Endoscopy 2019; 51(07): 617-618
DOI: 10.1055/a-0894-4457
Editorial
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic full-thickness transoral outlet reduction with endoscopic submucosal dissection or argon plasma coagulation: does it make a difference?

Referring to Hollenbach M et al. p. 684–688
Simon Kin Hung Wong
Upper Gastrointestinal and Metabolic Surgery Division, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
› Author Affiliations
Further Information

Publication History

Publication Date:
27 June 2019 (online)

Obesity continues to be a major and growing health concern globally. Bariatric surgery has been recognized as the most effective method to achieve weight reduction and an improvement in comorbidities. According to the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) worldwide survey [1], there has been a 50 % increase in the number of bariatric surgeries from 2013 to 2016 and approximately a third of these procedures are Roux-en-Y gastric bypasses (RYGBs). However, 20 % – 30 % of bypass patients will experience significant weight regain in the years following their nadir weight loss, which poses a difficult challenge for both surgeons and patients. While the factors leading to weight regain are complex, anatomically a dilated (> 10 mm) gastrojejunal anastomosis (GJA) has been shown to be a major factor in weight regain [2]. Surgical revision with either a restrictive and/or a malabsorptive component can achieve more weight reduction compared with endoscopic revision. However, surgical revision is technically more difficult and associated with high morbidity, with the reported rate of major complications ranging from 9 % to 44 % [3].

Endoscopic revision of a dilated stoma has been increasingly used as a less invasive option to revisional surgery. The techniques used for endoscopic revision have evolved with the technology over the past decade, and include: sclerotherapy; argon plasma coagulation (APC); and transoral outlet reduction (TORe) using a plication device (such as the stomaphyX or G-Prox device), a suturing device (OverStitch), or an over-the-scope clip (OTSC; Ovesco). In a recent review of different endoscopic techniques for stoma reduction [4], analysis showed that the 1-year weight losses were significantly higher in the patients who underwent endoscopic full-thickness transoral outlet reduction (efTOR) with suturing combined with APC (mean 10.6 kg; 7 studies, 320 patients) when compared with suturing alone (mean 5.7 kg; 19 studies, 828 patients).

“At the moment, this study cannot demonstrate a significant weight loss difference with the ESD-efTOR technique.”

To date, efTOR using the Apollo OverStitch has been the most widely adopted endoscopic revision method, with interrupted figure-of-eight or purse-string stitches being placed transmurally at the anastomosis using the suturing device. Vargas et al. reported that the average weight loss at 12 months after efTOR was 7.75 kg with 67 % of patients achieving > 5 % of total body weight loss [5]. Hedberg et al. also reported that efTOR after APC provided significantly greater weight loss at 2 years compared with medical management with psychologist and dietitian counselling alone [6]. The purpose of adding APC before efTOR is to achieve a deeper submucosal-to-submucosal tissue apposition, which provides stronger bonding at the suture site. This reflects the importance of a durable stoma restriction in maintaining weight loss after TORe.

In this issue of Endoscopy, Hollenbach et al. report the results of 15 patients who underwent efTOR after a semicircumferential endoscopic submucosal dissection (ESD-efTOR) and retrospectively compare the outcome with 26 patients who underwent the traditional efTOR after APC (APC-efTOR) [7]. The authors report that the ESD-efTOR technique resulted in significantly fewer ruptured sutures and a greater reduction in GJA 3 months after treatment. They propose that direct submucosal contact after ESD can lead to stronger tissue adherence and cicatrization.

Despite this novel technique appearing better than the traditional APC-efTOR, we must interpret the result with caution. Apart from the bias in experience of endoscopic suturing and lack of objective assessment of stoma size, the time interval for endoscopic reassessment of the two groups is not stated. The APC-efTOR group had a relatively longer follow-up duration, which raises the possibility of a difference in the timing of the assessment. Nevertheless, only 20 % of patients had significant downsizing of the GJA (> 50 %) in ESD group and none in APC group, and there was no additional weight loss achieved using ESD-efTOR. Additionally, the extent of GJA reduction in this series seems to be less than with other techniques. Patel et al. performed purse-string suturing after APC and, when compared with interrupted suturing, purse-string suturing produced a greater percentage of stoma reduction (87.2 % vs. 72.8 %) and a trend toward greater weight loss at 1 year [8].

There are two main challenges in endoscopic stoma reduction: the degree of technical difficulty, and recurrent dilation of the GJA after TORe, with the former relating to the complexity of the technique and the skill of the endoscopist. ESD is an advanced endoscopic therapy for early gastrointestinal cancer, which is technically more challenging and carries a higher risk of bleeding and perforation, which occurred in the authors’ series. The idea of promoting stronger tissue adherence by adding ESD is good, but should not be offset by increasing the morbidity of efTOR. Moreover, the durability of the weight loss effect after efTOR is another important outcome and disruption of a previously repaired stoma plays an important role in the failure of revision.

At the moment, this study cannot demonstrate a significant weight loss difference with the ESD-efTOR technique. We look forward to the long-term outcome of this study and, in conjunction with a robust lifestyle and behavioral intervention program, I believe that TORe offers an effective management strategy for weight regain after RYGB in a select group of patients with a dilated GJA. Perhaps in future, a better-designed comparative study can prove that this new technique is superior to the traditional stoma revision methods in maintaining weight loss after TORe.

 
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