Transoral antirefluxplication for new-onset refractory GERD following laparoscopic sleeve gastroplasty. New-onset gastroesophageal reflux disease following laparoscopic sleeve gastroplasty is a challenging entity with very limited treatment options available. Risk of Barrett's esophagus is high at 5%, with accumulative long-term risk for esophageal cancer if untreated. Surgical conversion to Roux-en-Y remains the only treatment for GERD refractory to optimal medical therapy. Here we present a new minimally invasive approach for post-LSG GERD. A 54-year-old female with BMI 40.4 status post-LSG, diabetes, and hyperlipidemia presented with severe new-onset reflux symptoms and a 50-pound weight regain over the past two years. GERD symptoms persisted despite optimized PPI use combined with dietary and lifestyle modifications. Upper endoscopy revealed erosive esophagitis and dilated gastric pouch, with abnormal pH study confirming persistent GERD while on PPI. We proceeded with endoscopic revision in a transoral antirefluxplication technique. Endoscopic exam showed evidence of prior sleeve gastrectomy with significantly enlarged gastric lumen. Grade 1a erosive esophagitis was also noted. First we performed endoscopic revision of gastric sleeve. Four sutures were used with the end result of reduced gastric lumen. Following, we proceeded with antirefluxplication. Here is an illustration overview of the steps of this technique. Submucosal injection of saline mixed with methylene blue was made at approximately 4 cm distal to the GE junction. Afterwards, a semicircumferential transverse mucosal incision was made with a high-pressure ESD knife with adequate exposure of the submucosal layer. Endoscopic suturing was then performed using a dual-channel endoscope and a suturing device. Helix was used to ensure full thickness involvement of the muscle layer. Repetitive stitches were made along the incision. This was followed by a second reinforcement suture. Finally, a cinch was used to tighten and cut the sutures. Here is the anti-refluxplication, and here is the neofundus created to reduce acid reflux. We strategically scheduled a pH study four weeks after our TARP procedure to assess the technique's impact on GERD, eliminating confounding effects of subsequent weight loss. The results showed a complete quantitative resolution of the patient's acid reflux, with a post-procedural Demester score of 1.9 on day 2, on now-effective PPI therapy. TARP is a novel technique that improves GERD symptoms in patients with post-LSG anatomy. This approach can be combined with endoscopic revision for weight regain due to dilated gastric pouch. Future research will be essential to assess the long-term viability of our findings.

Transoral antirefluxplication

GERD treatment

minimally invasive

endoscopic revision

post-surgical complications