Demonstration of transoral gastric outlet reduction: 2-fold running suture technique.

Weight regain after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of the RYGB. Endoscopic revision of a dilatated GJ, called transoral outlet reduction (TORe), has been proved effective and allows patients to avoid reoperation. A 43-year-old woman who had undergone gastric bypass 3 years previously regained 40% of her lost weight, lost postprandial satiety, and had symptoms of dumping syndrome. Endoscopy revealed a dilatated (30 mm) GJ anastomosis (Fig. 1A). Video 1 (available online at www.VideoGIE.org) demonstrates a 2-fold running suture method, a novel method to perform TORe. Before endoscopic suturing, we performed aggressive argon plasma coagulation therapy to the gastric side of the gastric outlet to devitalize the tissue (Fig. 1B). Eight bites were taken in a circumferential manner around the anastomosis, with the initial bite traveling from the jejunal side to the gastric side. The T-tag was dropped without cinching. An identical suture pattern was performed (Fig. 1C) without removing the endoscope, and then the T-tag was dropped. A dilation balloon was inserted through the stoma and was inflated to 8 mm. In a sequential manner, each suture was cinched over the balloon, so the stoma was 8 mm in diameter. At her 12-week follow-up visit, the patient had lost 20% of her gained weight and was experiencing postprandial satiety without any symptoms of dumping syndrome. Repeated endoscopy revealed a well-healed scar and a GJ diameter maintained at 8 mm (Fig. 1D).

Figure 1

A, Endoscopic view showing dilatated gastrojejunostomy. B, Endoscopic view after tissue around the gastric outlet was devitalized. C, Endoscopic view immediately after completion of the procedure. D, Endoscopic view 12 weeks after the procedure.

Disclosure

Dr Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook Medical. Dr Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery. All other authors disclosed no financial relationships relevant to this publication.