Transoral outlet reduction: could additional sutures cause more harm?

Abstract

Background The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastrojejunal anastomosis (GJA). However, there is a paucity of literature pertaining to post-TORe stenosis as an adverse event. Our aim was to determine the rate of stenosis, its potential predictors, and other complications of DPSP TORe.

Methods We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019.

Results The adverse event rate of TORe was 17.1 % (n = 22), with a 13.3 % (n = 17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter pre- and post-TORe, the difference between these values, and procedure duration were not predictive of stenosis. Of patients who developed stenosis, 10 (58.8 %) responded to endoscopic balloon dilation and 7 (41.2 %) required stent placement.

Conclusion As the DPSP technique is a challenging procedure, with high complication rate and limited benefit, it should not be used for TORe.

Publikationsverlauf

Eingereicht: 14. Juni 2020

Angenommen nach Revision: 30. November 2020

Accepted Manuscript online:
30. November 2020

Artikel online veröffentlicht:
08. Februar 2021

• References

• 1 Brethauer SA, Kothari S, Sudan R. et al. Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis 2014; 10: 952-972
• 2 Maleckas A, Gudaitytė R, Petereit R. et al. Weight regain after gastric bypass: etiology and treatment options. Gland Surg 2016; 5: 617
• 3 Tran DD, Nwokeabia ID, Purnell S. et al. Revision of Roux-En-Y gastric bypass for weight regain: a systematic review of techniques and outcomes. Obes Surg 2016; 26: 1627-1634
• 4 Jirapinyo P, Kröner PT, Thompson CC. Purse-string transoral outlet reduction (TORe) is effective at inducing weight loss and improvement in metabolic comorbidities after Roux-en-Y gastric bypass. Endoscopy 2018; 50: 371-377
• 5 Kumar N, Thompson CC. The pursestring technique for endoscopic revision of gastric bypass. Gastrointest Endosc 2015; 82: 956
• 6 Barola S, Schweitzer MA, Chen Y-I. et al. Demonstration of transoral gastric outlet reduction: 2-fold running suture technique. VideoGIE 2016; 2: 2-3
• 7 Fayad L, Schweitzer M, Raad M. et al. A real-world, insurance-based algorithm using the two-fold running suture technique for transoral outlet reduction for weight regain and dumping syndrome after Roux-en-Y gastric bypass. Obes Surg 2019; 29: 2225-2232
• 8 Vargas EJ, Bazerbachi F, Rizk M. et al. Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis. Surg Endosc 2018; 32: 252-259
• 9 Carrodeguas L, Szomstein S, Zundel N. et al. Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery: analysis of 1291 patients. Surg Obes Relat Dis 2006; 2: 92-97
• 10 Almby K, Edholm D. Anastomotic strictures after Roux-en-Y gastric bypass: a cohort study from the Scandinavian obesity surgery registry. Obes Surg 2019; 29: 172-177
• 11 Itani MI, Fayad L, El Nahla A. et al. Gastrogastric fistula as a possible adverse event of transoral gastric outlet reduction. Gastrointest Endosc 2020; 91: 1395-1396
• 12 Vargas EJ, Storm AC, Bazerbachi F. et al. Endoscopic management of weight regain. In: Wagh M, Wani S. Gastrointestinal interventional endoscopy. Cham: Springer; 2020: 223-231
• 13 Vargas EJ, Bazerbachi F, Rizk M. et al. Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis. Surg Endosc 2018; 32: 252-259
• 14 Tsai C, Steffen R, Kessler U. et al. Endoscopic gastrojejunal revisions following gastric bypass: lessons learned in more than 100 consecutive patients. J Gastrointest Surg 2019; 23: 58-66
• 15 Jirapinyo P, Slattery J, Ryan M. et al. Evaluation of an endoscopic suturing device for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass. Endoscopy 2013; 45: 532-536
• 16 Schulman AR, Kumar N, Thompson CC. Transoral outlet reduction: a comparison of purse-string with interrupted stitch technique. Gastrointest Endosc 2018; 87: 1222-1228
• 17 Högström H, Haglund U, Zederfeldt B. Suture technique and early breaking strength of intestinal anastomoses and laparotomy wounds. Acta Chir Scand 1985; 151: 441-443
• 18 de Moura EG, Orso IR, Aurélio EF. et al. Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2016; 12: 582-586