Gastroplasty with endoscopic myotomy is a revision procedure after weight regain following remote endoscopic sleeve gastroplasty. Obesity is a rapidly growing epidemic in the United States and worldwide. Recently endovariatric procedures have grown in popularity, such as endoscopic sleeve gastroplasty or ESG. Post-ESG weight regain can occur due to suboptimal lifestyle compliance, suture dehiscence, and or gastric sleeve dilatation. Gastroplasty with endoscopic myotomy, or GEM, is a novel endoscopic procedure that involves a pylorus-bearing antramyotomy via a submucosal tunneling technique and a suture-based gastric volume reduction. We present a case of GEM notably used as a revision procedure after ESG. This GEM utilized a unique suture technique called Modify U. Shown here is a diagram of three different suturing patterns used in GEM, with the sutures going in numerical order. The Modify U is a variation of the conventional U pattern, with more sutures. A 52-year-old male with class 1 obesity presented with weight regain 7 years after his original ESG. ESG was performed in 2016 for treatment of obesity. The weight at the time was 245 pounds, or a BMI of 31.5. After ESG, the weight decreased to 210 pounds with improvement in liver enzymes. He returned in 2023 with a weight of 267 pounds, or a BMI of 34.3, and elevated liver enzymes. At the time, various revision options were discussed with the patient, including pharmacotherapy, repeat ESG, or GEM. The decision was ultimately made to proceed with a GEM. Prior suture sites were appreciated, and the stomach was large in volume. Initial mapping of the suture sites was done by argon plasma coagulation. The antramyotomy was started with a blood injected 8 cm proximal to the pylorus, followed by a hybrid knife incision to create the submucosal tunnel. The submucosal space was dissected up to 1 cm prior to the pylorus, and a 6 cm partial full thickness myotomy was performed with lysis of significant submucosal fibrosis. After lavage with topical gentamicin, the mucosal entry site was closed with one suture. The gastroplasty portion of the procedure was then started, by placing a linear stitch to oppose the anterior and posterior stomach to reduce tension on the mucosotomy closure site. Eight suture bites were performed in a running modified U-pattern. The stitching pattern was repeated, from distal to proximal. A total of four sutures were utilized to further decrease gastric volume and to create the central length of the sleeve.

Gastroplasty with Endoscopic Myotomy

GEM procedure

Endoscopic Sleeve Gastroplasty revision

Modify U suture pattern

Pylorus-bearing antramyotomy