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Incisionless Endoscopic Procedures for Unsuccessful Gastric Bypass

obesity gastric bypass

The most popular and effective procedure for the treatment of obesity is the Roux-en-Y gastric bypass (RNYGB). The RNYGB is a combination of a restrictive and malabsorptive procedure.  Firstly, the stomach size is reduced and then a section of the small intestine (called the jejunum) is bypassed so that less calories are absorbed. In case of such weight regain, Dr. Starpoli examines the stomach of those having had gastric bypass who have regained weight.  The examination is performed by way of a simple upper endoscopic camera inspection of the stomach pouch and the bypassed connection.  Basically, in patients that regain weight after gastric bypass, Dr. Starpoli looks for dilated bypassed connection.

Altogether, studies show the following rates of excess weight loss after RNYGB:

  • 67% of excess weight at 1-2 years post-op.
  • 60% at 5 years post-op.
  • More than 50% at years 5 through 10 post-op.
  • All things considered, RNYBG will fail and patients will regain weight in some 20-35% of patients.

Weight regain after gastric bypass anti-obesity surgery is referred to as post-gastric bypass recidivism.  Basically, gastric bypass patients can experience failure causing weight regain and may undergo revision.

Weight regain after Gastric Bypass may very well be related to lifestyle and dietary habits.  Studies conducted and published by Dr. Starpoli, show that the stomach pouch and/or outlet made smaller by Gastric Bypass surgery can gradually stretch over time.  The dilated stomach pouch and outlet make the patient lose the sense of fullness.  As a result, patients can consume more and regain weight.

Read Dr. Starpoli’s published work on the success of stomal revision with TORe

We know that surgical revision of stomach pouch and/or outlet is undesirable because of the inherent surgical risks.  Accordingly, there is a possibility of an anastomotic (connection) leakage after an attempt of surgical revision.  As an alternative, incisionless, endoscopic through the mouth suturing can reduce the diameter of the bypassed connection known as the anastomosis.  The point is that the so called outlet reduction is restored to the original post-operative size.  Therefore, the reduction causes a restriction of calories consumed and absorbed.

Dr. Starpoli offers qualified patients a safe and effective incisionless, endoscopic suturing procedure.   The goal is reduce the size of an enlarged outlet to the original post-bypass proportions. The procedure is referred to as the Transoral Outlet Reduction (TORe).  

Dr. Starpoli performs the procedure using a small flexible endoscope passed through the mouth.  In this case, a specialized sewing device is affixed to the end of the scope that allows sutures to be placed in the stomach pouch.  Sutures are then placed around the outlet to reduce the diameter.  As a result,  he reduces the opening from the size of a silver dollar to less than the size of a dime. Additionally, the same technique may then be used to place additional sutures in the stomach pouch to diminish its volume capacity.

“In the evolution of natural orifice, translumenal endoscopic surgery (NOTES), transoral suturing techniques for stomal revision of the dilated GJ anastomosis are examples of NOTES.  As a matter of fact, there may be a chance that your poor weight control after gastric bypass surgery may be the result of an expansion or stretching of the connection between the stomach pouch and the intestine. In this case, I perform a simple upper endoscopy exam of the stomach pouch can make the diagnosis.  After that, you could be offered an incisionless, nonsurgical approach to correct the problem.  Naturally, sound nutritional advice should be available, as well as close follow up with your medical or bariatric physician.” Dr. Starpoli


Patients feel little discomfort from the endoscopic revision procedure.  Minor side effects may include gas pain, nausea and a sore throat.  Additionally, a swollen tongue and lip pain from device insertion may occur.  These conditions are usually very temporary.

Another key point is that patients typically return to their normal routine within 48 hours. Accordingly, following endoscopic outlet and pouch repair, Dr. Starpoli places patients are placed on a 2 week liquid based diet.  Subsequently, they should follow a similar diet and exercise regimen used after their initial weight loss surgery.

Basically, coverage depends on the patient’s insurance plan. Additionally, self-pay options are available.  For further information, please speak with our offices.  Our office attempts to obtain a preauthorization or predetermination for coverage by your carrier.

The TORe Procedure

Endoscopic gastric bypass revision is a less invasive approach to revising a previous gastric bypass surgery using an endoscope. Over time, some patients who undergo Roux-en-Y gastric bypass (RYGB) might experience weight regain or may not achieve the desired weight loss initially. One reason for this can be the enlargement or stretching of the stomach pouch and/or the gastrojejunal anastomosis (the connection between the stomach pouch and the small intestine).

The endoscopic approach to gastric bypass revision aims to reduce the size of the stomach pouch and/or the diameter of the gastrojejunal anastomosis without the need for open or laparoscopic surgery. Here’s a brief overview of the procedure:

  1. Endoscope Insertion: The procedure begins by inserting an endoscope, which is a flexible tube with a camera and light at the end, through the mouth and down into the stomach. Instruments can be passed through the endoscope to perform the necessary surgical modifications.

  2. Suturing or Plicating: Specialized devices are used to place sutures (stitches) or pleats in the stomach pouch and/or gastrojejunal anastomosis. This effectively reduces their size.

  3. Endoscopic Suturing Devices: Several devices, like the OverStitch™ system, allow for suturing through an endoscope. This tool can be used to place sutures in the stomach, helping to reduce its volume or tighten the anastomosis.

  4. Recovery: Since the procedure is less invasive than traditional surgical revisions, recovery times tend to be quicker, and there’s often less associated pain and risk of complications.