a calorie restricted diet and exercise regimen, and was evaluated and counseled monthly in our medical weight loss clinic for at least six months. Each case was reviewed independently by a bariatric review committee that comprised bariatric surgeons, a psychologist, an internist, and the program director to ensure compliance with all medical and psychological metrics prior to approval for revision.

A laparoscopic approach was utilized in two cases but precluded by dense adhesions in one. All patients underwent complete circumferential dissection of their gastrojejunostomy and antecolic, antegastric Roux limbs. Each collagen graft was sutured around the old gastrojejunostmy at the level of the old staple line using 0-Nurolon suture (Nurolon®, Ethicon, Cincinnati, Ohio). In each case a 32 Fr. Bougie was used as a sizer.

Case Series
Case 1. Our first case is of a 32-year-old white female patient (body mass index [BMI] 52kg/m2, weight 141kg) who underwent an open gastric bypass in 2001 with a 25mm end- to-end anastomosis (EEA). Her BMI reduced in one year to 23kg/m[2] (weight 66kg). She maintained this weight for 10 years, until treatment with clomiphene and subsequent pregnancy resulted in weight gain to 130kg. Preoperative endoscopy revealed a dilated anastomosis equal to the diameter of the pouch and small intestine with no constriction at the staple line. A cadaveric fascia lata graft (2x6cm) was laparoscopically placed around the gastrojejunostomy using a 32 Fr. Bougie as a sizer (Figure 1).

She reported immediate return of restriction. Four months after revision, her weight was 73kg, reflecting a 46-percent excess weight loss (%EWL) with a BMI of 28kg/m[2].

Case 2. Our second case is of a a 33-year-old white female patient with a BMI of 47kg/m[2] (weight 128kg) who underwent a laparoscopic gastric bypass with linear stapled anastomosis in 2009. She enjoyed rapid and dramatic weight reduction prior to loss of restriction two years later. Endoscopy demonstrated a dilated gastrojejonostomy to 3.0cm.  Submucosal injection of sodium morrhuate resulted in no reduction. A cadaveric fascia lata graft (2x6cm) was placed laparoscopically around the gastrojejunostomy using a 32 Fr. Bougie as a sizer.

She noted immediate return of restriction with a 27-persent EWL after six months. Since that time, her BMI has remained at 36kg/m[2] (weight 99kg).

Case 3. Our third case is of a 48-year-old white female with a BMI of 53kg/m[2] (weight 154kg) who underwent an open gastric bypass in 2005. Her weight reduced to 109kg in four months. Loss of restriction caused her weight to increase to 153kg. Preoperative endoscopy and UGI demonstrated a 3.0cm dilated anastomosis with “candy-cane” anatomy and a large blind limb. After failing medical management she underwent open resection of the blind limb and placement of a 2x7cm collagen graft (Veritas Collagen Matrix, Baxter Healthcare Corporation, Deerfield, Illinois) around the gastrojejunostomy using a 32 Fr. Bougie as a sizer.

She reported immediate food restriction with a weight reduction of 20kg in the first eight weeks of follow up, reflecting a 17-percent EWL, which she maintained. An upper endoscopy performed at six months showed an appropriately sized gastrojejunostomy measuring an estimated 1.5cm.

No immediate or delayed surgical complications occurred in any patient in this series.

Discussion
Acellular collagen matrices of all types are potentially useful adjuncts for reinforcement of intestinal anastomoses.[6] They are typically obtained from porcine and bovine sources. Fascia lata tendon, composed of type I collagen, may be obtained as a human cadaveric donor graft or harvested directly from the patient.

We are not aware of any published reports describing bariatric anastomotic revision using collagen matrices. A similar technique described by Moon et al[7] combined gastric pouch re-sizing with placement of a bovine pericardial patch ring around the gastrojejunostomy. Their work represents the largest similar effort published to date, with extended follow up to 24 months. Despite mean reduction in excess weight, a significant number of patients required reoperation or further inpatient treatment for procedure-related complications.[7]

Salvage banding using an adjustable synthetic gastric band around the dilated outlet has shown minimal promise as a weight loss tool.[8] Additionally, a review of the pertinent literature by Vijgen et al[8] cited a substantial number of band-related complications, including slippage or erosion necessitating subsequent band removal, complications avoided with our technique.

Weight loss and stabilization after submucosal injection of the sclerosing agent sodium morrhuate is described as modest at best.[9] Four quadrant submucosal injection of sodium morrhuate has been reported in a small case series to successfully reduce gastric outlet diameter; however, a minority of patients were found to experience lasting weight loss.[10] Furthermore, multiple procedures may be required to decrease stoma size and the procedure has been shown to cause anastomotic ulcers and stomal stenosis.[11]
Endoscopic stomal plication appears to be another safe method of reducing anastomotic diameter, however, weight loss after this procedure is also nominal.[12] The technique has questionable durability and the added problems of potential device failure and the inherent risk of bleeding or perforation.

It will be difficult to accrue patients for a prospective study of this technique, but there are a number of physiologic and anatomic reasons to expect long-term success if applied to the appropriate candidate. Diminution of an enlarged gastric outlet with a collagen wrap does delay emptying into the Roux limb, re-inducing satiety with small food volumes and restoring control of weight management. Based upon knowledge of the physiology of incorporation of collagen biomatrices, the reduction of stoma size should be expected to be permanent as the biologic scaffold remodels and incorporates with the patient’s native tissues. Limiting the anastomotic revision to the placement of a collagen wrap around the gastrojejunostomy (foregoing complete recreation of the anastomosis) as we describe should also reduce the likelihood of postoperative complications. This approach has the added benefit of being easily performed as a minimally invasive, low cost, outpatient procedure in many cases.

Conclusion
This procedure represents a novel low-risk treatment for the patient with recurrent morbid obesity due to a dilated gastrojejunostomy after gastric bypass, and may be a simple long-term solution for what has been a vexing problem for the bariatric surgeon. An external biological “wrap” avoids all of the problems inherent with every other currently described technique. Early case results are encouraging and justify additional investigation into the short and long-term results of such an approach.

References
1.    Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010; 200:378–385.
2.    Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC. Long term weight regain after gastric bypass: a 5-year prospective study. Obes Surg. 2008; 18:648–651.
3.    Suppiah A, Hamed M, Milson C, Pollard S. Caution in using a unique technique of banded revision gastric bypass: successful endoscopic and surgical management of a rare complication. Int J Surg Case Rep. 2013;4(6): 554–557.
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7.    Moon R, Teixeira A, Jawad M. Treatment of weight regain following Roux-en-Y gastric bypass: revision of pouch, creation of new gastrojejunostomy and placement of proximal pericardial patch ring. Obes Surg. 2014;24(6):829–834.
8.    Vijgen G, Schouten R, Bouvy N, Greve JW. Salvage banding for failed Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2012; 8: 803–808.
9.    Dakin G, Eid G, Mikami D, Pryor A, Chand B. Endoluminal revision of gastric bypass for weight regain—a systematic review. Surg Obes Relat Dis. 2013;9:335–343.
10.    Spaulding L. Treatment of dilated gastrojejunostomy with sclerotherapy. Obes Surg. 2003;13:254–257.
11.    Catalano M, Rudic G, Anderson A, Chua Y. Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision. Gastrointest Endosc. 2007;66(2):240–245. Epub 2007 Feb 28.
12.    Leitman I, Virk C, Avgerinos D, et al. Early results of trans-oral endoscopic plication and revision of the gastric pouch and stoma following Roux-en-Y gastric bypass surgery. JSLS. 2010; 14(2): 217–220.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts relevant to the content of this article.

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