Elsevier

Surgery for Obesity and Related Diseases

Volume 6, Issue 1, January–February 2010, Pages 36-40
Surgery for Obesity and Related Diseases

Original article
Peroral endoscopic anastomotic reduction improves intractable dumping syndrome in Roux-en-Y gastric bypass patients

https://doi.org/10.1016/j.soard.2009.04.002Get rights and content

Abstract

Background

Dumping syndrome is a well-described consequence of Roux-en-Y gastric bypass. Although the condition can benefit some patients with morbid obesity, a subset will develop intractable dumping syndrome characterized by symptomatic episodes with most meals. We describe the first series of patients successfully treated endoscopically for intractable dumping syndrome.

Methods

Endoscopic gastrojejunal anastomotic reduction was performed in patients with intractable dumping syndrome after Roux-en-Y gastric bypass using a combination of argon plasma coagulation, endoscopic suturing, and fibrin glue. The technical feasibility of endoscopic anastomotic reduction and the clinical improvement in dumping symptoms were assessed by clinical follow-up.

Results

Endoscopic anastomotic reduction was technically successful in 6 consecutive patients with a dilated gastrojejunal anastomosis and intractable dumping syndrome. One patient reported hematemesis 2 days after the procedure that was treated endoscopically. No other significant complications occurred. Complete and persistent resolution of the dumping symptoms was achieved in all patients, with a median follow-up of 636 days.

Conclusion

Endoscopic anastomotic reduction appears technically feasible and safe and might be a minimally invasive treatment option for patients who experience intractable dumping symptoms after Roux-en-Y gastric bypass. Additional studies are needed to determine the long-term efficacy of this procedure.

Section snippets

Inclusion criteria

The patients who were referred to our center for evaluation and/or treatment of symptoms thought to be related to intractable dumping syndrome after RYGB were evaluated for possible endoscopic management. All dumping-related symptoms were recorded. Patients then underwent routine screening endoscopy. At endoscopy, the gastric pouch and the area of the gastrojejunostomy were evaluated for signs of post-RYGB complications. In addition, the size of the gastrojejunostomy and the length of the

Results

From July 2005 to July 2007, a total of 20 patients with RYGB presented with dumping symptoms. However, only 6 (30%) had intractable dumping syndrome and presented with a dilated gastrojejunal anastomosis. All patients were women, with a mean age of 45 ± 11 years (range 33–63) and an average preprocedure body mass index (BMI) of 34.5 ± 7.1 (Table 1).

The intractable dumping symptoms reported before the endoscopic procedure are listed in Table 1 and included immediate postprandial nausea and

Discussion

RYGB remains the most common bariatric surgical procedure in the United States, and its effectiveness in inducing significant weight loss has been well-documented [8], [9], [10]. Although dumping syndrome is a common effect after gastric bypass that might help patients adjust their dietary habits and attain their weight loss goals, intractable dumping syndrome that significantly affect their quality of life is relatively rare. A general agreement has been reached that accelerated gastric

Conclusion

According to this initial series, the gastrojejunal aperture appears to have an effect on the symptoms of patients with intractable dumping syndrome. Additionally, endoscopic anastomotic reduction appears to be safe and could offer a minimally invasive treatment option for patients who experience intractable dumping symptoms after RYGB. Additional prospective studies with larger numbers of patients and more substantial follow-up are needed to confirm these early findings.

Disclosures

G. Fernández-Esparrach was supported by a grant from Generalitat de Catalunya (AGAUR, BE-100022). The authors claim no commercial associations that might be a conflict of interest in relation to this article.

References (20)

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    One patient underwent a distal pancreatectomy in attempts to treat the condition. Endoscopic trans-oral plication of the gastric pouch or outlet has been described for treatment of intractable post-RYGB dumping but not specifically for treatment or improvement of post-RYGB postprandial hyperinsulinemic hypoglycemia [59,60]. RYGB reversal has been described in a few small series for cases of postprandial hyperinsulinemic hypoglycemia after RYBG resistant to all other treatment modalities.

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G. Fernández-Esparrach is currently at Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIPAPS), Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.

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