A significant proportion of patients regain weight after Roux-en-Y gastric bypass. Endoscopic revision of dilated gastrojejunal anastomosis, called transoral outlet reduction (TORe), has proven effective and allows patients to avoid reoperation. Traditionally, TORe has been performed with an interrupted stitching technique with placement of stitches across the anastomosis. In this video, we demonstrate the pursestring and double pursestring techniques for TORe.
The procedure begins with ablation of the anastomotic margin using end-firing argon plasma coagulation at 30 W. A 5- to 10-mm ring is ablated around the anastomosis. The running pursestring stitch is started at the 11 o’clock position and is continued in a counterclockwise fashion. A dilation balloon is deployed via the second endoscope channel and is inflated to a diameter of 8 mm inside the anastomosis. The pursestring suture is then tightened around the balloon and cinched. This technique allows for precise and consistent sizing of the final anastomotic aperture, avoiding excessive or insufficient restriction. It also reinforces the entire margin of the anastomosis.
In the double pursestring technique, a pursestring is created but not cinched. A second pursestring is placed and cinched around a dilation balloon. The first pursestring is then cinched. This technique provides additional reinforcement. Study is ongoing.
Supplementary Material
Figure.
Pursestring suture around a dilated gastrojejunal anastomosis, with reduction around a dilation balloon.
Video: The pursestring and double pursestring techniques for transoral outlet reduction are demonstrated and compared with the interrupted technique.
Footnotes
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Contributor Information
Nitin Kumar, Developmental Endoscopy Lab, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, nitinkumar.101@gmail.com, P: 314-332-4224.
Christopher C. Thompson, Director of Therapeutic Endoscopy, Division of Gastroenterology, Brigham and Women’s Hospital, 75 Francis St., ASB II, Boston, MA 02115, christopher_thompson@hms.harvard.edu, P: 617-525-8266, F: 617-264-6342.
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