Prospective evaluation of transoral outlet reduction (TORe) after Roux-en-Y gastric bypass (RYGB) failure.

BACKGROUND AND AIMS: Weight regain after RYGB is multifactorial including dilatation of the gastro-jejunal anastomosis. Transoral outlet reduction (TORe) procedure is a minimally invasive alternative to surgical anastomotic revision. METHODS: We conducted a prospective, multicenter, simple blind, randomized study in patients with weight regain following RYGB, comparing the efficacy of conventional nutritional and behavioral management associated with a TORe procedure (TORe group) with conventional management alone and a Sham procedure (Sham group). The main objective of this study was to evaluate the percentage of excess weight loss (%EWL) at 12 months after endoscopy. RESULTS: From January 2015 to January 2019, 73 subjects were randomized in four French Bariatric centers. The final analysis involved 50 subjects, 25 in each group, 44 women, 6 men, with an average BMI of 40.6 kg/m2. At 12 months, the average %EWL was significantly higher in the TORe group than in the Sham group (13.5 ± 14.1 vs. - 0.77 ± 17.1; p = 0.002). Cohen's d was 0.91, indicating a large effect size of the procedure on the %EWL. There was no significant difference between groups concerning the improvement of obesity-related comorbidities (diabetes and dyslipidemia) and quality of life at 12 months. We report frequent adverse events in the TORe group (20% had adverse events related to the procedure). Three adverse events were serious, including two perforations of the gastro-jejunal anastomosis after TORe group that led to the premature termination of the study. CONCLUSIONS: After RYGBP failure linked to the dilatation of the gastro-jejunal anastomosis, TORe procedure with nutritional management results in significantly higher %EWL at 12 months compared to patients with nutritional management alone. As surgery, this minimally invasive endoscopic procedure can be associated with severe adverse events.

Video. Transanal specimen retrieval using the transanal endoscopic microsurgery (TEM) system in minimally invasive colon resection.

BACKGROUND: During laparoscopic colectomy, the specimen is retrieved through substantial incisions, which increase postoperative pain, wound infections, and incisional hernias. In the era of natural orifice transluminal endoscopic surgery (NOTES), incisionless transrectal approaches for colon resections have been investigated with promising results [4-6]. Transanal retrieval of the colonic specimen in laparoscopic colectomy has been described but not widely adopted, although it seems to be an appealing step towards NOTES colectomy. We have used the TEM rectoscope (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL, USA) as a retrieval conduit, which facilitates transanal extraction of the specimen, and protects the rectal edge and anal sphincter during laparoscopic left colectomy. TECHNIQUE: After standard laparoscopic dissection and vascular control, the colon is divided distally, whereas the proximal colonic end is ligated to prevent fecal spillage. The TEM rectoscope is advanced through the rectal stump. The proximal colon is grasped and withdrawn through the rectoscope. The colon is stapled off proximally, and the specimen is removed transanally. An anvil is introduced into the pelvis through the rectoscope and inserted in the descending colon through a colotomy, which is subsequently sealed with an endo-loop. The rectoscope is withdrawn, and the rectal stump edge is stapled off. A circular stapler is introduced in the rectum, and end-to-end anastomosis is performed. DISCUSSION: The extraction incisions in laparoscopic colectomy increase invasiveness and compromise the "purity" of the laparoscopic approach. Retrieval of the specimen through natural orifices constitutes a stepping stone in the transition to future incisionless NOTES colectomy. These techniques have not been widely adopted because of technical difficulties and concerns regarding trauma. In our experience, transanal retrieval of the colonic specimen is hampered by friction between the specimen and the rectum, which requires countertraction to the edges of the open rectal stump. These manipulations are time consuming and increase the risk of injury, even when retrieval bags are used. The TEM rectoscope allows gentle dilation of the anus, provides stability during extraction, and protects the edges of the rectum, therefore decreasing the risk of rectal or anal canal injuries. It maintains pneumoperitoneum and eases retrieval of the specimen through the large-caliber metal conduit. Alternative options in the form of a rigid conduit would be the use of the transanal endoscopic operation device (Karl Storz, Tuttlingen, Germany), the plastic McCartney tube (Tyco Healthcare, Norwalk, CT, USA) used for transvaginal operations, or an anecdotally reported, "homemade" rectoscope from a customized polyvinyl chloride tube. Potential limitations of this technique include the increased cost of acquiring and using the TEM rectoscope, although this should not be significant if this reusable system is already available for transanal procedures. The 4 cm diameter of the TEM rectoscope can also be a limiting factor in the case of large, bulky, incompressible specimens or large colonic tumors. We have also avoided using this technique in patients with preexisting anal sphincter dysfunction and fecal incontinence, as well as in the presence of severe perianal disease (i.e., fistulae or fissures). Naturally, the open lumen in the peritoneal cavity raises concerns regarding bacterial contamination and potential tumor cell seeding in cases of cancer. Preliminary evidence on these issues comes from TEM and NOTES research without obvious signs of increased risk currently. We do not perform preoperative bowel preparation for our colectomies, but we do perform rectal enema with Betadine solution at the beginning of the procedure. CONCLUSIONS: Use of the TEM system facilitates transanal removal of the specimen and protects the anorectum during laparoscopic colectomy.

Electrical stimulation of the vagus nerve restores motility in an animal model of achalasia.

Esophageal peristalsis generally does not return to normal after surgical treatment of achalasia. Direct electrical stimulation of the vagus nerve is known to stimulate antegrade peristalsis in the normal esophagus; however, it is not known whether electrical stimulation will induce return of peristalsis once an achalasia-like disorder has been established. The objective of this study was to perform quantitive and qualitative measurements of motility during electrical stimulation of the vagal nerve in an animal model of achalasia. An already established and verified animal achalasia model using adult North American opossums (Didelphis virginiana) was used. Fifteen opossums were divided into three groups. Sham surgery was performed on three animals (group 1). In group 2 (n=6) a loose Gore-Tex band (110% of the esophageal circumference) was placed around the gastroesophageal junction to prevent relaxation of the lower esophageal sphincter during swallowing. In group 3 (n=6) a relatively tighter band (90% of the esophageal circumference) was used to further elevate the lower esophageal sphincter pressure. At 6 weeks, after manometric and radiolologic confirmation of achalasia, electrical stimulation of the esophagus was performed before and after removal of the band using a graduated square-wave electrical stimulus. Changes in esophageal neural plexi were assessed histologically. Pre- and postoperative manometric data were compared using standard statistical techniques. No difference was observed in esophageal characteristics and motility after sham surgery in group 1. Animals in group 2 demonstrated a vigorous variety of achalasia (high-amplitude, simultaneous, repetitive contractions), moderate esophageal dilatation, and degeneration of 40% to 60% of intramuscular nerve plexi. Animals in group 3 developed amotile achalasia with typical low-amplitude simultaneous (mirror image) contractions, severely dilated ("bird beak") esophagus, and degeneration of 50% to 65% of nerve plexi. Vagal stimulation in group 2 demonstrated a significant increase in the amplitude of contractions (P<0.001) and return of peristaltic activity in 49% of swallows before band removal. After band removal, all of the contractions were peristaltic. In group 3 vagal stimulation before and after removal of the band demonstrated a significant increase in amplitude of contractions (P<0.0001) but no return of propagative peristalsis before band removal, however, 44% of contractions were progressive in the smooth portion of the esophagus after removal of the band. Electrical stimulation of the vagus nerve improved the force of esophageal contractions irrespective of the severity of the disease; however, peristaltic activity completely returned to normal only in the vigorous (early) variety of achalasia. Removal of the functional esophageal outlet obstruction, as with a surgical myotomy, may be necessary to obtain significant peristalsis with vagal pacing in severe achalasia.