PLEDGET REINFORCEMENT OF ENDOSCOPIC SLEEVE GASTROPLASTY

Background: Malnutrition is a complication of Roux-en-Y gastric bypass (RYGB) and can range from micronutrient deficiencies to protein-calorie malnutrition. Malignant neoplasms and certain surgical complications can increase this risk. Surgical reversion of RYGB can be associated with increased morbidity and mortality.

Case Presentation: A 59-year-old female with a history of a RYGB for obesity and protein-calorie malnutrition (49 kgs, BMI of 16 kg/m2) was admitted with septic shock secondary to intra-abdominal abscesses due to a dislodged percutaneous endoscopic gastrostomy (PEG) placed for management of failure to thrive. She underwent exploratory laparotomy with G-tube removal, gastric wedge resection, J-tube insertion, and vacuum-assisted closure (VAC). Her course was complicated by the inadvertent removal of her J-tube. Given non-surgical candidacy for surgical reversion and previous complications, the patient opted to undergo an endoscopic reversal of her RYGB.

Endoscopic Methods: During stage 1 of her procedure, an endoscopic ultrasound (EUS)-guided gastrogastrostomy using a 20x10 mm cautery-enhanced LAMS was performed thus creating a gastric-gastric (G-G) access. The LAMS was dilated up to 18 mm. Visual confirmation of the remnant stomach was obtained. Two weeks after the index procedure, no gross lesions were noted in the remnant stomach and excellent apposition of the LAMS was noted. Thus, we decided to complete the endoscopic reversion of her RGYB by using a transoral outlet occlusion (TORO) technique. First, a 1.5-2 cm circumferential area of mucosal tissue at the gastrojejunal anastomosis (GJA) rim was ablated using straight fire argon plasma coagulation (APC; forced APC, flow of 0.8 L/min, power of 70 W). Afterward, we loaded an endoscopic suturing system in a dual-channel scope and a single 2.0 nonabsorbable polypropylene suture was then used to place multiple full-thickness stitches around the GJA in a running fashion. The suture was then cinched and complete closure of the GJA was achieved. She had no post-procedural complications and was discharged on BID open-capsule PPI, QID liquid sucralfate, and an antiemetic regimen. At a 2-week post-procedure follow-up, the patient continues to do well with an excellent appetite and weight regain of 3.5 kgs.

Clinical Implications: There is a paucity of data on endoscopic reversion of RYGB aiming at a partial reversion of the RYGB with no targeted therapy for the GJA which can help prevent the bypass of the oral intake of these patients and thus potentially improve nutritional parameters.

Conclusion: Combined EUS-guided gastrogastrostomy and the TORO technique for the endoscopic reversion of a Roux-en-Y gastric bypass (RYGB) appears to be technically feasible in patients with failure to thrive after RYGB. Larger studies are necessary to examine long-term efficacy and safety in this population.

Background
Endoscopic sleeve gastroplasty (ESG) is an effective weight loss procedure that uses endoscopic suturing to reduce gastric volume. For a proportion of patients, weight regain occurs and is associated with suture loss. Suture loss is a complex process affected by the forces experienced at the interface of the mucosa and suture. Based on follow up endoscopy studies, suture failure appears to involve both breakdown of the gastric mucosa, suture material deformation, and erosion of the tissue anchors through the gastric wall. Pledgets are flexible pads used during approximation of delicate tissues to spread forces along a suture line without needing to reduce suture tension. To reduce the likelihood of suture failure, we developed a technique to place surgical pledgets endoscopically to distribute forces at the tissue anchor/gastric mucosal interface.

Case Presentation
A 31 year old female with a history of obesity (BMI 37.8) refractory to lifestyle modification and GLP-1 agonist therapy as well as diabetes and fatty liver disease elected to undergo ESG after consideration of bariatric surgery and further medication trials. The procedure was uncomplicated, and she was discharged the same day with minimal pain and nausea. She underwent standard follow up and diet progression. At one month follow up she had lost 8% of her total body weight.

Endoscopic Methods
We performed ESG using a standardized U-stitch pattern with reinforcing interrupted sutures after each U. To optimize durability, we reinforced selected interrupted sutures with 1cm x 2cm teflon pledgets. The procedure was completed in 75 minutes with a total of 60 stitches. Pledget reinforcement was achieved by replacing the suture needle onto the needle driver and withdrawing the endoscope after both bites of the interrupted suture were taken. With both ends of the suture outside the patient, the needle end of the suture was advanced through the pledget and then pulled into the stomach through an overtube by placing gentle traction on the trailing suture end. The trailing suture end was then advanced through a separate pledget and the trailing suture pulled through the endoscope channel using biopsy forceps. The trailing pledget was then pushed in the gastric lumen by advancing the endoscope while placing gentle traction on the trailing end of the suture at the instrument channel opening. The suture was then secured using a standard suture cinch.

Conclusions
Pledget reinforcement for endoscopic suturing is feasible and does not add significantly to procedure time. Pledgets have been shown effective at distributing suture tension and may improve the durability of endoscopic sleeve gastroplasty. Further studies looking at comparative long-term outcomes are indicated and ongoing.