Title: Modified endoscopic submucosal dissection techniques before endoscopic revision of a gastric bypass
Abstract: Preparation of the mucosa is one of the most important parts of endoscopic mucosal apposition and suturing. We show the endoscopic revision of a gastric bypass with the use of modified endoscopic submucosal dissection (ESD) techniques to incise the mucosa surrounding the gastrojejunal anastomosis and suture directly into the exposed submucosa and muscularis propria. A 34-year-old woman who had undergone a laparoscopic Roux-en-Y gastric bypass presented for weight regain and was found to have a dilated gastrojejunal anastomosis. Endoscopic revision was pursued. We first injected the submucosa with a methylene blue and epinephrine solution in saline solution. We made an incision circumferentially about 5 mm away from the gastrojejunal anastomosis, using a needle-knife and insulated tip knife. We then extended the incision with an insulated tip knife. Finally, we placed an endoscopic suture in a purse-string fashion and secured it over a balloon to reduce the aperture of the anastomosis (Fig. 1; Video 1, available online at www.giejournal.org). This technique may not be appropriate for patients with extensive scarring or fibrosis at the anastomosis. The patient lost a total of 42 pounds in 3 months. Thus, a modified ESD before purse-string anastomotic suturing can result in a durable gastric bypass revision with excellent weight-loss outcomes.