ENDOSCOPIC VERSUS SURGICAL TREATMENT OF WEIGHT REGAIN FOLLOWING SLEEVE GASTRECTOMY

Introduction:
Weight regain following sleeve gastrectomy (SG) is not uncommon. This condition is often treated with surgical re-sleeve (SRS) or conversion to Roux-en-Y gastric bypass (SG-GB), especially for patients with concomitant acid reflux. More recently, endoscopic revision of SG, also known as sleeve-in-sleeve (SIS), has emerged as a less invasive treatment alternative. This study aims to compare endoscopic versus surgical management approaches for patients experiencing weight regain following SG.

Methods:
This was a retrospective study of patients with SG who underwent SIS or SRS/SG-GB. SIS: An endoscopic plication system was used to place plications in the sleeve body to reduce its volume. SRS/SG-GB: During SRS, the redundant fundic remnant and sleeve body proximal to the incisura was resected vertically to reduce its volume. During SG-GB, the sleeve was resected horizontally to create a pouch, prior to creation of the Roux limb, jejunojejunal anastomosis and gastrojejunal anastomosis. Outcomes included technical feasibility, efficacy reported using percent total weight loss (%TWL) at 6 and 12 months, and safety graded using the ASGE adverse event lexicon in the two groups.

Results:
153 SG patients were included. Of these, 70 (46%) underwent SIS and 83 (54%) underwent SRS/SG-GB. Baseline characteristics are summarized in Table 1. Technical Feasibility: Technical success was 100% in both groups. SIS: A total of 12±4 plications were placed per case. The sleeve body length was shortened by 49%. SRS/SG-GB: Of the 83 patients, 34 (41%) underwent SRS and 49 (59%) underwent SG-GB. For SRS, the most common Bougie sizes were 38 Fr (66%), 40 Fr (28%) and 36 Fr (6%), respectively. Efficacy: At 6 and 12 months, the amount of weight loss was similar between the SIS and SRS/SG-GB groups (6 months: 12.3±6.8% vs 12.8±8.3% TWL, p=0.67; 12 months: 12.4±9.7% TWL vs 12.7±10.8% TWL, p=0.91) (Figure 1). Safety: The SAE rate was higher in the SRS/SG-GB group compared to the SIS group (13% vs 0%; p=0.005) (Figure 1). Specifically, the SAEs in the SRS/SG-GB group included fluid collections (x3), small bowel/anastomotic obstruction (x3), internal hernia (x3), leaks (x2), ventral hernia (x1), and incisional hernia (x1). All were treated with a re-operation or percutaneous drainage. The hospital length of stay was longer in the SRS/SG-GB group compared to the SIS group (2.2±2.7 days vs 1.5±0.9 days, p=0.03).

Conclusion:
Endoscopic sleeve-in-sleeve appears to be associated with similar weight loss compared to surgical re-sleeve and sleeve conversion to RYGB, with a better safety profile.