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Transoral Outlet Reduction Post Roux-En-Y Gastric Bypass: Evaluation Of A Treatment Algorithm Using Two-Fold Running Sutures
ASMBS E-Poster Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S66–S226
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Average operative time was 105.6 ± 32.6 minutes with length of stay averaged 2.5 days (range, 1-5). 30-day readmission rates were 29% with no mortalities. 3 patients (18%) had anastomotic leak with 2 patients requiring reoperations. One patient required reoperation for bleeding. All patients healed with the use of fully covered endoscopic esophageal stents. 2 patients developed anastomotic stenosis 1 year after surgery that resolved with endoscopic dilations. One year follow up rates was 71%. 71% of all patients were off all PPI. 18% (n¼2/11) patients reported reflux symptoms. 100% of patients reported total resolution of symptoms. Post-operative endoscopy was performed selectively without recurrence of ulcer and all patients had no clinical recurrence of ulcer symptoms. Discussion: Revision of RYGB with total or near total pouch excision is curative for chronic marginal ulcers. The procedure carries high morbidity including major complications of leaks, as well as high risk for re-operation and post-discharge re-admission, even at a center with a large experience in RYGB revision. All leaks healed with use of esophageal covered stent and drainage.
A5215
TRANSORAL OUTLET REDUCTION POST ROUX-EN-Y GASTRIC BYPASS: EVALUATION OF A TREATMENT ALGORITHM USING TWO-FOLD RUNNING SUTURES Sindhu Barola1; Abhishek Agnihotri2; Christine Hill3; Margo K. Dunlap2; Saowonee Ngamruengphong1; Yen-I Chen2; Vikesh Singh1; Mouen A. Khashab2; Vivek Kumbhari4; 1Johns Hopkins Hospital, Richmond VA; 2Johns Hopkins Hospital, Baltimore MD; 3Johns Hopkins Univ Bloomberg School, Newark DE; 4Johns Hopkins Medical Instutions, Baltimore MD Background: Endoscopic suturing plus argon plasma coagulation (ES-APC) of the gastrojejunal outlet (GJ) is not always reimbursed for transoral outlet reduction (TORe). Further, it is unknown whether TORe via ES-APC as a single procedure is effective in achieving an outlet diameter o12mm at follow-up. Aims: To assess: (a) the technical feasibility and durability performing TORe with a two-fold running technique and, (b) clinical outcomes in patients undergoing TORe using a treatment algorithm that caters to the restrictions of reimbursement. Method: Patients who presented between August 2015 and March 2017 with weight gain post-RYGB, and EGD showing GJ diameter ≥20mm, were retrospectively analyzed. Patients whose insurance declined prior authorization for ES-APC of the outlet underwent APC alone. Patients in the ES-APC group underwent TORe using a novel two-fold running suture technique leaving an outlet diameter of 8mm. Follow-up EGD was performed at 8 weeks to assess GJ diameter and to perform APC if GJ diameter was ≥12mm (Figure 1). Technical success and efficacy (% BMI loss) were assessed. We used a validated self-assessment questionnaire, the Dumping Symptom Rating Scale (DSRS) pre and post completion of the treatment algorithm. Results: Thirty-three patients (30F) were included. The average time to TORe was 8.4±3.5 years after RYGB. Patients had
regained a mean of 41.6±20.2 % of lost weight before undergoing TORe. Twenty-two patients (66.7%) gained insurance approval and underwent ES-APC. The remainder underwent APC alone. The technical success of ES was 100%. Fifteen of the ES-APC cohort (65%) underwent follow-up EGD at 8 weeks, of which 13 (86.7%) with GJ ≥12 mm underwent further APC and 2 (15.4%) developed gastric stenosis, which was treated with balloon dilation (Table 1). Mean BMI significantly reduced post-TORe (8.84 ± 8.97%, Po0.001) at a mean follow-up of 6.03 ± 0.38 months. Mean % reduction in BMI post-TORe was similar in patients who underwent ES compared to APC (9.33±10.11% vs 8.20±6.42%, P¼0.3). Mean reduction in DSRS score is 9.63 ± 10.84 (Pre TORe Vs Post TORe 22.48; 15.06) Conclusion: Despite using the two-fold running suture TORe, further intervention using APC was necessary to get the diameter of the GJ to o12mm. This study highlights the necessity for follow-up endoscopic reassessment. APC alone is a viable strategy in patients not approved for endoscopic suturing.
A5216
MODELING SUTURE PATTERNS FOR ENDOSCOPIC GASTROJEJUNOSTOMY REVISION: ANALYZING A TECHNIQUE TO ADDRESS WEIGHT REGAIN AFTER GASTRIC BYPASS Herbert Hedberg1; Alexander Trenk1; Stephen Haggerty3; John Linn3; Woody Denham1,2,3; Michael Ujiki3; 1University of
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Average operative time was 105.6 ± 32.6 minutes with length of stay averaged 2.5 days (range, 1-5). 30-day readmission rates were 29% with no mortalities. 3 patients (18%) had anastomotic leak with 2 patients requiring reoperations. One patient required reoperation for bleeding. All patients healed with the use of fully covered endoscopic esophageal stents. 2 patients developed anastomotic stenosis 1 year after surgery that resolved with endoscopic dilations. One year follow up rates was 71%. 71% of all patients were off all PPI. 18% (n¼2/11) patients reported reflux symptoms. 100% of patients reported total resolution of symptoms. Post-operative endoscopy was performed selectively without recurrence of ulcer and all patients had no clinical recurrence of ulcer symptoms. Discussion: Revision of RYGB with total or near total pouch excision is curative for chronic marginal ulcers. The procedure carries high morbidity including major complications of leaks, as well as high risk for re-operation and post-discharge re-admission, even at a center with a large experience in RYGB revision. All leaks healed with use of esophageal covered stent and drainage.
A5215
TRANSORAL OUTLET REDUCTION POST ROUX-EN-Y GASTRIC BYPASS: EVALUATION OF A TREATMENT ALGORITHM USING TWO-FOLD RUNNING SUTURES Sindhu Barola1; Abhishek Agnihotri2; Christine Hill3; Margo K. Dunlap2; Saowonee Ngamruengphong1; Yen-I Chen2; Vikesh Singh1; Mouen A. Khashab2; Vivek Kumbhari4; 1Johns Hopkins Hospital, Richmond VA; 2Johns Hopkins Hospital, Baltimore MD; 3Johns Hopkins Univ Bloomberg School, Newark DE; 4Johns Hopkins Medical Instutions, Baltimore MD Background: Endoscopic suturing plus argon plasma coagulation (ES-APC) of the gastrojejunal outlet (GJ) is not always reimbursed for transoral outlet reduction (TORe). Further, it is unknown whether TORe via ES-APC as a single procedure is effective in achieving an outlet diameter o12mm at follow-up. Aims: To assess: (a) the technical feasibility and durability performing TORe with a two-fold running technique and, (b) clinical outcomes in patients undergoing TORe using a treatment algorithm that caters to the restrictions of reimbursement. Method: Patients who presented between August 2015 and March 2017 with weight gain post-RYGB, and EGD showing GJ diameter ≥20mm, were retrospectively analyzed. Patients whose insurance declined prior authorization for ES-APC of the outlet underwent APC alone. Patients in the ES-APC group underwent TORe using a novel two-fold running suture technique leaving an outlet diameter of 8mm. Follow-up EGD was performed at 8 weeks to assess GJ diameter and to perform APC if GJ diameter was ≥12mm (Figure 1). Technical success and efficacy (% BMI loss) were assessed. We used a validated self-assessment questionnaire, the Dumping Symptom Rating Scale (DSRS) pre and post completion of the treatment algorithm. Results: Thirty-three patients (30F) were included. The average time to TORe was 8.4±3.5 years after RYGB. Patients had
regained a mean of 41.6±20.2 % of lost weight before undergoing TORe. Twenty-two patients (66.7%) gained insurance approval and underwent ES-APC. The remainder underwent APC alone. The technical success of ES was 100%. Fifteen of the ES-APC cohort (65%) underwent follow-up EGD at 8 weeks, of which 13 (86.7%) with GJ ≥12 mm underwent further APC and 2 (15.4%) developed gastric stenosis, which was treated with balloon dilation (Table 1). Mean BMI significantly reduced post-TORe (8.84 ± 8.97%, Po0.001) at a mean follow-up of 6.03 ± 0.38 months. Mean % reduction in BMI post-TORe was similar in patients who underwent ES compared to APC (9.33±10.11% vs 8.20±6.42%, P¼0.3). Mean reduction in DSRS score is 9.63 ± 10.84 (Pre TORe Vs Post TORe 22.48; 15.06) Conclusion: Despite using the two-fold running suture TORe, further intervention using APC was necessary to get the diameter of the GJ to o12mm. This study highlights the necessity for follow-up endoscopic reassessment. APC alone is a viable strategy in patients not approved for endoscopic suturing.
A5216
MODELING SUTURE PATTERNS FOR ENDOSCOPIC GASTROJEJUNOSTOMY REVISION: ANALYZING A TECHNIQUE TO ADDRESS WEIGHT REGAIN AFTER GASTRIC BYPASS Herbert Hedberg1; Alexander Trenk1; Stephen Haggerty3; John Linn3; Woody Denham1,2,3; Michael Ujiki3; 1University of