Preparation of the mucosa is one of the most important parts of endoscopic mucosal apposition and suturing. We show the endoscopic revision of a gastric bypass using modified endoscopic submucosal dissection (ESD) techniques to incise the mucosa surrounding the gastrojejunal anastomosis and suture directly into the exposed submucosa and muscularis propria. A 34-year-old female with a history of a laparoscopic Roux-en-Y gastric bypass presented for weight regain and was found to have a dilated gastrojejunal anastomosis. Endoscopic revision was pursued. We first injected the submucosa with a methylene blue and epinephrine solution in saline solution. We made an incision circumferentially about 5 mm away from the gastrojejunal anastomosis using a needle knife and insulated tip knife. We then extended the incision with an insulated tip knife. Finally, we placed an endoscopic suture in a purse-string fashion and secured it over a balloon to reduce the aperture of the anastomosis. This technique may not be appropriate for patients with extensive scarring or fibrosis at the anastomosis. The patient lost a total of 42 pounds in 3 months. Thus, a modified ESD before purse-string anastomotic suturing can result in a durable gastric bypass revision with excellent weight loss outcomes.
Supplementary Material
A modified endoscopic submucosal dissection technique before purse-string anastomotic suturing can help to obtain a durable gastric bypass revision with excellent weight loss outcomes.
Figure 1.
Representative images of use of modified ESD techniques before endoscopic revision of a gastric bypass. A, Gastrojejunal anastomosis (GJ) before revision. B, GJ after incision using needle knife and insulated tip knife. C, GJ size was reduced using a purse-string suture. D, At follow-up, the anastomosis remained the intended size.
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Supplementary Materials
A modified endoscopic submucosal dissection technique before purse-string anastomotic suturing can help to obtain a durable gastric bypass revision with excellent weight loss outcomes.