Over-the-scope clips for transoral gastric outlet reduction as salvage therapy for weight regain after Roux-en-Y gastric bypass.

A 49-year-old man was referred for management of weight regain 3 years after Roux-en-Y gastric bypass (RYGB) surgery. He had gained 14kg in weight in the previous 6 months. Upper endoscopy revealed a 35-mm gastrojejunal anastomosis. Three sessions of transoral gastric outlet reduction over 7 months using endoscopic suturing (OverStitch; Apollo Endosurgery, Austin, Texas, USA) had not resulted in any response. After discussion with the bariatric surgeon, it was decided that gastrojejunal anastomosis reduction using the “type t” over-the-scope clip (OTSC) (Ovesco AG, Tubingen, Germany) would be trialed before redo surgery [1]. At upper endoscopy, two suture remnants were seen (●" Fig.1) and the gastric outlet measured 30mm in diameter. The anastomosis was treated aggressivelywith argon plasma coagulation at 35W. A diagnostic gastroscope preloaded with a 12-mm OTSC was inserted. Using the twin graspers, the edges of the anastomosis were grasped at the 7-o’clock and 10-o’clock positions and, with the application of suction, the OTSC was deployed (●" Fig.2a). The process was repeated with a second OTSC but this time grasping the edges at the 2-o’clock and 5-o’clock positions (●" Fig.2b). The endoscope with cap removed was reinserted and was barely able to pass through the anastomosis indicating that it had been reduced to 10mm in diameter. The procedure duration was 19minutes and thepatientwasdischarged home the same day, on a liquid diet for 2 weeks. An X-ray obtained 2 weeks after the procedure confirmed the optimal position of the OTSCs (●" Fig.3). The patient reported early satiety and weight loss of 9kg at 3 months and an upper gastrointestinal series confirmed a persistently narrowed anastomosis (●" Fig.4). Weight regain after RYGB is noted in 20% to 35% of patients and dilation of the gastrojejunal anastomosis is a major determinant [2,3]. Currently, most centers perform gastrojejunal anastomotic reduction using flexible endoscopic suturing [4,5]. We report here a technique using OTSCs to reduce the gastric outlet in a patient with failure to respond to multiple sesFig.2 Transoral reduction of dilated gastrojejunal anastomosis using over-the-scope clips (OTSCs). a Twin grasping forceps being used to bring two edges of the outlet into close apposition prior to deployment of an OTSC. b Second OTSC deployed on the opposite side to the first, resulting in narrowing of the gastrojejunal anastomosis to approximately 10mm in diameter. Fig.1 Endoscopic view of a dilated gastrojejunal anastomosis in a 49-year-old man, despite prior attempts at reduction using flexible endoscopic suturing. Roux-en-Y gastric bypass had been done 3 years previously.