Table 1.
Summary of all consensual statements for the APC treatment of post-RYGB weight regain associated with dilated gastrojejunostomy
| Statements | Level of agreement | Grade of recommendation[21] |
|---|---|---|
| Required qualification | ||
| Local regulatory certification for performing endoscopy is required | 100% | D |
| Theoretical and practical hands-on courses is the minimum training required | 100% | D |
| Multidisciplinary team | ||
| A dietitian is required in the multidisciplinary team | 97% | A |
| A bariatric endoscopist is required for evaluation and follow-up | 100% | A (extreme plausibility) |
| A psychologist is recommended in the multidisciplinary team | 97% | C |
| The endocrinologist is not required in the multidisciplinary team | 91% | D |
| A physician nutrition specialist is not required in the multidisciplinary team | 100% | D |
| A psychiatrist is not required in the multidisciplinary team | 98% | D |
| A bariatric surgeon is not required in the multidisciplinary team | 77% | D |
| A physical educator is not required in the multidisciplinary team | 100% | D |
| Preprocedural workup | ||
| An upper diagnostic endoscopy is required before APC treatment, but it may be performed as a same-session procedure | 100% | B |
| For patients with weight regain undergoing an upper diagnostic endoscopy, the report should provide the measures of pouch and stoma but not suggest APC treatment | 97% | D |
| An upper GI series is not necessary | 100% | D |
| Abdominal ultrasound or abdominal computed tomography is not necessary | 97% | D |
| A coagulation profile is required to perform APC treatment | 83% | D |
| General lab tests (full blood count, electrolytes, renal panel) are required before APC treatment | 85% | D |
| Gastric scintigraphy is not necessary | 100% | D |
| Indications and contraindications | ||
| Standard indications and definitions | ||
| There is no minimum age for indication | 83% | D |
| There is no maximum age for indication | 94% | D |
| Dilated GJA is defined as diameter ≥ 15 mm | 89% | B |
| The assessment of the anastomotic diameter requires the employment of an objective parameter (endoscopic ruler or foreign body forceps) | 94% | B |
| A dilated stoma is a criterion for indication | 97% | A |
| Weight regain ≥ 20% of the lost weight is a criterion for indication | 98% | B |
| Time from surgery ≥ 18 months a criterion for indication | 77% | C |
| Successfully attending the multidisciplinary visits is a criterion for indication | 89% | D |
| Clinical complaints of delayed satiation or short-term satiety are criteria for indication | 89% | D |
| The presence of co-morbid conditions (hypertension or diabetes) is not a necessary criterion for indication | 94% | D |
| Absolute contraindications | ||
| GJA diameter < 10 mm is an absolute contraindication | 100% | A |
| GJA diameter < 12 mm is an absolute contraindication | 92% | D |
| Current use of anticoagulation drugs not amenable to withholding is an absolute contraindication | 86% | D |
| Severe erosive esophagitis (Los Angeles grades C and D) is an absolute contraindication | 73% | D |
| Active anastomotic and marginal ulcers are absolute contraindications | 100% | D |
| Uncontrolled psychiatric disorders are absolute contraindications | 86% | D |
| The presence of a gastro-gastric fistula is an absolute contraindication for anastomotic APC ablation | 80% | D |
| Severe anemia (Hb < 8 g/dL) is an absolute contraindication | 88% | D |
| Dysplastic Barrett’s esophagus is an absolute contraindication | 82% | D |
| Untreated AIDS is an absolute contraindication | 97% | D |
| Pregnancy is an absolute contraindication | 100% | D |
| Relative contraindications | ||
| Gastric pouch < 2 cm is a relative contraindication | 95% | D |
| Coagulopathy is a relative contraindication | 98% | D |
| Migrated silastic ring is a relative contraindication | 86% | D |
| Intact normal silastic ring (diameter < 15 mm) is a relative contraindication | 78% | C |
| Chronic use of non-steroidal anti-inflammatory drugs is a relative contraindication | 91% | D |
| Not contraindications | ||
| Dilated silastic ring (diameter ≥ 15 mm) is not a contraindication | 95% | D |
| Gastritis is not a contraindication | 97% | D |
| Mild erosive esophagitis (Los Angeles grades A and B) is not a contraindication | 97% | D |
| Long gastric pouch (> 7 cm) is not a contraindication | 97% | C |
| Wide gastric pouch (> 5 cm) is not a contraindication | 92% | C |
| Non-dysplastic Barrett’s esophagus is not a contraindication | 92% | D |
| Positive serology for HIV is not a contraindication | 100% | D |
| Treated AIDS is not a contraindication | 94% | D |
| Off-label indications | ||
| Insufficient weight loss associated with a dilated stoma is an off-label indication | 94% | D |
| APC treatment for optimization of weight loss before completing 18 postoperative months is an off-label indication | 88% | D |
| Struggle to maintain weight or progressive weight regain associated with a dilated stoma is an off-label indication | 97% | D |
| Dumping syndrome is an off-label indication | 94% | C |
| Equipment and settings | ||
| The minimum required setting is an endoscopy clinic with advanced life support equipment and a well-established referral protocol | 94% | D |
| Any kind of gastroscope is suitable for APC treatment | 95% | D |
| Routine CO2 insufflation is recommended | 80% | D |
| For Covidien (WEM, Covidien, Medtronic, Ribeirão Preto, Brazil) electrosurgical units, the suggested setting is power = 70–80 watts and flow = 2 L | 100% | D |
| For ERBE (Erbe Elektromedizin GmbH, Tuebingen, Germany) electrosurgical units, the suggested setting is power = 45–60 watts and flow = 1–2 L | 88% | D |
| Patient preparation | ||
| Eight hours fasting is recommended before the APC ablation | 91% | A |
| Routine preprocedural PPI is not recommended | 85% | D |
| Technique | ||
| The procedure may be performed under monitored anesthetic care | 100% | B |
| An accompanying anesthesiologist is recommended | 86% | D |
| Circumferential ablation is the standard approach | 100% | A |
| Intraprocedural gas exchange is recommended | 98% | D |
| Cessation of ablations is recommended when stoma size < 12 mm (Fig. 4) | 94% | C |
| The proximal extension of the ablation is 1–2 cm | 100% | B |
| Antispasmodic drugs are recommended if peristalsis creates technical difficulties | 100% | D |
| Cardinal preprocedural marking is not routinely recommended | 86% | D |
| Postprocedural care | ||
| Liquid diet is recommended for at least two weeks | 88% | D |
| Sucralfate and full-dose PPIs are routinely recommended | 83% | D |
| Painkillers and antispasmodic drugs are only recommended if pain or cramps | 100% | D |
| The recommended interval between ablation sessions is 6–8 weeks | 100% | B |
| Management of adverse events | ||
| Endoscopic dilation is indicated only if consistent clinical presentation (refractory nausea and vomiting) AND stoma size < 10 mm | 97% | D |
| Balloon dilation to 10–12 mm is the primary therapeutic approach to post-APC strictures | 97% | D |
| Refractory stricture is defined as symptoms and stricture persistence after 3 balloon dilation sessions (from 10–15 mm) | 100% | D |
| The primary approach to refractory strictures is endoscopic stricturotomy | 92% | D |