Endoscopic Gastrojejunal Revision (Transoral Outlet Reduction) for Persistent Hypoglycemia After Gastric Bypass

The patient presented with symptomatic postprandial biweekly hypoglycemic seizures. Her hypoglycemic episodes were aggravated by stress and also occurred during sleep. She managed these hypoglycemic episodes with an endocrinologist, trying both nutritional and medical management without successful control of her symptoms. An endoscopic gastrojejunal revision (EGJR) was recommended to provide more restriction and prolong transit time into the Roux limb to decrease the chance of postoperative dumping syndrome and subsequent hypoglycemia.

This video is a case study of an EGJR done for persistent postoperative hypoglycemia. The gastroscope was introduced and using Argon Plasma Coagulation at a flow of 8 liters/min and 30 watts; the mucosa around the gastrojejunal stoma was ablated circumferentially. This was done to decrease bleeding from needle placement and to promote adherence of the mucosa after the sutures were placed. The purse-string technique was favored for this procedure due to an inherent reduction in suture tension. Several full-thickness bites were taken to narrow the stoma from 20 to 4 mm in diameter.

The patient was discharged home the same day following the procedure. She was placed on a two week liquid bariatric postoperative diet. At two week follow-up, the patient reported normal  blood sugars and no hypoglycemic episodes since surgery. At six month follow-up, the patient reported significant improvement in her hypoglycemia symptoms, and no further syncopal episodes or seizures.

We believe this case demonstrates that endoscopic gastrojejunal revision (or EGJR) is an effective treatment option for postprandial hypoglycemia following Roux-en-Y gastric bypass.