Clinical Trial for Weight Regain Post-RYGB: APC Versus APC Plus Endoscopic Suture Technique

Obesity is a worldwide health and sociopolitical problem. Excessive body-weight currently affects over 50% of the Brazilian population. It has been well established that obesity is an independent health risk. Obese individuals are at increased to extremely high risk for many diseases and for early death relative to those with normal weights and waist circumferences. The increased disease susceptibility for this subset of patients includes hypertension, stroke, hyperlipidemia, sleep apnea, Type 2 diabetes, neoplasms, Gastro-Esophageal Reflux Disease, and musculoskeletal disorders.

Bariatric surgery is the most effective treatment for obesity. As bariatrics grow, the number of patients suffering from surgical-related complications also grows. One of the most worrisome long-term complications is weight regain, once the patient may be again affected by overweight-related comorbidities and face again pre-operative esthetic issues.

This trial focus on testing efficacy and safety of two endoscopic revisional procedures in patients suffering from weight regain following Roux-en-Y Gastric Bypass: Ablation with Argon Plasma Coagulation (APC) versus APC plus Endoscopic Full-thickness Suture (with Apollo Overstitch device). Pouch volume, gastric emptying and gut hormones changes will also be assessed.

Obesity is a worldwide health and sociopolitical issue. Excessive body-weight currently affects over 50% of the Brazilian population and around 13% of all world population. It has been well established that obesity is an independent risk factor. Obese individuals are at increased risk of diseases and earlier death compared to those with normal weight and waist circumferences. The increased disease susceptibility of this subset of patients includes hypertension, stroke, hyperlipidemia, sleep apnea, Type 2 diabetes, neoplasms, GERD, and musculoskeletal disorders.

Obese patients and their physicians have increasingly turned to surgery to solve the excess weight issue and the frequent co-morbid conditions that impact their health and quality of life. Roux-en-Y Gastric Bypass (RYGB) and Laparoscopic Gastric Banding (LGB) comprise around 70% of all weight loss procedures performed every year. They induce significant and perennial weight loss and reduce or eliminate associated co-morbid diseases, including Type 2 diabetes. Despite improvements in postoperative morbidity and mortality rates over the years, (in part due to the use of a laparoscopic approach), these procedures still carry significant risk. Recent studies have shown mortality rates with RYGB as high as 1.9%, and complications associated with LGB as high as 13%. Nonetheless, a secondary bariatric procedure due to weight regain carries significant complication rates and worse outcomes, compared to the primary procedure. Consequently, less invasive techniques are needed to reduce such risks.

Gastric restriction is an important principle of both RYGB and LGB. The OverStitchTM Endoscopic Suturing System (Apollo Endosurgery, Inc. Austin, Texas) is an approved device designed to endoscopic placement of suture(s) and approximation of soft tissue. This system offers the assistant doctor the ability to restrict gastric pouch size by approximating tissue endoluminally through an incisionless (per-oral) approach. The use of this system has the potential to reduce the complications associated with the current surgical approach but still reaching the desired gastric restriction. The OverStitch has safely been used clinically for a great number of procedures that demanded an incisionless or minimally invasive approach, including endoluminal revisions for post-bypass gastric stoma and/or pouch dilatation, post-bypass fistulae repair, and oversewing of marginal ulcers.

Besides this suturing device, other endoscopic methods have already been used to reduce dilated stoma. Among them, ablation with argon plasma coagulation (APC) is one of the most important since this device is worldly available and presents an acceptable cost. Recent studies associate APC prior to endoscopic suture and initial evidence supports superiority of this association.

However, literature is still lacking of studies to support the use of APC associated with endoscopic suturing instead of APC alone. Therefore, the main focus of this study is to directly compare short and long-term effectiveness and safety of APC versus APC plus Endoscopic Full-thickness suture with OverStitch device in patients suffering from weight regain following RYGB.

Moreover, gut hormones regulation regarding bariatric and revisional procedures have been studied recently and evidence suggests that hormonal changes may be an important factor in weight loss. Three of the most important gut hormones regarding weight balance are ghrelin, GLP1 and peptide YY. Ghrelin is known as hunger hormone. It is produced by cells in gastric fundus. Glucagon-like Peptide 1 (GLP1) and Peptide YY (PYY) are both hormones that regulate satiety and are produced by L cells along distal intestine. Evidence in bariatric show that after long-term ghrelin levels diminish while GLP and PYY reach higher post-prandial peak. Regarding revisional endoscopic therapy, gut hormone changes have never been studied. That is also focus of this study as secondary outcome.

Eligibility Criteria:
Inclusion Criteria:

1. Subject has stoma dilation defined as greater than 12mm, assessed with an esophagogastroduodenoscopy performed pre-operatively
2. Subject is ≥ 18 yrs. of age and ≤ 60 yrs. of age
3. Subject has a BMI of \> 30
4. Subject has history of obesity for \> 2 yrs
5. Subject has had no significant weight change (\<5% of total body weight) in last 6 months
6. Subject must have failed standard obesity therapy (diet, exercise, behavior modification, and pharmacologic agents either alone or in combination), which will be assessed through an interview performed by a team member of the study at baseline
7. Subject is a reasonable candidate for general anesthesia
8. Subject agrees not to have any additional weight loss surgery or reconstructive surgery that may affect body weight (i.e. mammoplasty, liposuction, lipoplasty, etc) during the trial
9. Subject must be willing and able to participate in all aspects of the study and agree to comply with all study requirements for the duration of the study. This includes availability of reliable transportation and sufficient time to attend all follow-up visits.
10. Subject must be able to fully understand and be willing to sign the informed consent.

Exclusion Criteria:

1. Subject has had significant weight loss in the last 3 months, or between baseline and the study procedure
2. Mallampati (intubation) score greater than 3
3. Subject is observed during esophagogastroduodenoscopy to have heavily scarred, malignant or poor quality/friable tissue in areas of the stomach where sutures are to be placed
4. Subject has history of inflammatory disease of GI tract
5. Subject has a history of intestinal strictures or adhesions
6. Subject has renal and/or hepatic insufficiency
7. Subject has chronic pancreatic disease
8. Subject has history of/or signs and/or symptoms of gastro-duodenal ulcer disease and/or active peptic ulcer
9. Subject has significant esophageal disease including Zenker's diverticulum, grade 3-4 reflux esophagitis, stricture, Barrett's esophagus, esophageal cancer, esophageal diverticulum, dysphagia, achalasia, or symptoms of dysmotility
10. Subject has a history of any significant abdominal surgery
11. Subject has had previous bariatric, gastric or esophageal surgery; intestinal obstruction; portal gastropathy; gastrointestinal tumors; esophageal or gastric varices, or gastroparesis
12. Subject has a hiatal hernia \> 2cm
13. Subject has chronic/acute upper GI bleeding conditions
14. Subject has severe coagulopathy (prothrombin time \> 3 seconds over control or platelet count \< 100,000) or is presently taking heparin, coumadin, warfarin, or other anticoagulants or other medications which impede coagulation or platelet aggregation, if they cannot be ceased for the procedure
15. Female subject is of childbearing age and not practicing effective birth control, is pregnant or is lactating
16. Subject has symptomatic congestive heart failure, cardiac arrhythmia or unstable coronary artery disease.
17. Subject has cancer or life expectancy of \< 2 yrs