DISCUSSION
The recurrence of obesity is associated with decreased quality of life
and recurrence of comorbidities in these patients and in this group of
patients [17,18]. Thus, endoscopic techniques have been developed in
an attempt to effectively reduce the anastomotic diameter and consequent
weight loss.
In this sense, the present study presented results of a systematic
review followed by a meta-analysis of the works that used the techniques
of APC, SUT, and SUR in an attempt to minimize the RWL and its
comorbidities. In this context, the works listed in this study, despite
the difference in the number of articles found between SUT and APC and
SUR, showed that the APC technique showed excellent results in terms of
RWL and SR compared to the other techniques, with no statistically
significant difference. Thus, the results of the APC strongly point to
its potential use.
Added to this, an important data was demonstrated by the results of
Table 4 of this study, since the normal behavior in relation to the APC
RWL results showed greater precision of the values obtained, that is,
by the meta-analysis, the APC technique showed homogeneity of the
results. results, proving that it is an efficient and effective
technique.
Another notorious result was presented by Figures 4 and 5 of the present
study, revealing that there was little difference between the values
of the means of the APC with SUT and SUR, both in relation to RWL and
SR, and all comparisons did not present significant statistical
difference. by Tukey’s analysis. These findings clearly show that the
endoscopic use of APC is as safe and efficient as the SUT and SUR
techniques, showing a high association in each comparison between the
paired groups, with R2 ≥ 50% (homogeneity).
As a corollary of weight gain recurrence in the studies evaluated in
this meta-analysis work, abnormal anatomical findings are found in
71.2% of the patients, 58.9% with gastrojejunoanastomosis dilation,
28.8% with pouch dilation, and 12.3% with changes in both [13].
Thus, several methods such as endoluminal reduction of gastrojejunal
anastomosis: - endocinch (Bard®, Billerica, Massachusetts); Rose
procedure: - restorative obesity surgery, endoluminal (USGI®, San
Clemente, CA); Stomaphyx (Endogastric Solutions®, Redmond, Washington);
OTSC Clip (Ovesco AG®, Tubingen, Germany); Overstitch (Apollo
Endosurgery®, Inc Austin, TX) and fulguration of the gastrojejunal
anastomosis with argon have been proposed to reduce weight in patients
undergoing gastric bypass [13].
Thus, surgical treatments are the most performed, however, they are
associated with a higher incidence of complications and morbidity and
mortality when compared to the other treatments proposed above
[8-10]. Suturing techniques in the gastrojejunal tract have been
used to manage complications over years of clinical practice. In this
sense, the Endocinch suture system (C.R. BARD, Inc, Murray Hill, NJ,
USA) was developed for the endoscopic treatment of gastroesophageal
reflux disease (GERD) [19]. Endoscopic sutures are placed in the
cardia in order to reduce and narrow the esophageal-gastric transition.
Thus, Thompson et al. (2006) demonstrated the applicability of this
method in 8 patients with post-gastric bypass weight regain with dilated
gastrojejunal anastomosis. The mean diameter of the anastomosis was 25
mm and after the procedure, there was a reduction of 68% of the
diameter (mean final diameter of 10 mm). The percentage of loss of
excess weight was 23.4% [18]. In 2010, the same authors
demonstrated the applicability of this method in 220 patients with an
average of 4 sutures in the anastomosis and its reduction to less than
10mm in diameter in 89% of patients [20].
Stomaphyx (Endogastric Solutions) was approved by the Food and Drugs
Administration (FDA) in 2007 and consists of the suction of the operated
gastric tissue (pouch and anastomosis), forming a fold and the same is
fixed with an ”H” shaped device. Thus, Mikami et al. 2010 submitted 39
patients to endoscopic therapy with Stomaphyx (Endogastric Solutions,
Redmond, Washington). All patients had previously undergone gastric
bypass and had regained weight after 24 months. The average weight loss
in 1 year was 10.0 kg and without noticeable complications [21].
In addition, the Endoscopic System - Over the Scope Clip - OTSC CLIP
(OVESCO AG) consists of a nitinol clip positioned on a cap at the end of
the endoscope, in order to reduce the diameter of the gastrojejunal
anastomosis in patients with post-weight regrowth - gastric bypass. As
an example, Heylen et al. (2011) performed this procedure in 94 patients
after gastric bypass who had an average dilated gastrojejunal
anastomosis of 35 mm in diameter and a 10% weight regain. 1 to 2 clips
were applied on average and the final mean anastomotic diameter was 8.0
mm, with an average reduction of 80%. The BMI in 1 year of follow-up
reduced from 32.8 kg m-2 to 27.4 kg m-2 on average [22].
Furthermore, the OVERSTITCH endoscopic suture platform (APOLLO
ENDOSURGERY), is based on a dual-channel endoscope with a suture system
and the purpose of reducing the diameter of the gastrojejunal
anastomosis in patients with post-bypass gastric weight regain.
Preliminary results in 8 patients in Chile showed a reduction in the
diameter of the anastomosis from 20.0 mm to 10.0 mm and a loss of
6.0-8.0 kg in 3 months [23].
Surgical procedures are performed with an endosurgical operating system
and a small flexible endoscope for viewing. In 2010, Horgan et al.
performed this procedure in 116 patients with post-gastric bypass weight
regain, demonstrating a 50.0% reduction in the diameter of the
anastomosis and 44.0% in the length of the pouch. Six months after the
procedure, there was a 32.0% reduction in the weight recovered
[24].
Regarding therapy with the gastrojejunal application with an argon
plasma, it is important to note first that argon is an odorless, inert,
non-toxic, inexpensive, and easily ionizable gas, it has been used in
conventional surgeries since the 1980s and, in the field of endoscopy,
was introduced in 1991 [25].
There are countless endoscopic applications of fulguration with an argon
plasma, such as gastrointestinal bleeding of the most diverse
etiologies, tissue growth after stent implantation, the opening of the
lumen of hollow organs obstructed by tumor growth, a section of the
parenchyma of solid organs such as liver and spleen, and more recently,
in the field of bariatric endoscopy [25,26].
The use of AP in the treatment of anastomosis has stood out as an
effective and safe method in the treatment of obesity relapse, although
there are few studies since endoscopic AP is very effective in its
indications, technically easy to be performed, and with numerous
advantages over the usual electrocoagulation. Complications are rare.
The depth limit of tissue penetration of 2 to 3 mm associated with
excellent coagulation allows its application in critical areas such as
the duodenum and the colon [27].
In the case of gastrojejunal anastomosis, fulguration with argon has
promoted a reduction in its diameter and consequent delay in gastric
emptying, early satiety, and weight reduction [8,28]. Reducing the
diameter of a dilated anastomosis can lead to a 23.0% reduction in
excess weight [29]. From an endoscopic point of view, information
such as the diameter of the anastomosis, complications after bariatric
surgery, monitoring by a specialized team, and physical activity
contribute to a better indication criterion to be adopted in patients
who regained weight after gastric bypass [30]. Thus, the relevance
of studies on the effect of argon on weight reduction in patients
undergoing gastric bypass points to its increasing use [8].
In this context, a study compared the relative efficacy of TORe and the
use of argon plasma coagulation at 3 and 6 months in the treatment of
weight recovery after gastric bypass (RYGB). Ten consecutive patients
submitted to TORe using an interrupted tissue plication were included.
These were combined with 20 patients undergoing argon plasma. The mean
age was 50.9 ± 1.7 years with a pre-RYGB BMI of 46.7 ± 1.1 kg m-2.
Nadir’s BMI was 28.8 ± 0.8 kg m-2 (SCHULMAN et al., 2013). The TORe was
performed 10.5 ± 0.9 years after RYGB, with a pre-TOR BMI of 36.6 ± 1.0
kg m-2. The average opening of JGA was 18.5 ± 0.7 mm. The average number
of treatments with APC was 1.3 (range 1-4). There were no major adverse
events. Weight loss results were better for patients undergoing
plication, both at 3 and 6 months. Larger and longer-term studies are
needed to assess differences in the durability of these results
[29].
A retrospective study was also carried out by De Souza et al (2015) with
37 participants. In this work, the use of argon plasma had a success
rate of 50% and a 24.0% reduction in relapsed weight [30]. In
addition, a prospective controlled longitudinal study with APC conducted
by Cambi et al (2015) showed a success rate of 90.0% and a reduction of
up to 41% in weight with recurrence [31].
In addition, a recent randomized controlled clinical study with the
crossover between APC and multidisciplinary management evaluated the
efficacy and safety of endoscopic treatment of increased anastomosis and
weight relapse. Forty-two patients were divided into two APC (n = 22)
and control (n = 20) groups. After 14 months of follow-up with a
crossover at 6 months, significant improvement in satiety and greater
weight loss was found in the APC group, as well as after the crossover.
APC was associated with significant weight loss (9.73 (7.46, 12) vs. +
1.38 (- 1.39, 2.15)), a reduction in the diameter of the anastomosis (p
<0.001), early satiety and increased quality of life measured
using the EQ5D index and the EQ5D VAS scale. The average weight loss
over the entire follow-up was similar in both groups (13.02 kg in the
APC and 11.52 kg in the control). Thus, this study showed that the
treatment of gastrojejunal anastomosis with APC was effective and safe
[32].
Another randomized controlled study analyzed ablation with argon plasma
coagulation (APC) with or without full-thickness endoscopic suture
(FTS-APC) for the treatment of weight gain when associated with
gastrojejunal dilation. Patients with at least 20% of nadir weight
recovery and GJ ≥ 15 mm were considered eligible. Forty patients who met
the eligibility criteria were enrolled from October 2017 to July 2018.
The technical and clinical success rates were similar between groups. At
12 months, the mean% TWL was 8.3% ± 5.5% in the APC group alone
versus 7.5% ± 7.7% in the FTS-APC group (p = 0.71). The%
pre-revisional solid gastric retention in 1 hour was positively
correlated with the probability of reaching ≥10% TWL in 12 months. Both
groups experienced significant reductions in low-density lipoprotein and
triglyceride levels in 12 months, and improvement in eating behavior and
quality of life in 3 months. There were 2 cases of stenosis (1 from each
group), which were successfully treated with endoscopic balloon dilation
[33].
In addition, a multicenter study comprising eight centers performed a
retrospective review of medical records and analyzed the effectiveness
of APC for weight recovery in terms of weight loss in RYGB patients. The
study analyzed data from 558 patients in eight bariatric centers in the
USA (1) and Brazil (7) who underwent the APC procedure between July 31,
2009, and March 29, 2017. As a result, the mean BMI decreased slightly
during the first 24 months. The average weight was 94.5 ± 18.6 kg and
the average BMI was 34.0 kg / m2 in the APC. The average weight loss was
6.5, 7.7 and 8.3 kg at 6, 12, and 24 months, respectively, and the
changes in weight over time were statistically significant (p
<0.0001). Of the 333 patients in four centers who provided
information on complications, complications after PCA included stenosis
(n = 9), GJ ulcer (n = 3), vomiting (n = 3), GJ leak (n = 2) and melena
(n = 1). Thus, APC can be useful in reducing the weight recovered after
RYGB, and patients experienced 6-10% total weight loss in 12 months.
[34].
In addition, a single-center retrospective study compared the
effectiveness of different APC configurations for the treatment of
weight recovery. Patients who received only low-dose APC (45-55 W) or
high-dose APC (70-80 W) were compared. Two hundred and seventeen
patients met the inclusion criteria and underwent 411 APC sessions. Of
these, 116 (53.5%) patients underwent 267 low-dose PCA sessions (2.4 ±
1.5 sessions / patient) and 101 (46.5%) patients underwent 144 high-PCA
sessions. dose (1.4 ± 0.7 sessions / patient). Follow-up rates were
82.9% and 75.3% at 6 and 12 months. At 6 months, the low and high dose
groups experienced 7.3% ± 6.6% and 8.1% ± 7.4% TWL, respectively (p
= 0.41). At 12 months, the low and high dose groups experienced 5.1% ±
8.5% and 9.7% ± 10.0% TWL, respectively (p = 0.008). Technical
success was 100%. The overall complication rate was 8.0%, involving
gastrojejunal stenosis (4.6%) [35].
In this scenario, to consolidate and confirm the findings of the present
meta-analysis study, a meta-analysis study summarized the efficacy and
safety of full-thickness suture plus mucosal coagulation with argon
plasma (ft-TORe) and mucosal coagulation with argon plasma alone
(APMC-TORe). Nine ft-TORe studies (n = 737) and seven APMC-TORe studies
(n = 888) were included. The percentage of total body weight loss was
8.0%, 9.5%, and 5.8% after ft-TORe and 9.0%, 10.2%, and 9.5% after
APMC-TORe in 3, 6, and 12 months, respectively, with no difference in
weight loss at 3 and 6 months. Only one serious complication was
observed after APMC-TORe and none after ft-TORe. Therefore, both ft-TORe
and APMC-TORe offer significant and comparable weight loss results with
a high and comparable safety profile, however, several endoscopic
sessions on the APMC-TORe were required [36].
Finally, a prospective study with 252 patients with RYGB determined the
technical viability and safety of TORe in the bag and assessed its
impact on weight and metabolic profiles. A suture was used to place
stitches around the JGA in a continuous ring. The suture was tightened
over a balloon (8 - 12 mm). Patients with RYGB underwent 260 TORes in
the bag. They had recovered 52.6 ± 46.4% of the weight lost and weighed
107.6 ± 24.6 kg. The technical success rate was 100%. At 6 and 12
months, the% TWL was 9.6 ± 6.3 and 8.4 ± 8.2. Two serious adverse
events (0.8%) occurred gastrointestinal bleeding and JGA stenosis. At
12 months, blood pressure, hemoglobin A1c and ALT improved. Thus, the
TORe in the bag to treat weight recovery after the RYGB proved to be
technically feasible and safe. In addition, it is associated with
improved weight profile and comorbidities up to 12 months after the
procedure [37].