DISCUSSION
The GJA review by APC is known to be a relatively safe and effective
strategy to manage weight recovery after RYGB. Bleeding at the
anastomotic site is an uncommon complication associated with this
therapy. Another possible complication is the stenosis of the
anastomosis. Endoscopic treatment is the first-line therapy for both
situations [13].
In the present study, the endoscopic APC has used with the objective of
reducing the diameter of GJA and, therefore, promoting weight loss after
RYGB that was relapsed. The results obtained were similar to the
literature. Figures 2 and 3 show the results of weight loss in both
groups, with the average weight reduction in the APC group being 15.02 ±
9.63 in relation to the Sham control group after 6 months. Thus, the
present study confirms the literary findings, showing that this
reduction in weight that has relapsed after RYGB is closely related to
the reduction of the anastomotic diameter from 34.25 ± 6.13 mm (initial)
to 12.65 ± 2.11 mm (final), with a reduction of 21.60 ± 3.19 mm,
considering that the liquid diet and nutritional counselling were
applied in both groups.
Another important fact that the present study confirmed has in relation
to the safety and efficacy of the APC outlet reduction procedure, given
that there has only one complication due to stenosis after the first
session of the APC, not requiring treatment. In addition, the technique
has 100% successful.
According to the results of the present study, authors studied 30
patients undergoing treatment with an argon plasma, after gastric
bypass, and observed after 3 endoscopic sessions of APC spaced between
each other by 8 weeks, with an average weight loss of 15.0 kg. In
addition, a prospective controlled longitudinal study with APC showed a
success rate of 90.0% for weight loss using APC and a reduction of up
to 41.0% in the relapsed weight.[19] Another
study retrospective with 37 participants, the use of APC had a success
rate of 50.0% for weight loss using APC and a 24.0% reduction in
relapsed weight.[21]
Further, a study analyzed APC with a 3 and 6-month follow-up as
anastomotic reduction therapy after RYGB and showed that in 53 patients
(age 49.0 ± 1.3 years, BMI mean was 52.1 ± 10.7 kg
m-2. The postoperative period, BMI mean was 29.6 ± 1.1
kg m-2. The argon plasma has performed 8.6 ± 3.4 years
after RYGB, with weight recovery resulting in a BMI of 35.4 ± 1.1 kg
m-2. The reduction in anastomosis was 16.1 ± 3.7 mm to 13.5. The average
number of sessions was 1.3.[24] An anastomotic
diameter size over 15.0 mm in the weight regain scenario may be subject
to endoscopic review.[18,32,33]
Also, authors published retrospective analysis data obtained from 558
patient records with regained weight in eight bariatric centers in the
USA and Brazil, who underwent APC between July 31, 2009, and March 29,
2017. The mean weight was 94.5 ± 18.6 kg and the mean BMI was 34.0
kg/m2 in the APC. When data were available, the mean
of the lowest weight was 67.0 ± 23.0 kg and the mean of the lowest BMI
was 24.1 kg/m2 after RYGB. 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.[11]
Besides, authors evaluated the efficacy and safety of endoscopic
treatment of increased GJA with APC. A randomized controlled study was
performed comparing APC to exclusive multidisciplinary management after
regaining weight. Forty-two patients were divided into two groups: APC
(n=22) and control (n=20). After 14 months of follow-up with a crossover
in 6 months, significant improvement in satiety and greater weight loss
has found in the APC group and after crossing. APC has associated with
significant weight loss 9.73 vs. + 1.38), reduction in anastomosis
diameter, early satiety (0.77 vs. 0.59), p<0.001, and
increased quality of life. Considering the average total weight loss
during the entire follow-up, weight loss was similar in both groups
(13.02 kg in the APC and 11.52 kg in the
control).[12]
Also, another study published in 2020[14],
reported ablation with argon plasma coagulation (APC) plus
full-thickness endoscopic suture (FTS-APC) and ablation alone for the
treatment of weight recovery. A randomized, single-pilot study with
forty patients, comparing the efficacy and safety of APC alone versus
FTS-APC for transoral outlet reduction. Patients weighing at least 20%
recover from the nadir and GJA ≥ 15 mm were considered eligible. The
primary endpoint was the percentage of total weight loss (% TWL) in 12
months. Secondary outcomes were the incidence of adverse events,
improvement in laboratory metabolic parameters and improvement in the
quality of life, and eating behavior. At 12 months, the mean %TWL was
8.3% ± 5.5% in the APC group alone versus 7.5% ± 7.7% in the STF-APC
group. The percentage of solid pre-revision gastric retention in 1 hour
was positively correlated with the probability of reaching ≥10% TWL in
12 months. Both groups experienced significant reductions in levels of
low-density lipoprotein and triglycerides at 12 months.
A recent retrospective study of two hundred and seventeen patients
compared the effectiveness of different APC configurations in the
treatment of weight recovery. Patients who received low-dose (45-55 W)
and high-dose (70-80 W) APC were compared. Of the selected patients, 116
(53.5%) patients underwent low-dose APC sessions (2.4 sessions/patient)
and 101 (46.5%) patients underwent 144 APC sessions. in high doses (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 showed 7.3%
and 8.1% TWL, respectively. At 12 months, the low and high dose groups
experienced 5.1% and 9.7% TWL, respectively. Technical success was
100%. The overall rate of AE was 8.0%, with stenosis being 4.6%.
Therefore, the higher watt APC has associated with greater weight
loss.[15]
In this context, the authors Heneghan et al.
(2012)[25] concluded that patients with normal
post-surgical anatomy regain less weight than patients with altered
proximal surgical anatomy, especially in the increase in the diameter of
the gastrojejunal anastomosis. In addition, the authors Abu et
al[26] and Ramos et al.
(2017)[27] evaluated the size of GJA and its
influence on weight loss, where an anastomosis calibrated to 15.0 mm
shows better results when compared to the anastomosis of 45.0 mm in a
2-year follow-up. Therefore, values between 10 and 15.0 mm are the
desired GJA diameter.
Thus, several methods such as endoluminal reduction of GJA such as
surgery[28],
suturing[29,30], and APC in gastrojejunal
anastomosis have been proposed to reduce the recovered weight in
patients undergoing RYGB.[12] In this scenario,
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.[28]
Besides, transoral outlet reduction (TORe) performed using a traditional
suture pattern is effective in inducing short and medium-term weight
loss in patients with weight recovery after
RYGB.[30] In this sense, a study analyzed the
technical feasibility and safety of TORe in stock markets were
determined and its impact on weight and metabolic profiles has assessed.
Patients with RYGB who underwent pouch TORe were included. The GJA has
ablated by coagulation with argon plasma or dissected by endoscopic
submucosal dissection. A suture has used to place stitches around the
GJA in a continuous ring. The suture has attached to a balloon (8-12
mm). The primary endpoint was technical feasibility. Secondary outcomes
were the percentage of total body weight lost (% TWL), adverse events,
impact on comorbidities, and predictors of weight loss. Thus, 252
patients with RYGB were submitted to 260 TORe. They 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. At 12 months, blood pressure, hemoglobin A1c and ALT had
improved.[31]
A systematic review and meta-analysis study evaluated the effectiveness
of endoscopic therapies for recovered weight after RYGB. The primary
endpoints were absolute weight loss (AWL), excess weight loss (EWL), and
total body weight loss (TBWL). Thirty-two studies were included in the
qualitative analysis. Twenty-six full-thickness (FT) endoscopic sutures
described and AWL, EWL, and TBWL combined in 3 months were 8.5 kg, 21.6
kg and 7.3 kg, respectively. At 6 months, they were 8.6 kg, 23.7 kg and
8.0 kg, respectively. At 12 months, they were 7.63 kg, 16.9 kg and 6.6
kg, respectively. Subgroup analysis showed that all results were
significantly greater in the group with suture with TF combined with
APC. Two articles described APC alone with an average AWL of 15.4 ± 2.0
and 15.4 ± 9.1 kg at 3 and 6 months, respectively. When performing APC
before the suture, it seems to result in greater weight
loss.[32]
Since the loss of gastric restriction in the bypass can be one of the
main causes of obesity recurrence. Therefore, the present study showed
that the use of argon plasma in reducing the gastrojejunal anastomosis
diameter promoted greater weight loss compared to the control group that
underwent only to upper digestive endoscopy with sedation and liquid
diet.