肥胖是一个复杂的疾病过程,这通常需要多因素,为患者量身定制的有效管理策略。治疗选择包括生活方式的优化,药物治疗,儿科,和肥胖症代谢内窥镜检查。基于肥胖的干预措施在患有严重肥胖的患者人群中可能具有挑战性。尤其是胃旁路术后。我们报告了一例非手术患者的远程开放胃旁路术失败,他接受了内窥镜小肠改道手术,导致部分热量转移,通过创建EUS引导的空肠造口术(EUS-JC)。该手术是先前报道的EUS引导和基于磁体的小肠旁路手术的延伸,在这种情况下,为了减肥的目的(Kahaleh等人。,1;Jonica等人。GastrointestEndosc.97(5):927-933,2;Machytka等人。GastrointestEndosc.86(5):904-912,3;)。该手术没有围手术期并发症,在随访期间有效减肥。针对小肠的内镜减肥干预措施,例如EUS-JC,为肥胖管理提供有希望的工具,应该进一步研究。许多因素包括生活方式,社会心理,遗传,行为,和继发性疾病过程导致肥胖。严重肥胖(定义为BMI>50kg/m2)与发病率和死亡率增加相关,对治疗的反应显着降低(Flegal等人。JAMA.309(1):71-82,4;)。在RYGB后,高达50%的患者可以注意到体重恢复。在严重肥胖的人群中,相关的5年手术失败率为18%(Magro等人。肥胖Surg.18(6):648-51,5;)。这些患者可能不是进行翻修的手术候选人,也可能会出现翻修后的慢性蛋白质热量营养不良(Shin等人。ObesSurg.29(3):811-818,6;)。生活方式,修改,药物治疗,或内窥镜经口减少术(TORE)通常是有效的;然而,严重肥胖患者,所需的总的过量体重减轻可能不可能仅通过这些策略来实现。内窥镜小肠干预可以从小肠吸收中转移一部分热量摄入,这可能会促进体重减轻,类似于Roux肢体的手术延长(Shah等人。ObesSurg.33(1):293-302,7;Hamed等人。AnnalSurg.274(2):271-280,8;),在这个意义上说,总小肠表面积的吸收减少。Roux肢体扩张可有效恢复旁路术后患者的体重。EUS-JC技术旨在通过减少用于吸收的总小肠表面积来类似地工作。由于该患者被视为非手术候选人,提供了EUS指导的空肠造口术。在程序之前,患者通过我们的减肥营养师和肥胖医学服务建立了纵向护理。对广泛的减肥前实验室进行了筛选,以排除复发性严重肥胖的混杂因素。术中,患者接受了1剂500mg静脉注射左氧氟沙星.手术后,根据术后腹泻的需要,每8小时服用洛哌丁胺。2周内,患者不再服用止泻药。手术后的饮食包括2天的流质饮食,然后进行1个月的低残留饮食,然后有规律的饮食.
Obesity is a complex disease process, which often requires multifactorial, patient-tailored strategies for effective management. Treatment options include lifestyle optimization, pharmacotherapy, endobariatrics, and bariatric metabolic endoscopy. Obesity-based interventions can be challenging in patient populations with severe obesity, particularly post-gastric bypass. We report the case of a non-surgical patient with a failed remote open gastric bypass, who underwent an endoscopic small bowel diversion procedure, resulting in partial caloric diversion, via the creation of an EUS-guided jejunocolostomy (EUS-JC). The procedure is an extension of prior reported EUS-guided and magnet-based small bowel bypass procedures, in this case, for the purposes of weight loss (Kahaleh et al., 1; Jonica et al. Gastrointest Endosc. 97(5):927-933, 2; Machytka et al. Gastrointest Endosc. 86(5):904-912, 3;). The procedure was performed without peri-procedural complications, with effective weight loss during follow-up. Endoscopic bariatric interventions that target the small bowel, such as EUS-JC, offer promising tools for obesity management and should be studied further. Numerous factors including lifestyle, psychosocial, genetic, behavioral, and secondary disease processes contribute to obesity. Severe obesity (defined as a BMI > 50 kg/m2) is associated with increased morbidity and mortality with a significantly reduced response to treatment (Flegal et al. JAMA. 309(1):71-82, 4;). Weight regain can be noted in up to 50% of patients post-RYGB. In populations with severe obesity, there is an associated 5-year surgical failure rate of 18% (Magro et al. Obesity Surg. 18(6):648-51, 5;). These patients may not be surgical candidates for revision or can develop post-revision chronic protein-caloric malnutrition (Shin et al. Obes Surg. 29(3):811-818, 6;). Lifestyle, modification, pharmacotherapy, or endoscopic transoral reduction (TORe) can be effective generally; however, in patients with severe obesity, the total desired excess body weight loss may not likely be accomplished solely by these strategies. An endoscopic small bowel intervention that diverts a portion of caloric intake from small bowel absorption can potentially promote weight loss similar to a surgical lengthening of the Roux limb (Shah et al. Obes Surg. 33(1):293-302, 7; Hamed et al. Annal Surg. 274(2):271-280, 8;), in the sense that there is a reduction in the total small bowel surface area for absorption. Roux limb distalization can be effective for weight regain for post bypass patients. The EUS-JC technique aims to work similarly by reducing the total small bowel surface area utilized for absorption. Since this patient was deemed a non-surgical candidate, an EUS-guided jejunocolostomy was offered. Prior to the procedure, the patient established longitudinal care with our bariatric nutritionist and obesity medicine services. Extensive pre-bariatric labs were screened to rule out confounders for recurrent severe obesity. Intra-procedure, the patient received one dose of 500 mg intravenous levofloxacin. Post-procedure, loperamide was prescribed every 8 h as needed for post-procedure diarrhea. Within 2 weeks, the patient was no longer taking anti-diarrheals. The post-procedure diet consisted of a liquid diet for 2 days before advancement to a low-residue diet for 1 month, and then a regular diet.