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BACKGROUND: Some patients are thought to regain weight after gastric bypass surgery because of dilation of the gastrojejunal anastomosis (GJA) and/or gastric pouch. OBJECTIVE: To assess the technical success and safety of an endoscopic procedure, Revision Obesity Surgery Endoscopic (ROSE), using an endoscopic operating system for the placement of tissue anchors to reduce the diameter of the GJA and size of the gastric pouch. DESIGN: Prospective case series. SETTING: Brigham and Women's Hospital, Boston, Massachusetts. PATIENTS AND INTERVENTIONS: A total of 20 patients who had regained a mean of 13 kg after gastric bypass, with a dilated pouch and GJA on screening endoscopy, underwent the ROSE procedure. MAIN OUTCOME MEASUREMENTS: Technical success, reduction in size of the GJA and gastric pouch, and early complications. Early weight loss was also assessed. RESULTS: Technical success was achieved in 17 of 20 (85%) patients with an average reduction in stoma diameter of 16 mm (65% reduction) and an average reduction in pouch length of 2.5 cm (36% reduction). The mean weight loss in successful cases was 8.8 kg at 3 months. There were no major complications. LIMITATIONS: Single-center case series with a relatively small number of patients and short duration of follow-up, which was inadequate for assessing durable long-term weight loss. CONCLUSION: The ROSE procedure is technically feasible and appears safe. Data from this series suggest that the ROSE procedure is effective in reducing not only the size of the GJA but also the gastric pouch and may provide an endoscopic alternative for weight regain in gastric bypass patients. [ABSTRACT FROM AUTHOR]

Background and Aims: Liver fibrosis staging is challenging in patients with obesity and metabolic dysfunction-associated steatotic liver disease (MASLD). Liver biopsies are invasive, whereas noninvasive tests such as vibration-controlled transient elastography (VCTE) can be inaccurate in patients with obesity. We hypothesized that EUS-guided shear wave elastography (EUS-SWE) is more accurate for liver fibrosis staging in patients with MASLD and obesity; the aim of this pilot study was to test this hypothesis and establish optimal fibrosis stage cutoffs for EUS-SWE., Methods: This was a multicenter, cross-sectional study from prospectively collected data. Consecutive patients who underwent EUS-SWE with subsequent liver biopsy were included. EUS-SWE was compared with Fibrosis-4 Index (FIB-4) and VCTE. Area under the receiver-operating characteristic (AUROC) curve analysis was performed, and 90% sensitivity and specific cutoffs were calculated to determine optimal cutoffs., Results: Sixty-two patients were included. Mean body mass index was 40.74 kg/m 2 . EUS-SWE was superior to FIB-4 in discriminating significant fibrosis (F2; AUROC, .87 vs .61; P < .0048) and advanced fibrosis (F3; AUROC, .93 vs .63; P < .0001), but not cirrhosis (F4; AUROC, .95 vs .81; P = .099). EUS-SWE was superior to VCTE in predicting advanced fibrosis and cirrhosis (P = .0067 and P = .0022, respectively). The 90% sensitivity cutoffs for EUS-SWE were 7.50, 8.48, and 11.30 for F2, F3, and F4, and the 90% specificity cutoffs were 9.82, 10.20, and 14.60., Conclusions: In this pilot study, EUS-SWE was superior to FIB-4 and VCTE for liver fibrosis staging in patients with MASLD and obesity. (Clinical trial registration number: NCT05728697.)., Competing Interests: Disclosure The authors disclosed the following financial relationships: M. Ryou: consultant for Olympus, Fujifilm, Cook, Boston Scientific, GI Windows Surgical, and EnteraSense. P. Jirapinyo: consultant/advisory board member/research support, Apollo Endosurgery and Fractyl; consultant/research support, Boston Scientific; consultant, ERBE and Spatz Medical; and research support, GI Dynamics and USGI Medical. C.C. Thompson: consultant/research support, Apollo Endosurgery, Boston Scientific, GI Dynamics, Olympus/Spiration, Fujifilm, Lumendi, and EndoQuest Robotics; general partner, BlueFlame Healthcare Venture Fund; consultant, Covidien/Medtronic and Xenter; founder/consultant/board member, Enterasense Ltd, EnVision Endoscopy, and GI Windows; research support, ERBE; consultant/advisory board, Fractyl; and consultant/advisory board member/research support, USGI Medical. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Endoscopic liver "palpation" can be performed by indenting the liver surface under EUS. Indentation depth is measured with the use of sonographic calipers. We hypothesized that fibrotic livers are more difficult to indent, and that indentation can accurately predict liver fibrosis staging. We compared EUS-guided liver palpation and conventional screening modalities in patients with suspected metabolic dysfunction-associated steatotic liver disease., Methods: This was a cross-sectional pilot study. Consecutive patients at 3 hospitals from 2021 to 2023 underwent EUS-guided palpation with liver biopsy. Liver palpation was compared with fibrosis-4 index (FIB-4), aspartate transaminase to platelet ratio index (APRI), nonalcoholic fatty liver disease fibrosis score (NFS), and transient elastography in predicting fibrosis staging on histology. Area under the receiver operating characteristic curve analysis was performed., Results: Seventy-three patients were included. Mean age was 49.1 years, and 71.2% were female. Mean body mass index was 41.1 kg/m. 2 Indentation depth was negatively correlated with fibrosis stage (Kruskal-Willis test, P < .0001). EUS palpation demonstrated c-statistics of 0.79 and 0.95 in discriminating advanced fibrosis and cirrhosis, respectively. EUS liver palpation was superior to NFS in predicting advanced fibrosis (P = .0057) and superior to APRI and NFS in predicting cirrhosis (P = .0099 and P = .045, respectively). EUS palpation was not significantly different from FIB-4. EUS palpation was superior to transient elastography in predicting cirrhosis (P = .045). When optimal cutoffs were used, indentation measurement ≤3.5 mm yielded 100% predictive value for ruling in advanced fibrosis, and ≥4.0 mm yielded 100% predictive value for ruling out cirrhosis., Conclusions: EUS liver palpation is a novel, accurate, and easy-to-use screening tool for advanced fibrosis and cirrhosis in patients with metabolic dysfunction-associated steatotic liver disease., Competing Interests: Disclosure The following authors disclosed financial relationships: C. C. Thompson: Consultant, Apollo Endosurgery and Covidien/Medtronic; Venture Fund General Partner, BlueFlame Healthcare; Consultant/Research Support, Boston Scientific; Founder/Consultant/Board Member, Enterasense Ltd; Founder/Consultant/Board Member, EnVision Endoscopy; Research Support, ERBE; Consultant/Advisory Board, Fractyl; Consultant/Research Support, GI Dynamics; Founder/Consultant/Board Member, GI Windows; Consultant/Research Support, Olympus/Spiration; Consultant/Advisory Board Member/Research Support, USGI Medical; Consultant/Research Support, Fujifilm, Consultant/Research Support, Lumendi; Consultant, Xenter; Consultant/Research Support, Endoquest Robotics. K. Chang: Consultant for Olympus and Fujifilm. M. Ryou: Consultant for Olympus, Fujifilm, Cook, Boston Scientific, GI Windows Surgical, and EnteraSense. P. Jirapinyo: Consultant/Advisory Board Member/Research Support, Apollo Endosurgery; Consultant/Research Support, Boston Scientific; Consultant, ERBE; Consultant/Advisory board Member/Research Support, Fractyl; Research Support, GI Dynamics; Consultant, Spatz Medical; Research Support, USGI Medical. The other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Introduction: There is a growing interest in minimally invasive endoscopic gallbladder drainage therapies. Unlike stenting, a technology based on magnetic compression could theoretically produce a durable drainage anastomosis without residual foreign material. This study aimed to evaluate the safety and technical feasibility of a cholecysto-duodenal magnetic compression anastomosis., Material and Methods: We performed a survival study of two Yorkshire pigs. Duodenal magnets were deployed endoscopically; reciprocal gallbladder magnets were placed laparoscopically, and the magnets were coupled. Pigs underwent serial endoscopy documenting magnet expulsion and evolution of cholecysto-duodenal anastomosis creation. Necropsies and histological evaluation were performed. Primary endpoints were technical success and safety. Secondary endpoints included anastomosis integrity, patency, and histologic characteristics., Results: Magnets were successfully delivered and coupled. Patent, leak-free anastomoses formed by day 4. Magnets were expelled by day 10. All anastomoses were widely patent at one month (mean diameter 15 mm). Necropsy showed the absence of adhesions affecting the anastomosis. Histology showed complete re-epithelialization without inflammation or foreign body reaction., Conclusions: Magnetic cholecysto-duodenal anastomosis for gallbladder drainage appears safe and feasible in the animal model. The anastomoses are patent, leak-free, and without inflammation from the presence of foreign material. Technical modifications for magnet delivery under endoscopic ultrasound (EUS) guidance are currently underway.

Background and Aims: Most patients with type 2 diabetes mellitus have obesity. Studies show that bariatric surgery is superior to medical treatment for remission of type 2 diabetes mellitus. Nevertheless, very few patients undergo surgery, and a less-invasive endoscopic alternative is desirable., Methods: This was a single-arm first-in-human pilot study designed to evaluate the technical feasibility, safety, and clinical performance of the incisionless magnetic anastomosis system (IMAS) to create a partial jejunal diversion (PJD). Ten patients with obesity and type 2 diabetes mellitus, prediabetes, or no diabetes were enrolled. A PJD to the ileum was attempted in all patients under general anesthesia. The IMAS was delivered through the working channel of a colonoscope, with laparoscopic supervision. The patients were not required to participate in an intensive lifestyle/diet management program. Endoscopic visualization of the anastomosis was obtained at 2, 6, and 12 months. Patient weight, glycemic profile, and metabolic panels were acquired at 0.5, 1, 2, 3, 6, 9, and 12 months., Results: A PJD was created in all patients with no device-related serious adverse events. The anastomosis remained widely patent in all patients at 1 year. Average total weight loss was 14.6% (40.2% excess weight loss at 12 months). A significant reduction in glycated hemoglobin level was observed in all diabetic (1.9%) and prediabetic (1.0%) patients, while reducing or eliminating the use of diabetes medications., Conclusions: Permanent anastomosis for PJD was created in all patients with the IMAS. This resulted in improvement in measures of hyperglycemia and progressive weight loss. (Clinical trial registration number: NCT02839512.)., (Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB., Methods: We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy., Results: Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p<0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p<0.001). Age and gender effects were also significant, with younger patients (p<0.04) and males (p<0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models., Conclusion: Our series suggest that vagotomy does not augment %EWL when performed with RYGB., (Copyright © 2014 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.)

Background: Retrograde intussusception (RI) at the jejunojejunostomy can occur after Roux-en-Y gastric bypass (RYGB). Although this complication is rare, it has been encountered more frequently as the number of bariatric procedures have increased. Little data is available to assist surgeons with the optimal management of this condition. Our objectives were to identify the risk factors for RI after RYGB and report on outcomes after surgical intervention at a tertiary academic surgical unit., Methods: We used our prospective longitudinal institutional bariatric surgical database to identify patients with post-RYGB RI from 1996 to 2011., Results: We identified 28 post-RYGB RI cases. The median interval between RYGB and RI was 52 months, and the median percentage of excess weight loss was 75%. Patients presented with acute symptoms in 36% of the cases. All patients underwent surgical exploration, including resection and revision of the jejunojejunostomy (46%) or operative reduction with or without enteropexy (54%). Those undergoing resection had a longer hospital stay but similar 30-day complication rates. At a median follow-up of 9 months, only 1 recurrence was documented., Conclusions: RI is a rare and late complication of RYGB and typically occurs after significant weight loss. In the presence of ischemia or nonreducible RI, resection and revision of the jejunojejunostomy is recommended. In less acute patients, laparoscopic management with reduction and/or enteropexy offers a reduced hospital length of stay while maintaining equivalent morbidity and low recurrence compared with resection., (Copyright © 2013 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Study Aims: A dilated gastrojejunal anastomosis (GJA) is thought to be associated with weight regain in patients with Roux-en-Y gastric bypass (RYGB). Due to a high rate of perioperative morbidity, surgical revision is not generally performed. The aim of this study was to assess the technical feasibility, safety, and early outcomes of a procedure using a commercially available endoscopic suturing device to reduce the diameter of the GJA., Patients and Methods: This was a retrospective analysis of 25 consecutive patients who underwent transoral outlet reduction (TORe) for dilated GJA and weight regain. An endoscopic suturing device was used to place sutures at the margin of the GJA in order to reduce its aperture. On chart review, clinical data were available at 3, 6, and 12 months., Results: Patients had regained a mean of 24 kg from their weight loss nadir and had a mean body mass index of 43 kg/m2 at the time of endoscopic revision. Average anastomosis diameter was 26.4 mm. Technical success was achieved in all patients (100 %) with a mean reduction in anastomosis diameter to 6 mm (range 3 - 10 mm), representing a 77.3 % reduction. The mean weight loss in successful cases was 11.5 kg, 11.7 kg, and 10.8 kg at 3, 6, and 12 months, respectively. There were no major complications., Conclusion: This case series demonstrated the technical feasibility, safety, and efficacy of performing gastrojejunostomy reduction using a commercially available endoscopic suturing device. This technique may represent an effective and minimally invasive option for the management of weight regain in patients with RYGB., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background & Aims: Weight regain or insufficient loss after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of RYGB. Endoluminal interventions for GJ reduction are being explored as alternatives to revision surgery. We performed a randomized, blinded, sham-controlled trial to evaluate weight loss after sutured transoral outlet reduction (TORe)., Methods: Patients with weight regain or inadequate loss after RYGB and GJ diameter greater than 2 cm were assigned randomly to groups that underwent TORe (n = 50) or a sham procedure (controls, n = 27). Intraoperative performance, safety, weight loss, and clinical outcomes were assessed., Results: Subjects who received TORe had a significantly greater mean percentage weight loss from baseline (3.5%; 95% confidence interval, 1.8%-5.3%) than controls (0.4%; 95% confidence interval, 2.3% weight gain to 3.0% weight loss) (P = .021), using a last observation carried forward intent-to-treat analysis. As-treated analysis also showed greater mean percentage weight loss in the TORe group than controls (3.9% and 0.2%, respectively; P = .014). Weight loss or stabilization was achieved in 96% subjects receiving TORe and 78% of controls (P = .019). The TORe group had reduced systolic and diastolic blood pressure (P < .001) and a trend toward improved metabolic indices. In addition, 85% of the TORe group reported compliance with the healthy lifestyle eating program, compared with 53.8% of controls; 83% of TORe subjects said they would undergo the procedure again, and 78% said they would recommend the procedure to a friend. The groups had similar frequencies of adverse events., Conclusions: A multicenter randomized trial provides Level I evidence that TORe reduces weight regain after RYGB. These results were achieved using a superficial suction-based device; greater levels of weight loss could be achieved with newer, full-thickness suturing devices. TORe is one approach to avoid weight regain; a longitudinal multidisciplinary approach with dietary counseling and behavioral changes are required for long-term results. ClinicalTrials.gov identifier: NCT00394212., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

The number of people who are obese or morbidly obese is increasing in the United States. Currently, the most effective means of losing a substantial amount of weight and maintaining the weight loss is bariatric surgery, and health care providers, especially those in surgical services, must be able to safely care for patients undergoing these surgeries. Financial implications of starting a bariatric surgery program and the ongoing costs must be fully understood and supported by both administrators and employees. Special equipment and supplies are needed to handle the higher weight of bariatric patients, and careful planning is required for adequate medical and nursing expertise, staffing, equipment, supplies, facility resources, and patient support services., (Copyright © 2013 AORN, Inc. Published by Elsevier Inc. All rights reserved.)

Background: We hypothesized that laparoscopic adjustable gastric band (LAGB) placement might result in the development of a hiatal hernia (HH) over time. The objective of our study was to determine whether HHs develop after LAGB in the setting of a university hospital., Methods: We retrospectively reviewed all outcomes for consecutive LAGB patients in our institutional, longitudinal prospective bariatric surgical database to identify those patients without evidence of a HH at LAGB placement, who subsequently underwent delayed HH repair., Results: From 2005 to 2009, 695 gastric bands were implanted. Twelve patients (1.72%) were identified who had no radiographic or intraoperative evidence of a HH at LAGB placement and who subsequently underwent HH repair at re-exploration. Patients presented 18 ± 10 months after band placement. Of these patients, 75% presented with gastroesophageal reflux disease or food intolerance (50% with gastroesophageal reflux disease alone). Also, 2 presented with acute pain due to band slippage and 1 with chronic pain and vomiting. In 50% of the patients, revision procedures detected the HH at operation despite negative preoperative studies., Conclusion: In our series, a significant HH developed in 1.7% of LAGB patients who had no clinically identifiable HH at LAGB placement. Persistent dysphagia after band deflation requires careful inspection of the hiatus during surgical revision, even in the absence of radiologic depiction of HH, and might represent an underlying etiology of LAGB dysfunction. This complication, along with esophageal dilation and annular pouch dilation, might represent a constellation of conditions with a common etiology. From the results of our small series, we raise the question of the existence of chronic backpressure created by LAGB restriction and accounting for these complications., (Copyright © 2013. Published by Elsevier Inc.)

Obesity is commonplace, and surgical treatment usually includes Roux-en-Y gastric bypasses (RYGBs). RYGBs have the most documented side effects including vitamin deficiencies, rebound weight gain, and symptomatic hypoglycemia; fewer series exist describing hypoglycemia following other bariatric operations. We reviewed all patients undergoing laparoscopic adjustable gastric banding (LAGB) at our institution between 2008 and 2012. Three patients were identified to have symptomatic hypoglycemia following LAGB. Mean time from surgery was 33 months (range 14-45 months), and mean weight loss was 32.7 kg (range 15.9-43.1 kg). None of the patients had preexisting diabetes. Therefore, symptomatic hypoglycemia should be investigated irrespective of bariatric operation.

Background: The advent of metabolic surgery and the increasing focus on the substantial resolution rate of type 2 diabetes after laparoscopic Roux-en-Y gastric bypass (LRYGB) call for additional fundamental investigations as to the mechanisms behind this effect. These investigations require an adequate animal model. Our objective was to develop a reproducible survival model of LRYGB performed in a large animal at a tertiary university hospital., Methods: LRYGB was performed on 11 Yorkshire pigs that where then followed for 6 weeks. The operative time, morbidity, and mortality were recorded for each case. Necropsy was performed, and the anastomoses were harvested and inspected for leaks., Results: The surgical technique and difficulties are carefully described. Of the 11 pigs, 10 survived to the end of the study period. The 1 death was from intraoperative cardiac dysrhythmia. The postoperative complications consisted of a postoperative febrile episode in 2 pigs. The mean initial weight was 31.5 ± 3.4 kg. The mean operative time was 214 ± 71 minutes. No anastomotic leaks were identified at necropsy or on histologic examination of anastomoses. The mean weight gain at the end of the study period was .8 ± 1.4 kg compared with an expected 17.5 kg weight gain., Conclusion: We have described an effective survival porcine model of LRYGB that can be consistently reproduced. This will enable additional investigation into the complex physiologic mechanisms that control hunger, weight loss, and the development, as well as resolution, of type 2 diabetes, potentially leading to the development of novel, targeted bariatric procedures and diabetic treatments., (Copyright © 2012. Published by Elsevier Inc.)

Background: Laparoscopic adjustable gastric band (LAGB) has gone through major design modifications to improve clinical endpoints and reduce complications. Little is known, however, about the effects of LAGB size on clinical outcomes, or whether outcomes differ based on gender. We set out to examine the impact of band size on surgical weight loss, reoperations, comorbidity resolution, and compare outcomes within gender., Methods: We reviewed our prospectively collected longitudinal bariatric database between 2008 and 2010, and compared patients with BMI 35-50 kg/m(2) who had undergone LAGB with the LAP-BAND® APS to those who had the larger APL. Those patients with initial BMI > 50 kg/m(2) were excluded to reduce any possible selection bias which favors larger band use in such subjects., Results: Three hundred ninety-four patients met our inclusion criteria; 230 (58 %) in the APS group and 164 (42 %) in the APL group. Female patients in APS group experienced significantly higher percentage excess body weight loss at 6 months, 1 year, and 2 years in comparison to female patients in APL group (p < 0.001 for all time points). In contrast, a reverse pattern was observed for male patients. No significant differences were observed between the groups regarding frequency of band adjustments, complications, or comorbidity resolution., Conclusions: Male patients might benefit from APL bands, in contrast to female patients who appear to experience superior weight loss with the smaller APS bands. This study provides the first set of evidence to facilitate surgical decision making for band size selection and highlights differences between genders.

Background: Weight regain after Roux-en-Y gastric bypass (RYGB) is common. Endoscopic sclerotherapy is increasingly used to treat this weight regain., Objectives: To report safety, outcomes, durability, and predictors of response to sclerotherapy in a large prospective cohort., Design: Retrospective analysis of a prospective cohort study of patients with weight regain after RYGB., Patients: A total of 231 consecutive patients undergoing 575 sclerotherapy procedures between September 2008 and March 2011., Interventions: Single or multiple sclerotherapy procedures to inject sodium morrhuate into the rim of the gastrojejunal anastomosis., Main Outcome Measurements: We report weight loss, complications, and predictors of response. We also used Kaplan-Meier survival analysis and log-rank test to compare time to continuation of weight regain after sclerotherapy in patients undergoing a single versus multiple sclerotherapy procedures., Results: At 6 and 12 months from the last sclerotherapy procedure, weight regain stabilized in 92% and 78% of the cohort, respectively. Those who underwent 2 or 3 sclerotherapy sessions had significantly higher rates of weight regain stabilization than those who underwent a single session (90% vs 60% at 12 months; P = .003). The average weight loss at 6 months from the last sclerotherapy session for the entire cohort was 10 lb (standard deviation 16), representing 18% of the weight regained after RYGB. A subset of 73 patients (32% of the cohort) had greater weight loss at 6 months (26 lb, standard deviation 12), representing 61% of the weight regained. Predictors of a favorable outcome included greater weight regain and the number of sclerotherapy procedures. Bleeding was reported in 2.4% of procedures and transient diastolic blood pressure increases in 15%, without adverse health outcomes. No GI perforations were reported., Conclusions: Endoscopic sclerotherapy appears to be a safe and effective tool for the management of weight regain after RYGB., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Gastrogastric fistula (GGF) is a challenging complication of primary obesity surgery that often leads to revision surgery. The impact of prior endoscopic intervention on subsequent surgical revisional outcomes remains unknown. We present the largest series of Roux-en-Y gastric bypass GGF with subsequent surgical revision of fistulae to date., Methods: A database of bariatric surgical revisions performed at a single institution was collected. The cohort was divided between patients with and without attempted endoscopic fistula closure prior to surgical revision. Thirty-day morbidity and mortality was the primary outcome., Results: Thirty-five cases of revision were performed for GGF. Of the 35 cases, 22 patients had attempted endoscopic closure prior to surgical revision while 13 patients went directly to surgical revision. In the endoscopy group, two minor complications and seven major complications occurred (total 9 of 22; 40.9%). In the surgery only group, three minor complications and three major complications occurred (total 6 of 13; 46.1%). No deaths occurred., Conclusion: Prior attempts at endoscopic fistula closure do not lead to increased surgical complications at the time of surgical revision.

The aim of this article is to describe the context in which this issue of Gastrointestinal Endoscopy Clinics of North America is established. The authors review the current worldwide dimensions and trends of the obesity epidemic; associated mortality and comorbid diseases including diabetes, cancer, cardiovascular disease and obstructive sleep apnea; the financial impact of obesity; and current national and international guidelines for referral and qualification for surgical treatment of obesity., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background & Aims: Weight regain after Roux-en-Y gastric bypass (RYGB) is associated with reductions in health status and quality of life. We evaluated whether gastrojejunal stoma diameter is a risk factor for weight regain after RYGB., Methods: We examined data collected over 4 years from consecutive patients referred to a tertiary care bariatric center for upper endoscopy after RYGB. We used linear regression analysis to determine the association between the gastrojejunal stoma diameter and weight regain. We applied a logistic regression model using clinical and endoscopic parameters to develop a prediction rule for weight gain after RYGB., Results: Among 165 patients included in our study, 59% had significant weight regain (≥ 20% of maximum weight lost after the RYGB) and 41% did not. The mean percentage of maximal weight lost after RYGB that was regained in the entire cohort was 30% ± 22%. Gastrojejunal stoma diameter was associated significantly with weight regain after RYGB surgery in univariate analysis (β = .31, P < .0001). This association remained significant after adjusting for several known or purported risk factors for weight regain (β = .19, P = .003). We developed a simple prediction rule for weight regain after RYGB using a 7-point scoring system that includes the gastrojejunal stoma diameter, race, and percentage of maximal body weight lost after RYGB; a cut-off score of 4 or more points had an area under receiver operating characteristic curve of 0.76 and a positive predictive value of 75%., Conclusions: Increased gastrojejunal stoma diameter is a risk factor for weight regain after RYGB and can be incorporated in a novel prediction rule., (Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: With the increasing popularity of laparoscopic adjustable banding (LAGB), reoperations to treat band complications have become increasingly more common. Few studies, however, have documented the outcomes of such revisional procedures. The purpose of the present study was to compare the different reoperative approaches after LAGB placement. The present study was conducted at a tertiary referral academic medical center in the United States., Methods: We reviewed our bariatric database to identify patients who had undergone LAGB from 2004 to 2007 and had undergone either revision of their original band or conversion to Roux-en-Y gastric bypass., Results: Of the 66 patients who met our inclusion criteria, 47 (71.2%) had undergone revision and 19 (28.8%) conversion. The patient demographics were similar between the 2 groups. The interval to revision or conversion was 22 and 28 months, respectively. Band slippage was the most common surgical indication in the revision group, and inadequate weight loss was the most common in the conversion group. Although patients in the revision group had experienced good weight loss before their reoperation, the conversion group had not. However, the conversion group experienced good weight loss after their reoperation, with an average excess body weight loss of 48%., Conclusion: Patients who have experienced successful weight loss with LAGB and experience band complications will have satisfactory outcomes with band revision, maintaining their excess body weight loss. These data suggest that patients with inadequate weight loss after LAGB can do well after conversion to Roux-en-Y gastric bypass., (Copyright © 2011 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Common endoscopic findings in patients who have undergone Roux-en-Y gastric bypass (RYGB) with chronic abdominal pain have included marginal ulceration, gastrogastric fistula, and jejunal erosion. However, suture or staples eroding into the gastric pouch can also contribute to abdominal pain. Redundant suture is typically regarded as a normal part of the postoperative anatomy. The objectives of the present study were to assess the effects of endoscopic foreign body removal of partially exposed sutures and staples in post-RYGB patients with chronic abdominal pain at a university hospital in the United States., Methods: We performed a retrospective study of consecutive patients from January 2006 to July 2007. Post-RYGB patients with chronic abdominal pain underwent endoscopic foreign body removal of exposed sutures/staples. Pain scores were obtained before the procedure, immediately after the procedure, and at the telephone follow-up (median 7.2 months)., Results: Of 21 patients, 15 (71%) reported immediate symptomatic improvement. Specific endoscopic accessories were found to be more useful than others in managing the various foreign materials. Of the 21 patients, 15 (71%) were available for telephone follow-up. Of these 15 patients, 13 (87%) reported continued symptomatic improvement, with 9 (60%) reporting complete pain resolution and 4 (27%) reporting partial improvement. Eroded foreign material was seen in association with marginal ulcers in 3 patients (14%), gastritis in 7 patients (33%), and an inflammatory polyp in 1 patient (5%)., Conclusions: Eroded suture and staples can cause chronic abdominal pain in post-RYGB patients. In symptomatic patients, visible suture or staples should be considered a potential etiology of chronic pain, instead of normal postoperative findings. Endoscopic foreign body removal might be of therapeutic benefit in these patients., (Copyright © 2010 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Gastrogastric fistulas (GGFs) are a well-known complication of Roux-en-Y gastric bypass. Surgical repair of such fistulas is technically difficult, with significant associated morbidity. The aim of the present study was to evaluate the efficacy of endoscopic GGF closure at a university hospital in the United States., Methods: Patients with Roux-en-Y gastric bypass and confirmed GGFs on esophagogastroduodenoscopy or barium study. Endoscopic repair was performed with the EndoCinch suturing system (group 1) or clips (group 2). All patients were followed up in the outpatient clinic or interviewed by telephone at 1, 6, and 18 months after the procedure, then as indicated by symptoms., Results: A total of 95 patients were included in the present series (group 1, n = 71, 75%; group 2, n = 24, 25%). The mean GGF size was significantly larger in group 1 than in group 2 (14.5 +/- 8.7 versus 7.7 +/- 6, P = .01). An average of 2.2 sutures or 3 clips (range 2-7) was used. Complete initial GGF closure was achieved in 90 patients (95%), with reopening in 59 (65%) an average of 177 +/- 202 days. The average follow-up was 395 +/- 49 days, with 22 patients lost to follow-up. Two significant complications were reported (bleeding and an esophageal tear). None of the GGFs with an initial size >20 mm remained closed during the follow-up period compared with 10 (32%) of the 31 fistulas

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., (2010 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: For some gastric bypass patients, dilation of the gastrojejunal anastomosis (GJA) and/or gastric pouch is believed to contribute to weight regain. The present study had 2 objectives: (1) to assess the technical feasibility and safety of a novel endoscopic procedure called "revision obesity surgery endoscopic" (ROSE) using a second-generation, prototype endoscopic operating system that creates tissue plications to reduce the diameter of the GJA and the size of the gastric pouch; and (2) to assess the early outcomes regarding weight loss at a university hospital in the United States., Methods: This was a prospective study of 5 patients who had regained a mean of 14.7 kg after gastric bypass with a dilated pouch and GJA on screening endoscopy. The gastric pouch and the GJA were measured before and after the procedure. The patients were followed up for a minimum of 3 months after the procedure. Weight changes were recorded., Results: Technical success was achieved in all 5 patients (100%). The mean weight loss in the successful cases was 7.8 kg at 3 months. No major complications developed., Conclusion: The results of our study have shown that the ROSE procedure using this second-generation prototype endoscopic operating system is technically feasible and appears safe. Our preliminary results suggest that the ROSE procedure is effective in reducing the size of both the GJA and the gastric pouch and could therefore be an alternative therapy for weight regain in postgastric bypass patients.

Rapid shifts in the demographics and techniques of weight loss surgery (WLS) have led to new issues, new data, new concerns, and new challenges. In 2004, this journal published comprehensive evidence-based guidelines on WLS. In this issue, we've updated those guidelines to assure patient safety in this fast-changing field. WLS involves a uniquely vulnerable population in need of specialized resources and ongoing multidisciplinary care. Timely best-practice updates are required to identify new risks, develop strategies to address them, and optimize treatment. Findings in these reports are based on a comprehensive review of the most current literature on WLS; they directly link patient safety to methods for setting evidence-based guidelines developed from peer-reviewed scientific publications. Among other outcomes, these reports show that WLS reduces chronic disease risk factors, improves health, and confers a survival benefit on those who undergo it. The literature also shows that laparoscopy has displaced open surgery as the predominant approach; that government agencies and insurers only reimburse procedures performed at accredited WLS centers; that best practice care requires close collaboration between members of a multidisciplinary team; and that new and existing facilities require wide-ranging changes to accommodate growing numbers of severely obese patients. More than 100 specialists from across the state of Massachusetts and across the many disciplines involved in WLS came together to develop these new standards. We expect them to have far-reaching effects of the development of health care policy and the practice of WLS.

The objective of this study is to update evidence-based best practice guidelines for specialized facilities and resources for weight loss surgery (WLS). We performed systematic search of English-language literature on WLS and facilities, equipment, and resources published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. Evidence-based best practice recommendations from the most recent literature on specialized facilities and resources for WLS were developed. We identified 1,647 papers in our literature search; the 46 most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in facilities and resources for WLS are required to address technology advances and growing recognition of the need for adequate equipment and specially built nursing units. Key factors in patient safety include availability of trained personnel and specialized equipment for the care of extremely obese WLS patients.

Background: Gastrointestinal complications after lung transplantation remain a common yet poorly defined problem. In this study we examine our experience with gastrointestinal complications after lung transplantation., Methods: Between August 1990 and June 2005, we retrospectively analyzed 208 patients who had undergone lung transplantation (single, 65% [137 of 212]; double, 34% [72 of 212]; heart-lung, 0.5% [2 of 212]; living related, 0.5% [1 of 212]). Four patients were retransplanted. Gastrointestinal complications were defined as any post-transplant diagnosis related to the gastrointestinal tract., Results: Ninety of 208 (43%) transplant patients developed 113 gastrointestinal complications during follow-up (median 3.5 years [62 days to 10.0 years]). Biliary etiology was the most common (12% [25 of 208]), requiring cholecystectomy in 13 patients. Diarrheal syndromes occurred in 21 patients (10%) with 2 patients requiring laparotomies. Small bowel obstruction and/or gastroparesis were present in 17 (5%) and 12 (6%) patients, respectively. Fourteen patients required surgical lysis of adhesions for small bowel obstruction and 7 patients underwent gastric drainage procedures. Three patients had peptic ulcer disease with 2 patients requiring laparotomy for perforated duodenal ulcer. Ten patients developed gastrointestinal bleeding with 1 requiring a colectomy. Three patients presented with diverticulitis and 2 required colectomy. Three patients required laparotomy due to intraperitoneal leakage of gastric secretions after gastromy tube placement. Eleven (16%) deaths were directly related to gastrointestinal complications. Of those patients who required a laparotomy for indications other than cholelithiasis, 9 (35%) died within 8 weeks., Conclusions: Gastrointestinal complications are common after lung transplantation and are associated with considerable morbidity and mortality. Vigilance is required for early recognition and prompt treatment.

To update evidence-based best practice guidelines for coding and reimbursement and establish policy and access standards for weight loss surgery (WLS). Systematic search of English-language literature on WLS and health-care policy, access, insurance reimbursement, coding, private payers, public policy, and mandated benefits published between April 2004 and May 2007 in MEDLINE, EMBASE, and the Cochrane Library. Use of key words to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. We identified 51 publications in our literature search; the 20 most relevant were examined in detail. These included reviews, cost-benefit analyses, and trend and cost studies from administrative databases. Literature on policy issues surrounding WLS are very sparse and largely focused on economic analyses. Reports on policy initiatives in the public and private arenas are primarily limited to narrative reviews of nonsurgical efforts to fight obesity. A substantial body of work shows that WLS improves or reverses most obesity-related comorbidities. Mounting evidence also indicates that WLS confers a significant survival advantage for those who undergo it. WLS is a viable and cost-effective treatment for an increasingly common disease, and policy decisions are more frequently being linked to incentives for national health-care goals. However, access to WLS often varies by payer and region. Currently, there are no uniform criteria for determining patient appropriateness for surgery.

Obesity is a rapidly increasing, worldwide epidemic. Despite recent scientific advances, no currently recommended dietary program or medication results in long-term weight loss of more than 10% of body weight for the vast majority of people who attempt these interventions. Hence, surgical intervention is recommended for patients with a BMI > or =40 kg/m2. Although surgery is an effective, sustainable treatment of obesity, it can be associated with potentially significant perioperative risks and long-term complications. Current research is focused on developing a medical therapy, which produces more effective and sustainable weight loss, yet avoids the risks inherent in major surgery. With a reduced risk profile, such therapy could also be appropriately offered to those who are less obese and, in theory, help those who have BMIs as low as 27 kg/m2. Toward that end, numerous scientists are working to both unravel the pathophysiology of obesity and to determine why surgical intervention is so effective. This review briefly examines the current status of obesity pathophysiology and management, the reasons for failure of conventional medical treatments, and the success of surgical intervention. Finally, future areas of research are discussed.

Background: The objectives of this study were to evaluate outcomes and predictors of morbidity in patients undergoing Roux-en-Y gastric bypass (RYGB) during the Patient Safety in Surgery (PSS) Study., Study Design: National Surgical Quality Improvement Program data on PSS patients undergoing RYGB were analyzed for unadjusted and adjusted outcomes. Gender groups acted differently and were analyzed separately. Multivariable regression modeling was used to analyze hospital type as a predictor of risk. Stepwise logistic regression was performed to determine patient factors predictive of postoperative morbidity., Results: A total of 2,438 patients (2,064 private sector [PS], 374 Veterans Affairs [VA]) were identified for analysis. Adjusted odds ratio for postoperative morbidity for VA versus PS female patients was 1.14 (95% CI, 0.63-2.05), and for male patients 2.29 (95% CI, 1.28-4.10). Stepwise logistic regression showed that independent risk factors predictive of morbidity were open procedure, higher American Society of Anesthesiologists class, higher body mass index, diabetes, alcohol consumption, leukocytosis, SGOT > 40 U/L, smoking history, and older age. Importantly, male gender was not significant (p = 0.13) in the regression analysis. Subsequent and unrelated to this study, the VA has restructured its bariatric surgical program, including regionalization of centers, with a substantial lowering of associated mortality and morbidity., Conclusions: The VA male subset showed higher risk-adjusted postoperative morbidity compared with the PS male subset. The VA and PS female subsets had equivalent risk-adjusted postoperative morbidity. A systematic approach to quality-improvement processes resulted in improved bariatric surgical outcomes in the VA. Male gender might not be an independent risk factor in RYGB patients.

Background: Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity. However, many patients regain weight over time. The mechanisms for this are unclear, and several factors may contribute, including dilation of the gastrojejunal anastomosis. This study aimed to assess the feasibility of endoscopic gastrojejunal anastomotic tightening and to determine the effect of tightening on body weight., Methods: Eight patients with significant weight regain and dilated gastrojejunal anastomosis after RYGB were included in this pilot study. Sutures were placed endoscopically at the rim of the anastomosis. When tightened, the sutures formed tissue placations, reducing the size of the anastomotic aperture., Results: The average preprocedure body mass index (BMI) was 40.5, and the patients had regained a mean of 24 kg from their post-RYGB nadir. The average pouch length was 5.7 cm, and the average anastomotic diameter was 25 mm. The average postreduction diameter was 10.0 mm (68% reduction). Six of the eight patients showed weight loss (mean, 10 kg) at 4 months. Repeat procedures were performed for three patients who had lost 4, 5, and 9 kg, respectively with the initial procedure. After the second anastomotic reduction, the final diameters were, respectively, 14, 5, and 5 mm. The first patient did not have further weight loss. The remaining two patients showed a total weight loss of 19 and 20 kg, respectively, at 5 months. All 11 reductions were accomplished without significant complication. The average postreduction BMI was 37.7, and the percentage of excess weight loss was 23.4%., Conclusion: Peroral endoscopic suturing to tighten dilated gastrojejunal anastomoses appears technically feasible and safe. This procedure is associated with variable but significant weight loss, and preliminary results suggest that it may offer a new treatment option for postbypass weight regain in selected patients.

Dynamic cardiomyoplasty (DCM) is an emerging surgical procedure for heart failure in which the patient's latissimus dorsi (LD) muscle is wrapped around the heart and stimulated to contract in synchrony with the heartbeat as a cardiac assist measure. A 6 week training protocol of progressive electrical stimulation renders the normally fatigueable skeletal muscle fatigue-resistant and suitable for chronic stimulation. To date, over 500 procedures have been performed in worldwide clinical trials. Investigators typically report symptomatic improvement and modest hemodynamic improvement in patients. Controversy exists regarding the exact mechanism of DCM. To test the hypothesis that DCM augments cardiac stroke volume through improvement in systolic function, we formulated an engineering model of dynamic cardiomyoplasty to predict stroke volume. The heart and the LD were modeled as nested (series) elastance chambers, and the vasculature was represented by a two-element Windkessel model. Using five healthy goats, we verified model predictions of stroke volume for both stimulator ON beats (y = 1.00x-0.08, r = 0.87, p < 0.0001) and OFF beats (y = 1.01x+1.06, r = 0.91, p < 0.0001), where x and y are the measured and predicted stroke volumes, respectively. The model confirms that using untrained latissimus dorsi applied to the normal myocardium produces only moderate increases in stroke volume and suggests that future research should focus on increasing LD strength after training.

Background: Transmyocardial laser revascularization is a promising surgical technique used to treat nonreconstructable ischemic heart disease. Recent clinical data show that this technique improves the regional perfusion of ischemic myocardium and reduces angina. Presently, transmyocardial laser revascularization requires an open, lateral thoracotomy. We report here the use of thoracoscopic techniques to perform transmyocardial laser revascularization in a closed chest fashion., Methods: Five Yorkshire farm pigs underwent left chest thoracoscopic exploration and pericardiotomy. A specialized laser handpiece then was introduced into the chest and thoracoscopic transmyocardial laser revascularization was performed (one channel per square centimeter) using an 800-W CO2 laser., Results: Video analysis and gross pathology revealed that the anatomic area accessible to thoracoscopic transmyocardial laser revascularization included the entire left ventricular free wall distributions of the left anterior descending, left circumflex, and posterior descending arteries, from base to apex. Standard hematoxylin and eosin staining confirmed the creation of complete and patent 1-mm-diameter transmural channels throughout these distributions., Conclusion: We have shown that transmyocardial laser revascularization can be performed effectively and safely by thoracoscopy, and that this less invasive technique may reduce morbidity and provide a more cost-effective alternative therapy for nonreconstructable ischemic heart disease.

Background: To investigate the theory of decreased myocardial oxygen consumption (MVo2) in dynamic cardiomyoplasty (DCM), previous studies have calculated indices of MVo2 in DCM. These previous studies, however, used left ventricular pressure in formulas that assumed the assumed the heart to be in its native state, with the reference pressure at the epicardium assumed to be atmospheric. In DCM, however, the reference pressure at the epicardium is no longer atmospheric but rather is the compressive pressure generated by the latissimus dorsi (LD). We therefore used the transmural myocardial pressure, Pt, to calculate indices of MVo2 in DCM., Methods and Results: A half-ellipsoidal, fluid-filled balloon was interposed between the LD and myocardium in a balloon-mediated cardiomyoplasty procedure in five goats. With commonly used LD stimulation parameters, Pt was calculated as left ventricular pressure minus balloon luminal pressure. Using Pt, the transmural tension time index (TtTI) and transmural pressure volume area (PtVA) were calculated. In another series of four goats, LD stimulation parameters were optimized and the TtTI and PtVA recalculated. With standard LD stimulation parameters, the TtTI decreased by 48%, from 15.8 to 8.2 mm Hg.s, and the PtVA by 21%, from 775 to 612 mm Hg.mL, as the LD was stimulated to contract. When the optimized parameters were used, the TtTI decreased by 45%, from 11.2 to 6.2 mm Hg.s, and the PtVA by 33%, from 1984 to 1371 mm Hg.mL., Conclusions: Our results suggest that DCM with a fluid-filled balloon decreases MVo2 as the LD contracts and that LD stimulation parameters have a determining effect on this benefit.

Unsuspected microscopic adenocarcinoma of the gallbladder was identified after operation in a 66-year-old woman undergoing elective laparoscopic cholecystectomy for symptomatic cholelithiasis. An abdominal wall metastasis developed at the periumbilical incision site through which the laparoscope was introduced and through which the gallbladder was removed. A review of the available information on tumor seeding of laparoscopic tracts and drain tracts is presented, as well as implications for the further management of gallbladder cancer and other intraabdominal malignancies.