BRIGHAM AND WOMEN’S HOSPITAL HARVARD MEDICAL SCHOOL Endoscopic Repair of DilatedGastrojejunal Anastomoses Using aNovel Endoscopic Suturing Device Pichamol Jirapinyo, Barham K. Abu Dayyeh, James Slattery, Michele B. Ryan, Rabindra R. Watson, David B. Lautz, Christopher C. Thompson
Background: Weight Regain Definition of success after bariatric surgery 1. Loss of excess weight ≥ 50%* 2. For morbidly obese group (BMI < 50) BMI < 35 kg/m2** For super obese group (BMI ≥ 50) BMI < 40 kg/m2** Weight regain is common in this population * Reinhold RB. Surg Gynecol Obstet 1982; 155:385-394.** Biron S, et al. Obes Surg 2004; 14(2):160-4.
Background: Prevalence of Weight Regain Occurs after post-operative year 1 Most RYGB patients regain >30% of lost weight Over 25% of RYGB patients regained almost all of their lost weights Control Gastric Bypass 30% Year 1* Sjostrom L, et al. NEJM 2004; 351: 2683-93.
Background: Dilated GJ* Abu Dayyeh BK, Lautz DB, Thompson CC. Clin Gastroenterol Hepatol 2011; 9(3):228-33.
Background: Management of Dilated GJ Surgical revision Complication rate up to 50%* Mortality rate up to 2%* Endoscopic techniques Less invasive Multiple options Sclerotherapy Tissue plication Endoscopic suturing* Schwartz R, et al. Surgery 1988;104:806–12.
Endoscopic Suturing Device Suture arm Tissue anchor Anchor exchange
Endoscopic Suturing Device Sutures Cinch Absorbable and non-absorbable To secure closure without 2-0 & 3-0 Polyglycolic Acid (PGA) the need to tie surgical knots 2-0 & 3-0 Polypropylene (PP)
Endoscopic Suturing Device: Cinch System Tissue of interest Cylinder PostEndoscope Suture Tissue anchor
Pilot Study Aim: To demonstrate technical feasibility, safety and short term efficacy Study design: Prospective interventional case series 22 consecutive RYGB patients with weight regain and a dilated stoma
Methods Procedure Performed under general anesthesia CO2 insufflation 2-0 polypropylene Technical success Successful suture placement with reduction in stoma size to < 1 cm Follow-up Follow-up visits at 3, 6, 12 months Follow-up endoscopy at 6, 12 months
Patient Characteristics 22 RYGB patients presented with weight regain Age 48+9 years Gender 16/22 (72.7%) female Time from RYGB 6+2 years Stoma diameter 25.5+4.3 mm Pouch length 5.3+2.0 cm
Stoma vs. Pouch 10 outlet 8 outlet + pouchAverage weight loss 15.6 lbs 30.9 lbsAverage follow-up time 94.1 days 86 days% weight regain loss 63.2% 66.1%% excess weight loss 16.7% 26.3% N = 18
Limitations Small number of patients Short term outcomes Single tertiary center Nutritional and physical activity history not included
Conclusion Reducing GJ anastomosis size using this novel endoscopic suturing device is technically feasible and appears safe This technology could provide an option for treating weight regain in RYGB patients This technology may also have other applications: Ulcer oversewing Fistula closure