Endoscopic submucosal dissection, transoral gastric outlet revision, a modified ESD TOR technique for weight regain. These are our disclosures. Weight regain is commonly encountered among gastroenterologists caring for patients with a history of Roux-en-Y gastric bypass. Despite Roux-en-Y being a highly effective weight loss surgery and improving many obesity-associated comorbid conditions, up to 25 to 30 percent of individuals may regain weight at 10 years. While a variety of factors may be associated with weight regain, including medical, behavioral, and psychological etiologies, anatomic breakdown of the Roux-en-Y gastric bypass, including dilation of the gastrojejunal anastomosis or development of a gastrogastric fistula, may also result in weight regain. Although surgical revision is one option for weight regain, these surgeries are associated with high complication rates and may be associated with significant morbidity. As such, endoscopic treatment options provide a less invasive approach and are excellent alternatives to surgical revision. These endoscopic gastric bypass revision procedures are less invasive and associated with a shorter hospitalization as well as a reduced morbidity compared to their surgical counterparts. Multiple studies and meta-analyses have examined endoscopic gastric bypass revisions and found level one evidence to support their use as a treatment for weight regain. More recently, five-year data has shown that transoral outlet reduction is associated with 8.8% total body weight loss at five years. The most common type of endoscopic gastric bypass revision is the transoral outlet reduction or TOR procedure. TOR involves use of argon plasma coagulation and a full thickness endoscopic suturing system. Traditionally, ABC is performed in a circumferential manner around the outlet prior to introduction of a full thickness suturing device. After ABC is completed, the suturing device is used to place sutures in an interrupted or pursed string pattern around the gastrojejunal anastomosis. More recently, we have devised a modified endoscopic submucosal dissection or ESD TOR technique to improve weight loss for patients with weight gain after Rheum Y gastric bypass. This innovative technique involves a submucosal lift followed by a submucosal dissection to expose the submucosa and muscular layers prior to ABC and suturing. This case involves a 61-year-old woman with class 2 obesity and a history of Rheum Y gastric bypass who presented to our multidisciplinary weight loss clinic with concern for weight regain. Her pre-bypass weight in 2001 was 240 pounds, with a post-bypass nadir of 140 pounds achieved within six months of surgery. Unfortunately, the patient developed progressive weight gain with current weight of 230 pounds corresponding to a BMI of 38.27. Despite aggressive lifestyle interventions including diet and formalized high-intensity exercise programs, the patient was unsuccessful at achieving sustained clinically significant weight loss and thus the decision was made to pursue an upper endoscopy and evaluation for endoscopic gastric bypass revision with a modified ESD TOR procedure. On initial diagnostic endoscopy, the patient was found to have a two centimeter pouch extending from 40 to 42 centimeters and a dilated gastrojejunal anastomosis that was greater than 25 millimeters in diameter. After close inspection of the gastrojejunal anastomosis and evaluation of the root limb, we are ready to begin the modified ESD TOR procedure. To accomplish this, we first use an injection needle to inject a solution of five percent head of starch mixed with dilute ebinephrine and methylene blue around the gastrojejunal anastomosis. This is done to lift the muscularis propria and inject circumferentially around the entire outlet to facilitate easier incision and dissection. Once the mucosa has been adequately lifted around the outlet, a dual injection and dissection ESD knife is used to dissect the lifted mucosa and expose the muscularis propria layer around the gastrojejunal anastomosis. We can see here in this video this ESD knife is used to circumferentially expose the submucosa of the gastrojejunal anastomosis with incision begun in a clockwise pattern. This is continued until a circumferential incision is made around the entire gastrojejunal anastomosis. Here we see complete incision circumferentially around the gastrojejunal anastomosis. Once this is accomplished, we then use an electrocautery ESD knife with insulated ceramic tip to trim the incision, expanding visualization of the deeper layers. If vessels are encountered, as shown here, we are able to prophylactically cauterize vessels to prevent future bleeding during the dissection process. Dissection is again continued as this is critically important to maximize exposure of the muscular layer to approximately one centimeter wide, which provides improved visibility for suturing in a purse string pattern. After expansion of the dissected mucosa, APC is performed at the inner margins to trim mucosa in a circumferential pattern with careful attention to avoid the dissected muscle layer. At our institution and during this procedure, APC is applied to the rim of the dissected mucosa using a forced APC setting delivering 70 watts at 0.8 liters per minute. After APC is performed, we then identify any visible vessels that remain and prophylactically treat them with the hemostatic forceps. This is demonstrated nicely in this video here. Next, an esophageal overtube is placed and then the gastroscope is exchanged to a double channel endoscope, which is attached to the full thickness suturing system. During this procedure, we begin our running purse string suture pattern in the five o'clock position and move circumferentially counterclockwise with each bite approximately four to six millimeters apart from the last. It is very important to start in the five o'clock position to ensure the cinch device is on the right and the balloon on the left. This ensures optimal visualization when cinching of the suture. Again, careful attention is made to ensure the lower end of the suturing device is buried within the exposed muscle layer and the upper end of the suturing device is on the adjacent side of the anastomosis to ensure an adequate full thickness bite. As we progress around the outlet, we eventually flip the device to ensure we perform the procedure in one running purse string suture pattern. During this modified ESD tour procedure, the suturing device was used to place 16 stitches into the tissue in a purse string fashion surrounding the anastomosis. The suture was then tightened and secured over a six millimeter budgie where you can see the significant reduction in outlet size after cinching has been performed. Finally, an additional two interrupted sutures were placed in the gastric pouch to reinforce and protect the purse string sutures. The patient was discharged home the following day without issue and a four-week follow-up reported a 22 pound weight loss. To briefly summarize, we successfully performed a modified ESD tour procedure in a patient with a two centimeter pouch and dilated gastrointestinal anastomosis greater than 25 millimeters. To accomplish this, we combined a modified semiposal dissection technique with traditional endoscopic gastric bypass revision procedure. These still images show the individual steps associated with the ESD tour procedure and nicely demonstrate the ability to significantly reduce the size of the gastrointestinal anastomosis. This modified submucosal dissection technique allows for a deeper level of tissue exposure, which translates to significantly improved weight loss compared to the traditional tour procedure. In a previous study, total body weight loss was 12.6% at 12 months. In summary, weight regain is incredibly common after Roux-en-Y gastric bypass, with this case demonstrated ESD tour to be a highly effective procedure resulting in clinically significant weight loss results. The entire procedure was accomplished in under 60 minutes and has the potential to replace the traditional tour procedure given improved weight loss and similar rate of adverse events. In conclusion, a modified ESD tour technique is feasible, safe, and highly effective. Combining submucosal dissection and suturing provides greater and more durable weight loss for patients with weight regain after gastric bypass.

endoscopic submucosal dissection

modified transoral gastric outlet revision

weight regain

Roux-en-Y gastric bypass

endoscopic treatments