endoscopic revision of gastric bypass using placation technique, an adjustable approach. Here are the author's disclosures. The reason why gastric bypass is one of the most commonly performed bariatric surgeries worldwide, despite initial success, up to one-third of patients regain their weight to their pre-bypass weight. A common cause for weight regain is the presence of a dilated and incompetent gastrojejunal anastomosis. We present a case of a 65-year-old woman with obesity and prior Roux-en-Y gastric bypass, who despite an initial weight loss of 70 pounds, regained to her pre-bypass weight at four years. Diagnostic upper endoscopy demonstrated the presence of a dilated and incompetent gastrojejunal anastomosis. She was subsequently referred for endoscopic revision of her gastric bypass. A dilated and incompetent gastrojejunal anastomosis can be seen here. First, argon plasma coagulation is applied in a circumferential pattern around the anastomosis. Argon plasma coagulation reduces bleeding and encourages healing and tissue fusion following the procedure. The placation device used for endoscopic revision of gastric bypass using the placation technique contains five notable components. The surgical endoscope includes three working channels and a channel for an ultra-slim endoscope. A helix allows for gripping tissue and bringing into the tissue approximator, which contains two jaws for tissue approximation. After the tissue approximator is closed, a needle is used to guide the needle catheter to deliver the anchors on either side of tissue folds. This allows for restriction of the gastric lumen both in the longitudinal and horizontal direction. The first placations are placed to reduce the outlet diameter. This requires insertion of the helix into the tissue surrounding the outlet. Once this occurs, the tissue approximator is advanced and opened within the pouch. The tissue approximator can be rotated to optimize the amount of gastric tissue restricted during each placation. Once situated, the helix is gradually withdrawn to bring the tissue within the jaws of the approximator prior to closure. Immediately following closure, the needle is advanced through tissue. Careful note of needle tip location prior to advancement of the first anchor is imperative to avoid deployment within the gastric wall or peritoneum. The needle is then withdrawn following deployment of the first tissue anchor, followed by removal of the helix to improve visualization. Once the suture is again visualized on the other side, the second anchor may be safely deployed. A cinch maneuver is used to approximate the two tissue anchors prior to cutting the suture. Second tissue placation is applied to the outlet prior to directing attention to gastric pouch restriction. The device operative pattern is demonstrated in the corner of the screen during this placation. One hand controls directionality of the tissue approximator jaws, while the second hand is used to draw tissue into the approximator using the helix. The tissue approximator is then closed, followed by downward displacement of the blue needle handle. Once the needle tip is confidently visualized in the gastric pouch lumen, the first anchor is deployed by further advancing the green catheter lever downward. The needle is then withdrawn by moving the blue needle lever upward. Once the suture is visualized on the opposite side of the tissue fold, the second anchor is deployed with downward deflection of the green lever until an audible click is heard. Cinching occurs with repeated upward deflections of the green lever. Following this, tissue slack is produced with loosening of the needle catheter, followed by cutting of the suture with the tissue approximator jaws. There were a total of eight tissue placations placed, of which two were placed to restrict the outlet, and an additional six placations were placed to restrict the gastric pouch. The final outlet can be seen here. Following the procedure, the patient experienced weight loss, however she also developed nausea, vomiting, and poor oral intake. As a result, repeat endoscopy was performed. This demonstrated the presence of fluid and retained food particles suggestive of gastric retention. First, a rescue net was used to remove the contents to optimize visualization. Inspection of the anastomosis showed stenosis not amenable to passage of a standard upper endoscope. Given the presence of symptoms and visualization of the stenosis, the decision was made to pursue balloon dilation to 7 millimeters. Generally, this is performed over wire guidance and held up to 60 seconds at maximal inflation. However, despite dilation, her symptoms persisted, and a follow-up endoscopy was pursued for placement of a 10-millimeter luminoposing metal stent through the outlet for more durable dilation. For deployment of the luminoposing metal stent, a wire is initially passed through the outlet. Following this, the distal flange is deployed, which expands radially within the small Following this, the distal flange is deployed, which expands radially within the small bowel. The device is then retracted to allow for expansion of the proximal flange within the gastric pouch lumen. Balloon dilation to 8 millimeters is then performed to assist in initial stent expansion. This results in clear visualization of the small bowel on the other side of the luminoposing metal stent traversing the gastrointestinal anastomosis. Following placement of the luminoposing metal stent, symptoms of nausea, vomiting, and abdominal pain resolved. The patient was maintained on a liquid diet with gradual advancement to soft food over a duration of six weeks prior to repeat endoscopy. Follow-up endoscopy showed a widely patent luminoposing metal stent across the gastrointestinal anastomosis. A rat tooth forceps was used to remove the stent with gradual traction to avoid breaking the proximal flange upon attempted removal. Repeat balloon dilation was then performed over wire using a through-the-scope fluid-filled balloon technique. Blanching of the mucosa at the anastomosis can be seen, suggesting effective dilation. Incremental dilation can be performed to avoid over-dilation, which can create weight regain. Tissue strength remains intact to reduce compliance from the original endoscopic revision. The anastomosis then accommodated passage of the upper endoscope using gentle pressure, and healthy-appearing jejunum was then visualized. The patient lost a total of 25 pounds, representing a 16% total weight loss, and correlating with a reduction in BMI from 35.7 to 29 at six months following her endoscopic revision. This case demonstrates that endoscopic revision of a gastric bypass using a plication technique is effective at inducing weight loss. GJA stenosis is a potential risk. However, this can be corrected with incremental balloon dilation and luminoposing metal stent placement. In conclusion, endoscopic revision of a gastric bypass using the plication technique is safe and effective at inducing weight loss. Management of stenosis should target removal of symptoms while avoiding over-dilation to achieve effective weight loss.

endoscopic revision

gastric bypass

plication technique

adjustable approach

bariatric surgery