Endoscopic full-thickness suturing plus argon plasma mucosal coagulation versus argon plasma mucosal coagulation alone for weight regain after gastric bypass: a systematic review and meta-analysis

Background and Aims Endoscopic transoral outlet reduction (TORe) has been used to manage weight regain after Roux-en-Y gastric bypass (RYGB). We conducted a meta-analysis to summarize the efficacy and safety of the 2 most commonly used techniques: full-thickness suturing plus argon plasma mucosal coagulation (ft-TORe) and argon plasma mucosal coagulation alone (APMC-TORe). Methods A literature search of publication databases was performed from their inception through February 2020 for relevant studies. The outcomes of interest were %total body weight loss (%TBWL), gastrojejunal anastomosis (GJA) diameter, and adverse event (AE). The pooled effect estimates were analyzed using a random-effects model. Meta-regression was conducted to identify associations between GJA diameter and weight loss. Results Nine ft-TORe (n=737) and 7 APMC-TORe (n=888) studies were included. APMC-TORe was performed as a series of sessions (a mean number of sessions ranging from 1.2 to 3), whereas ft-TORe was mostly performed as a single session. Percentage TBWL was 8.0% (95% CI, 6.3%-9.7%), 9.5% (95% CI, 8.1%-11.0%), and 5.8% (95% CI, 4.3%-7.1%) after ft-TORe and 9.0% (95% CI, 4.1%-13.9%), 10.2% (95% CI, 8.4%-12.1%), and 9.5% (95% CI, 5.7%-13.2%) after APMC-TORe at 3, 6, and 12 months, respectively, with no weight-loss difference at 3 and 6 months (P > 0.05). Only one severe AE was observed after APMC-TORe and none after ft-TORe. Stricture formation was the most common AE (ft-TORe 3.3% and APMC-TORe 4.8%, P = 0.38). All were successfully treated by endoscopic dilation or conservative treatment. Smaller aperture of the post-TORe GJA and greater change in the GJA diameter correlated with greater weight loss in APMC-TORe and numerical trends in ft-TORe. Conclusions This meta-analysis demonstrated that both ft-TORe and APMC-TORe offer significant and comparable weight-loss outcomes with a high and comparable safety profile. However, APMC-TORe typically required multiple endoscopic sessions. Identifying a goal for final and change in GJA diameter could be useful treatment targets.