Endoscopic Management of Weight Regain post Gastric Bypass

Endoscopic revision of a dilated gastrojejunal (GJ) stoma using endoluminal suturing or argon plasma coagulation (APC) 1) Endoluminal suturing involves the placement of sutures at the GJ stoma using a suturing platform that fixed on the end of a flexible endoscope, resulting in reduction of the lumen size 2. APC involves the use of a jet of ionized argon gas (plasma) that is directed through a catheter placed down the working channel of an endoscope. The probe is placed near the mucosa, and argon gas is emitted then ionized by a high voltage discharge resulting in controlled thermal injury to the stoma. Subsequent healing with fibrosis leads to narrowing of the GJ stoma. This is a single-centre study (Endoscopy Unit, Gastroenterology and Hepatology Department, The Royal Brisbane and Women's Hospital, Queensland). All procedures will be performed by 1 of 2 experienced endoscopists (Dr Patrick Walsh or Dr Jason Huang). Participants undergoing the procedure will require either a general anesthetic or propofol based sedation depending on patient factors, as per standard practice. Eligible participants will be identified from the bariatric clinic and consented. The gastroscopy (Olympus, Japan), overstitch device (Apollo Endosurgery, USA), APC system (ERBE, Germany) and biopsy forceps (Boston, USA) will be utilized. Selecting therapy for participants based on the size of the GJ stoma: A gastroscopy will be performed to allow initial inspection and measurement of the size of the GJ stoma using a jumbo biopsy forceps, with an 8mm opening. The opened biopsy forceps will be placed at the lumen of the GJ stoma, allowing direct measurement of the size. Participants with a stoma size of less than 15mm will be treated with APC, while other participants (i.e.: stoma size more than or equal to 15mm) will be treated with the overstitch device. Participants will be routinely admitted into the ward for observation and discharge the following day. They are on small volume of clear fluids liquid on the day of the procedure. On discharge, the participants are placed on 2 weeks of very low energy diet meal replacements shakes. They will progress onto fluid diet and soft diet and gradually return to a normal diet over 8 weeks under the supervision of the dietitian in the bariatric clinic. Participants will then be reviewed in the bariatric clinic together with a dietitian at 3-, 6-, 9-, 12-, 18-, and 24- months. Follow up weight change, body mass index (BMI), percentage EWL and percentage of total weight loss will be measured in these clinic consultations. All participants will have a repeat endoscopy at 3 months to measure post intervention stoma size.