Endaloop-assisted transoral outlet reduction as a novel and cost-effective treatment for weight regain after Rouen Y gastric bypass. These are our disclosures. Transoral outlet reduction, or TOR, is currently the standard endoscopic procedure for patients with weight regain after Rouen Y gastric bypass. However, the procedure itself has certain limitations, including the costly equipment, the device is not widely available, and endosuturing requires a high level of expertise. Here we describe a novel technique called endaloop-assisted transoral outlet reduction using a readily available, non-technically demanding, and economical accessories in order to increase the accessibility of bariatric endoscopy in socioeconomic-challenged patients. Here are the step-by-step descriptions of the procedure, starting similarly to the full thickness suturing of transoral outlet reduction. We start off using by arcane plasma coagulation over the gastrointestinal anastomosis. An endaloop was then placed over the aperture of the anastomosis. Then endoclips were used to fix the endaloop along the anastomosis. The endaloop can then be closed over a 6mm hurricane balloon to close and reduce the size of gastrointestinal anastomosis. Here is an endoscopic finding of a 36-year-old male patient with known morbid obesity class 3 post Rouen Y gastric bypass for 5 years. He has now regained weight from 140kg to 157kg. As you can see here, the gastrointestinal anastomotic aperture was widely open of more than 3cm in size. We then use arcane plasma coagulation to ablate the mucosa along the gastrointestinal anastomosis. After ablation, we prepare the endaloop system to be placed over the anastomosis. This step can be done outside the patient with a hemoclip placed inside the accessory channel. The clip was then opened to grasp the tip of the endaloop. The loop was then closed and the loop itself was placed outside of the gastroscope. This system is then intubated into the patient's stomach. Once the endaloop is placed inside the stomach, it was opened along the curvature of gastrointestinal anastomosis. The clip was then placed to fix the endaloop to the ablated mucosal tissue along the anastomosis. Note that we used 16mm hemoclips as we believe that by applying a long-pronged clip, we could perform a deep submucosal suturing inducing the deep fibrosis at the muscularis propria layer and deep submucosa. Theoretically, this would be more effective than the suction-based superficial suturing. Once the clips were placed circumferentially along the anastomosis, the endaloop is then closed. By using 8-9 clips, this ensures the reduced tension of the endaloop. The process of endaloop closure in a purse-string manner is being done over a 6mm hurricane balloon. This helps standardize the final diameter of the gastrointestinal anastomosis after closure. At 3 months after the procedure, a gastroscopy showed markedly reduced gastrointestinal anastomosis to the size of less than 9mm. The gastroscope could not traverse this area, while the patient has achieved 10.5% total weight loss and 21% excess weight loss, confirming both technical and clinical success of the procedure. We performed a retrospective analysis of prospectively maintained database on post-Ruangwai gastric bypass patients with weight regain who underwent endaloop assistatory. A cross-matched cohort in 1-2 ratio were comparison control group. The results have been promising. At 3-month follow-up, we found that patients in endaloop-assisted transoral outlet reduction group had significantly higher excess weight loss, excess BMI loss, and excess total weight loss compared to those who received only physician-directed lifestyle modification. In conclusion, endaloop-assisted transoral outlet reduction is a safe and effective endoscopic procedure for Ruangwai gastric bypass patients with weight regain. Its key advantages include, one, affordability with a cost of less than 10% of the conventional full thickness suturing method. Two, accessibility as the required accessories were mostly available in many endoscopy unit. And lastly, generalizability as the procedure is not technically demanding. However, due to its novelty, long-term weight reduction efficacy remains to be determined.

endaloop-assisted transoral outlet reduction

weight regain

Rouen Y gastric bypass

arcane plasma coagulation

gastrointestinal anastomosis