Endoscopic revision of bariatric surgery: expanding the toolbox

The World Health Organization report published in February 2018 indicated that obesity rates have tripled since 1975. With this unabated obesity pandemic, it is not surprising that the number of bariatric surgical procedures continues to increase. According to the International Federation for the Surgery of Obesity and Metabolic Disorder 4th global registry report, the number of bariatric operations is estimated at 394 421 globally [1]. The two most common operations are laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB), representing 46 % and 38 % of operations, respectively [1].

“...these two studies add to the mounting evidence that supports the use of endoscopic techniques as an adjunct to lifestyle, behavioral, and pharmacologic interventions to manage weight regain after bariatric surgery.”

Another insightful trend gleaned from the published bariatric surgery registry data is that of revision bariatric operations, which have more than tripled since 2011, and currently represent 15.4 % of all bariatric operations in the United States. It is estimated that 10 % – 30 % of patients undergoing LSG and RYGB operations will have suboptimal weight loss or experience significant weight regain in the long term, highlighting the chronic relapsing nature of obesity and cautioning against a mass treatment trap, where the cost and risks of invasive treatment options, such as revision bariatric surgery are amplified when indiscriminately applied. Indeed, both morbidity and weight loss outcomes of revision LSG and RYGB operations are inferior to the primary procedures. This is not surprising given the technical challenges of revision bariatric surgery, which include distorted surgical planes and anatomic changes [2] [3].

In this issue of Endoscopy, two endoscopic management options for weight regain after RYGB and LSG are reported. In the first paper, Fayad et al. report on the novel use of an endoscopic cryoablation balloon that relies on the use of a cryogen to cause circumferential superficial mucosal layer ablation, resulting in fibrosis and a reduction in the diameter of the gastrojejunal anastomosis (GJA) and the volume of the gastric pouch [4]. The authors applied this treatment modality in 22 patients and achieved technical success in 89.5 % of the cohort, with a decrease in GJA diameter of 7 mm (30 % from baseline) and a decrease in the length of the gastric pouch of 1.1 cm (22 % from baseline); total body weight loss (TBWL) at 8 weeks was 8.1 % (standard deviation [SD] 12.8). This approach could represent a less invasive and more cost-effective option for weight regain after RYGB, compared with the standard technique that utilizes argon plasma coagulation and endoscopic suturing. However, significant limitations will need to be addressed before clinical use is recommended. First, only 2.5 % of patients reached the optimal desired GJA diameter of 10 mm [5], with the post-procedural GJA diameter being 17.1 mm (95 % confidence interval 13.1 – 21.1). Second, the rate of serious bleeding adverse events requiring blood transfusion was 9 %, which is higher than the standard approach [6]. Finally, conclusions about efficacy should be guarded given the limited 8-week follow-up period and the highly heterogeneous weight loss outcomes, as demonstrated by a SD value that exceeded the mean TBWL. Successful adoption of this technique will require careful patient selection to include patients with smaller GJA diameters, demonstration of the safety of the repeated cryoablation sessions that are likely to be required to reach an adequate reduction in GJA, and the provision of long-term weight loss and safety data as reported for the standard technique of argon plasma coagulation and full-thickness endoscopic suturing [7].

In the second paper, de Moura et al. report on the use of an endoscopic sleeve gastroplasty (ESG) technique to reduce the volume of LSG as a management strategy for weight regain [8]. This has been reported previously by Eid et al. in a small number of patients [9], but the de Moura paper represents the first multicenter experience with the technique, demonstrating excellent %TBWL of 13.2 % (SD 3.9) and 18.3 % (SD 5.5) at 6 and 12 months, respectively. Interestingly, this weight loss is analogous to ESG as a primary weight loss procedure and offers important physiologic insights that make this revision option very appealing. There is a divergent impact of ESG and LSG on gastric physiology. It has been shown that faster gastric emptying time after LSG and longer delays after ESG are associated with greater weight loss [10]. After LSG, the proximal portion of the stomach and the majority of the greater curvature are resected, reducing ghrelin production, reducing stomach accommodation, increasing intraluminal pressure, and promoting early nutrient delivery to the intestine and changes in bile acid metabolism to promote weight loss. As with any weight loss intervention, diminishing physiologic response ensues over time as a result of a robust counter-regulatory compensatory mechanism. Thus, it is intriguing to speculate that with LSG to ESG revision, we are targeting a new physiologic restrictive gastric pathway not previously activated by LSG alone, explaining the robust response. It is important to acknowledge the multiple limitations of this study, including its small sample size distributed across 12 centers, lack of standardized ESG technique, different follow-up intensities among sites, and lack of reporting on adjunct behavioral interventions or weight loss medication use. Future larger retrospective and prospective studies will be required to confirm the generalizability of these findings.

In conclusion, these two studies add to the mounting evidence that supports the use of endoscopic techniques as an adjunct to lifestyle, behavioral, and pharmacologic interventions to manage weight regain after bariatric surgery. As the toolbox of endoscopic bariatric offerings continues to expand, it is important to emphasize important constants that are agnostic to any endoscopic intervention or technology for management of weight regain after bariatric surgery. First, factors leading to weight regain after bariatric surgery are complex and include behavioral, genetic, and anatomical components; thus, the intervention should be multifaceted and administered by a multidisciplinary team with expertise in nutrition, psychology, and use of weight-loss medications. Second, early intervention before patients regain significant weight yields better outcomes. Finally, standardization of the endoscopic technique and appropriate training are important to reproduce the results reported in clinical trials.

Publication History

Article published online:
25 February 2020

• References

• 1 The International Federation for the Surgery of Obesity and Metabolic Disorders. The IFSO Global Registry. Available from: https://www.ifso.com/pdf/4th-ifso-global-registry-report-last-2018.pdf
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