Endoscopic full-thickness suturing and argon ablation for GERD symptoms on patient post-1-anastomosis gastric bypass surgery. 1-anastomosis gastric bypass is a widely used bariatric procedure known for its simplicity and effectiveness. However, a significant challenge with OAGB is the risk of postoperative reflux, which can be due to bile or acid. Managing bile reflux often requires conversion to Roux-en-Y gastric bypass, a more complex surgical approach that addresses the bile issue but introduces its own potential complications. On the other hand, acid reflux following 1-anastomosis gastric bypass can often be attributed to a weak lower esophageal sphincter or a dilated remnant gastric fundus. These anatomical factors compromise the barrier function, allowing acid to flow back into the esophagus and causing reflux symptoms. Acid reflux can frequently be managed using endoscopic therapeutic procedures, offering a less invasive and effective alternative to Roux-en-Y gastric bypass for these cases. We propose a novel endoscopic procedure designed to reduce the size of the dilated gastric fundus, thereby minimizing food accumulation and reflux into the lower esophagus. This technique utilizes a dual-channel endoscope for full-thickness suturing, combined with mucosal ablation using an APC probe to enhance repair durability and promote effective healing in the resized area. A 55-year-old female, who underwent 1-anastomosis gastric bypass 5 years ago, presents with persistent heartburn and retrosternal chest discomfort, unable to sleep flat. Her current weight is 56 kg, with a BMI of 24. She has been on proton pump inhibitors for the past 4 years, but continues to experience symptomatic GERD. Diagnostic evaluations, including a gastrographin swallow, confirmed gastroesophageal reflux disease, while endoscopy and pH capsule studies revealed acid reflux associated with the dilated gastric fundus. After thorough discussion with the patient and the multidisciplinary team, a decision was made to proceed with a less invasive therapeutic approach. The patient opted for endoscopic management to address her symptoms. EGD, showing the anatomy of the patient's bariatric status. A dilated remnant gastric fundus, then gastric pouch measured approximately 18 cm in a tubular shape was observed. This finding was consistent with the anatomy of a 1-anastomosis gastric bypass, specifically with a loop anastomosis configuration. The procedure starts by marking the dilated proximal fundal area with APC. Then with precise mucosal ablation using APC all over the target dilated area of the gastric fundus. To minimize the risk of stenosis at the gastroesophageal junction, we carefully maintained a distance of 1 cm from the scope. This step was crucial to ensure safe and effective treatment outcomes. Following the ablation, we proceeded with full thickness suturing by using a double-channel endoscope. A U-shaped suturing technique was employed, multiple bites were taken along the outlet of dilated marked area followed by cinching in order to reduce the dilated proximal pouch. This step was performed with precision to achieve the desired gastric restriction while maintaining structural integrity. The ablation was performed using an APC argon plasma coagulation probe to enhance the healing process and durability of the full thickness sutured area providing a solid foundation for the resizing. Final look after cinching of the GE junction and dilated gastric pouch showing a significantly luminal reduction. Preoperative gastrographin on the left and three months post-endoscopic procedure on the right, which showed small-size gastric fundus. Three months later, she is off PPI and able to sleep without GERD symptoms. The patient was discharged on a standard post-bariatric diet following the procedure. Three-month follow-up, she reported complete resolution of heartburn without needing PPIs, significant improvement in postprandial pain, no further episodes of regurgitation, and the ability to sleep in a flat position. She lost only 4 kg in first two months, then maintained her weight, and her laboratory tests showed optimal nutritional status. Management of acid reflux post-OAGB The procedure specifically targets acid reflux, a common complication following 1-anastomosis gastric bypass, by addressing the anatomical and functional abnormalities contributing to the condition. Preservation of nutritional status By focusing on reducing reflux without altering the gastric bypass anatomy, the risk of unintended weight loss is minimized. Reduction in fundal remnant size Decreasing the size of the dilated gastric fundus mitigates food accumulation, thereby alleviating pressure and reflux symptoms. Enhanced durability of repair The combination of argon plasma coagulation and endoscopic full-thickness suturing ensures a robust and durable repair, promoting effective healing and long-term symptom control. In conclusion, the endoscopic approach to managing GERD in post-1-anastomosis gastric bypass patients demonstrates technical feasibility and offers a promising, minimally invasive solution. By reducing the size of the dilated gastric fundus and enhancing the durability of repair through a combination of APC and full-thickness suturing, this technique effectively addresses reflux symptoms while preserving the patient's overall anatomy and nutritional status. This method presents a valuable alternative to surgical interventions, particularly for patients seeking less invasive options. However, further studies are necessary to validate the safety, long-term efficacy, and overall outcomes of this novel technique.

endoscopic procedure

GERD management

gastric bypass

argon plasma coagulation

minimally invasive