Endoscopic mucosal resection – transoral outlet reduction: treatment of excessively wide gastro-jejunal anastomosis

Excessively wide gastro-jejunal anastomosis (GJA) after gastric bypass can result in weight gain or refractory dumping syndrome. We propose an alternative endoscopic procedure to the so-called TORe (Transoral Outlet Reduction) performed by endoscopic suturing of the GJA.

The first case involved a 36-year-old woman with grade III obesity who had undergone multiple bariatric surgeries (gastric band placement and gastric bypass). Initially, significant weight loss has been obtained. However, 8 years later, she lost all her weight. Additional examinations were conducted to assess the surgical configuration. Gastroscopy revealed a nonstraight anastomosis.

The second case involved a 68-year-old man who had undergone repeated operations for a hiatal hernia with significant GERD, which led to a GJA. Since this surgery, he no longer has GERD, but a severe dumping syndrome is present at every meal 9 years later. Gastroscopy revealed a huge enlargement of GJA.

Therefore, we performed both the new endoscopic procedures that we call EMR-TORe.

This procedure regained almost involved a circular mucosectomy at the anastomosis site, performed using a large-channel operative endoscope, under CO₂ insufflation, with a Duette (Wilson cook) elastic band ligature system ([Video 1]). The diet was initially liquid and then blended, and a proton pump inhibitor treatment was initiated for 2 months. The patient was followed up every month clinically and a new endoscopy was realized at 2 months. The first patient has lost 8 kg and the second no longer has dumping syndrome.

This is the EMR-TORe endoscopic procedure. Using a large-channel operative endoscope, with a duette elastic band ligature system, after injection of adrenaline serum, a circumferential mucosectomy of the gastrojejunal anastomosis is performed from proximal to proximal.Video 1

This technique has been developed for the treatment of GERD [1] with an incomplete circumferential EMR to avoid stenosis, called in this indication ARMS. Nevertheless, the stenosis rate is approximately 20%. In these patients, a complete EMR was performed to narrow as much as possible the GJA, inducing a fibrotic scar. Thus, endoscopically the two anastomoses have been narrowed leading to an accurate clinical result.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• Reference

• 1 Monino L, Gonzalez J-M, Vitton V. et al. Antireflux mucosectomy band in treatment of refractory gastroesophageal reflux disease: a pilot study for safety, feasibility and symptom control. Endosc Int Open 2020; 8: E147-E154

Publikationsverlauf

Artikel online veröffentlicht:
06. Mai 2025