Revisional Gastric Pouch and Stoma Reduction Surgery for Weight Regain: Case Report of Gastric Bypass via an Endolumenal Approach

by G. Derek Weiss, MD, FACS, FASMBS

Introduction
Weight regain years after successful gastric bypass surgery is a fairly common therapeutic challenge facing today’s practicing bariatric surgeon. The majority of weight loss after Roux-en-Y gastric bypass (RYGB) tends to occur during the first 1 to 2 years postoperatively and averages 65 to 80 percent of excess body weight loss (EBWL).1-3 Magro et al recently showed that at two years, as many as 50 percent of RYGB patients had gained at least some weight from their nadir weight, with an average weight regain of some 8.8kg in that particular subset at five years.3 Other prospective studies have shown a weight regain of 20 percent of patients at 10 years.4 Well understood now in the medical community is the negative impact that this excess weight has on the incidence of cardiovascular, metabolic, orthopedic, and pulmonary disease.

Many have speculated that postoperative gastric bypass weight gain is related to gastric pouch and/or stomal dilatation as a result of surgical technique or dilatation over time post-surgery. This speculation has been driven in part by the long-accepted surgical principle of reducing gastric pouch and outlet size as an important component of weight loss for primary Roux-en-Y surgical patients.

Many patients report they lose the early satiety feeling they feel early on after the primary bypass surgery. Roberts et al revealed data that show pouch size correlated with weight loss in regard to laparoscopic Roux-en-Y.5

The surgical treatment options offered for these patients are tempered by the well-documented, significant incidence of morbidity and mortality rates associated with revisional gastric bypass surgery. Revisional bypass surgery has a significantly higher morbidity rate (15%) and mortality rate (1%) than the primary surgery.6, 7

These sobering statistics have prompted many clinicians and those in industry to consider less invasive, safer alternatives to the life-threatening ramifications of WLS patients’ recurrent, excess weight. These approaches have included band placement over the bypass, as well as other endoscopic/ endolumenal approaches to reduce the stoma and/or pouch size to more closely approximate immediate post- Roux-en-Y results. These “incisionless” options have included sclerotherapy of the stoma and various plicating devices that address either stoma or pouch dilatation.

I report on one of my initial cases with the Endoscopic Operating System™ (EOS) from USGI Medical (San Clemente, California) to reduce stoma and pouch dilatation post-bypass in a patient who was beginning to regain her lost weight.

CASE PRESENTATION
Miss P was a 34-year-old woman who presented with concern about weight regain of approximately 50 pounds over several years, after a “successful” open Roux-en-Y gastric bypass in 2002 by another surgeon. At the time of surgery in 2002, she weighed 328 pounds and had a BMI of 43.3. She had previously plateaued on a weight loss program that helped her lose 40 pounds of her excess weight preoperatively. Miss P proceeded to lose 99 pounds over the next few years following open Roux-en-Y gastric bypass. She was very happy with the surgical results, which greatly improved her quality of life. However, over the last couple years, she noticed less satiety and found she was able to eat larger and larger meals without much restriction.

After we discussed all of the surgical options, Miss P agreed to endoscopic evaluation to see if she might be a candidate for an endolumenal revision of her gastric pouch and stoma with the USGI EOS. Subsequent endoscopic evaluation revealed an enlarged gastric pouch at 10cm (distance between lower esophageal sphincter [LES] and gastrojejunal [G-J] stoma), and a marginally dilated stoma at 1.2cm (Figure 2). We conducted nutritional and medical evaluations to confirm she would be an appropriate surgical candidate for this procedure. She underwent stoma and gastric pouch reduction with the EOS. During the procedure, which was done under general anesthesia, she had two anchor pairs placed in the stoma and six anchors placed in the pouch, which reduced the stoma from 12mm to 8mm, and the pouch was reduced to 4cm (Figure 3).

She was discharged the same day uneventfully, and continues to follow up with our group closely. At seven weeks, she lost 24 pounds (23% of her excess body weight). She felt she was easily feeling sated eating 50 percent of what she used to, and her energy level was markedly improved. She felt like she had a second chance. Her follow-up esophagogastroduodenoscopy (EGD) at three months showed the pouch still measured 4cm and the stoma was 10mm. All anchors were visible and intact (Figure 4). She remains very pleased with the procedure and continues to have subjective restriction with food intake.

DISCUSSION
In 2007, an estimated 205,000 people with morbid obesity in the US will have undergone bariatric surgery.10 RYGB is the most commonly performed bariatric surgery, encompassing over 50 percent of US bariatric procedures.8-10 There is a large pool of patients post-gastric bypass who have gained weight and have dilated pouches and stomas.

Previous publications have reported evidence that gastric pouch size and stomal dilatation may be important factors regarding weight regain after Roux-en-Y gastric bypass.10,11 Herron et al reported on the feasibility of the USGI Medical tissue anchor system for gastric pouch and stoma reduction in a porcine model.12 Thompson et al had demonstrated that endoscopic reduction of stomal dilatation was feasible and safe, and led to significant weight loss.11

The expandable tissue anchors from USGI Medical are designed to address some of the durability challenges of gastric plication when dealing with mucosal tissue. Seaman et al showed in a porcine model that, as opposed to traditional T-bars and other anchor designs with limited or no force distribution, the USGI Medical expandable “basket design” was the only one to consistently achieve deep plications that apposed muscularis propria, with serosal fusion evident.13 This anchor delivery system can be reloaded without removing the TransPort™ or the g-Prox™ from the surgical site. All plications are done under direct visualization, and the system retains the familiar surgical need for tactile feedback, with the operator/clinician controlling tension during the “cinching” process. (The technical aspects of the available incisionless revision options were discussed thoroughly in the article by Dr. Herron et al in the January 2008 issue of Bariatric Times. I strongly encourage those interested to re-read their article.)

Briefly, in the procedure, an EOS is inserted through the mouth and into the pouch under direct visualization with a small, attached endoscope (GIF-N180, Olympus America, Inc., Center Valley, Pennsylvania). The EOS tools are then used to grasp tissue and deploy tissue anchors to create multiple, circumferential tissue folds around the stoma, reducing the diameter of the opening to more closely match original post-gastric bypass proportions. Additional anchors are then placed in the stomach pouch to reduce its volume capacity (Figure 1). By eliminating skin incisions, this new procedure provides important advantages to patients, including reduced risk of infection and associated complications, less postoperative pain, faster recovery time, and no abdominal scars.

After researching the various incisionless options available, we chose to perform the ROSE procedure (Restorative Obesity Surgery, Endoluminal) using the EOS over other available incisionless Roux-en-Y gastric bypass revision options for the following reasons:
1) Other methods use a
T-fastener design that concentrates the force on the tissue at a single point, which may limit durability. By using real suture material and mesh basket anchors which more evenly distribute tissue holding forces, the USGI Medical EOS system anchors remain secure over time.
2) Some other devices cannot be used to treat an enlarged stoma, only the pouch. USGI Medical’s EOS addresses both the pouch and the stoma.

CONCLUSION
Weight regain after successful gastric bypass surgery remains a common and challenging therapeutic dilemma for the practicing surgeon. Endolumenal and incisionless revision of gastric bypass surgery offers an exciting, potentially safer, and effective means to reduce stoma and pouch dimensions. Early results are promising, suggesting that subjective restriction is returned and that the dimensions achieved at the time of the procedure are maintained. Based on the results at three months for this particular patient and on the science that was done previously to ensure durability of the USGI basket design, this technology has great potential to have an impact on the armamentarium for Roux-en-Y gastric bypass revisions. Our hope is that it will create new alternatives and treatment regimes for patients anxious to reduce and/or recreate the health benefits that we all know are achieved by reducing BMI.

References
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12. Herron DM, Birkett DH, Thompson CC, et al. Gastric bypass pouch and stoma reduction using a transoral endoscopic anchor placement system: A feasibility study. Surg Endosc. 2007 Nov 20; in print.
13. Seaman DL, Gostout CJ, de la Mora et al. Tissue anchors for transmural gut-wall apposition. Gastrointest Endosc. 2006;64:577–578.

Category: Case Report, Past Articles