Endoscopic Sclerotherapy for Dilated Gastrojejunostomy After Gastric Bypass *

Introduction

Roux-en-Y gastric bypass (RYGB) is an excellent option for weight loss in the morbidly obese. Unfortunately, some patients do have weight regain or insufficient weight loss after RYGB. Revisional bariatric surgery after RYGB is not without risk. Studies have demonstrated a higher risk after revisional bariatric than primary bariatric surgery. ¹ In addition, it is not known which is the best treatment option for weight regain or insufficient weight loss after RYGB. ² At least two studies suggested the placement of a laparoscopic adjustable gastric band for patients who failed RYGB.^3,4 One article demonstrated impressive results, with a 52% excess weight loss (EWL) at the 2-year follow-up. ³ Others have reported surgical anatomic changes with limb lengthening and/or increasing malabsorption with mixed results.^5–7 Interestingly, decreasing the pouch size and performing another gastrojejunostomy has not demonstrated to provide significant weight loss either. ⁸ Unfortunately, the data are sparse in what is the best method to assist in further weight loss after “failed” RYGB. The literature is lacking any large series, let alone controlled studies, in techniques utilized when patients regain or have insufficient weight loss after RYGB. Thus, less invasive techniques may provide alternative treatments for weight regain or insufficient weight loss. In this report, we demonstrate a technique of endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass.

Methods

The technique of RYGB is applied to patients who have had weight regain or insufficient weight loss following gastric bypass. Before any type of procedure is considered, these patients undergo intense reeducation and recounseling of the necessary dietary and lifestyle changes needed for bariatric surgery. Upper endoscopy and upper gastrointestinal radiologic tests are performed. These are utilized to, first and foremost, ensure that there were no obvious technical issues with the RYGB, such as a gastrogastric fistula. Both the size of the pouch and the speed of the contrast emptying from the pouch into the jejunum were noted on the upper gastrointestinal radiologic test. The size of the pouch was estimated by the endoscopy as well; however, the main role of the endoscopy was utilized to verify an enlarged gastrojejunostomy. After an attempt of lifestyle changes, patients who had lost the feeling of satiety with dilated gastrojejunostomy and had either weight regain or insufficient weight loss were considered as candidates for endsocopic sclerotherapy.

All patient procedures were done under general anesthesia in the operating room. Patients were placed in the lateral decubitus position with the right side up, facing the surgeon. After a bite block was placed, the endoscope was placed into the mouth and the esophagus was entered. The pouch was examined for any ulcers or foreign bodies, which we have arbitrarily decided to be a contraindication for sclerotherapy. The gastrojejunostomy was examined and again verified to be dilated (i.e., greater than 12 mm). A fully opened biopsy forceps was measured with a ruler before being placed into the endoscope and then utilized to measure the size of the gastrojejunostomy. The jejunum was entered and inspected for ulcers or foreign bodies as well.

If the gastojejunostomy was larger than 12 mm, a standard endoscopic needle was placed at the gastric edge of the gastrojejunostomy. Sodium morrhuate was injected into the submucosa approximately 1 cc at a time circumferentially. Occasionally, 2 cc were placed into the dilated gastrojejunostomy. The total volume to be used was arbitrarily based on how much was needed to obtain the desired narrowing of the anastamosis. An obvious appreciation of narrowing of the gastrojejunostomy was desired after the injections. The mucosa appeared slightly discolored after the injections. The gastrojejunostomy was injected 360 degrees in the hope of maximizing its narrowing. The video demonstrates this technique.

Results

The gastrojejunostomy was injected with 6–30 cc of sodium morrhuate, depending on the size of the gastrojejunostomy. By visual inspection, the anastomosis usually appeared significantly smaller after the procedure. Bleeding was not uncommon, but was usually self-limiting. The average procedure lasted approximately 5–20 minutes. Patients were extubated and then discharged on the same day.

Few patients complained of some dysphagia and/or mild chest discomfort after the procedure. Except for mild nausea and some discomfort, the patients experienced no morbidity or mortality from the procedure. All patients were told to stay on liquids for 2 weeks. The postprocedure diet represents our postoperative laparoscopic RYGB diet. Patients are seen in clinic and again reeducated on their dietary habits and need for lifestyle changes.

Most patients reported a subjective feeling of satiety after the endoscopic sclerotherapy. Reinjection after 3 months was performed in patients who lost their feeling of satiety and still had a gastrojejunostomy greater than 12 mm. We have performed this procedure on 6 patients, with 50% losing 5 kg or more. No patients have had any complications from the procedure. The mild symptoms that have been noted all resolved within 48 hours of the procedure.

Discussion

Endoscopic sclerotherapy may offer an alternative treatment of dilated gastrojejunostomy after RYGB. The technique demonstrated in the video is a relatively easy, safe method that may become the first line of therapy in patients who lose the feeling of satiety after RYGB. While advanced endoscopic techniques are not necessarily required for this procedure, familiarity with the endoscope and injection therapy is a necessity. Care must be taken not to overinsufflate the gastrointestinal tract. Overinsufflation is a concern, since a pylorus does not limit the amount of air that transverses into the jejunum in this patient population. At this time, we perform these procedures under general anesthesia, although deep sedation with propofol and monitoring by anesthesia may be sufficient enough. ⁹

The literature has a few reports of the success of endoscopic sclerotherapy for dilated gastrojejunostomy after RYGB.^10–13 Our experience has demonstrated that this is effective in about 50% of patients. Spaulding first reported the use of sclerotherapy in 8 patients, in which 75% lost some weight. ¹⁰ A follow-up study with 32 patients and a minimum of 1 year of follow-up demonstrated a weight loss in 56.3% of patients and a weight gain in 9.4%. ¹¹ Loewen and Barba reported their experience in 71 patients. ¹² In their study, 21 patients lost weight, 20 patients gained weight, and 30 patients maintained their weight. They injected an average of 13 cc of sodium morrhuate; however, they did not report a range. They found no complications, and only 1 patient needed pain medications. Catalano et al. demonstrated a much higher rate of weight loss (average, 22.3 kg) in 28 pateints. ¹³ Their method of injection involved 8–20 cc (mean, 14.5 cc) until they noted the tissue was deep purple. They did have 10 patients who were unsuccessful who had larger stomal diameters. In addition, 75% of their patients required pain medications. One patient required dilation due to a stomal stenosis. They did note a 36% rate of stomal ulcers as well, which could be of potential concern. ¹⁴ It seems that while a more aggressive injection induces better weight loss, there is a higher chance of risk of ulcers and stenosis. The issue of weight gain and/or insufficient weight loss after RYGB is a difficult one to tackle. There is no single determining factor that causes weight gain and/or insufficient weight loss. Patient compliance, motivation, education, support, and expectations all could play some role in the degree and consistency of weight loss.^15–17

Obviously, some technical considerations are important when performing an RYGB. While RYGB is thought to be a malabsorptive, restrictive procedure, the exact mechanism for weight loss is unknown. Pouch size, if kept to a certain size, does not seem to matter. ¹⁸ The fact that limb lengths vary significantly between surgeons ¹⁹ most likely suggests that length of the limbs is relatively unimportant, as long as the common limb is not too long or short. At least one study demonstrated that placing an adjustable gastric band around the pouch does help with weight loss after RYGB. ³ Few surgeons will place a band during the initial operation around the pouch to help with weight loss. ¹⁹ It is still not convincing that this nonadjustable band results in better long-term weight loss. ²⁰ Unfortunately, the band is not without its possible complications.^21,22 These technical details may not be the cause of weight loss, but instead, dumping syndrome and/or hormonal changes caused by the bypass of the majority of the stomach and proximal small intestine may contribute more to weight loss.

Until the exact mechanism(s) of weight loss are elucidated, the utility of decreasing the stoma size will be debated. However, the fact that some patients lose weight justifies the use of endoscopic sclerotherapy for a “failed” RYGB. The low morbidity and mortality of this procedure justifies even a limited success rate. In experienced hands, it is a relatively simple procedure that can be performed as an outpatient.

Conclusions

In conclusion, endoscopic sclerotherapy can be performed for weight regain and/or insufficient weight loss after RYGB. A randomized, controlled, multi-institutional study would help to determine the short-term success and long-term durability of this procedure.