Endoluminal procedures for bariatric patients: expectations among bariatric surgeons

Overview on the endoscopic treatment for obesity: A review

Obesity rates have increased, and so has the need for more specific treatments. This trend has raised interest in non-surgical weight loss techniques that are novel, safe, and straightforward. Thus, the present review describes the endoscopic bariatric treatment for obesity, its most recent supporting data, the questions it raises, and its future directions. Various endoscopic bariatric therapies for weight reduction, such as intragastric balloons (IGBs), aspiration therapy (AT), small bowel endoscopy, endoscopic sleeve gastroplasty, endoluminal procedures, malabsorption endoscopic procedures, and methods of regulating gastric emptying, were explored through literature sourced from different databases. IGBs, AT, and small bowel endoscopy have short-term effects with a possibility of weight regain. Minor adverse events have occurred; however, all procedures reduce weight. Vomiting and nausea are common side effects, although serious complications have also been observed.

Medical devices for the treatment of obesity

Obesity is a major public health concern that leads to numerous metabolic, mechanical and psychological complications. Although lifestyle interventions are the cornerstone of obesity management, subsequent physiological neurohormonal adaptations limit weight loss, strongly favour weight regain and counteract sustained weight loss. A range of effective therapies are therefore needed to manage this chronic relapsing disease. Bariatric surgery delivers substantial, durable weight loss but limited access to care, perceived high risks and costs restrict uptake. Medical devices are uniquely positioned to bridge the gap between more conservative lifestyle intervention and weight-loss pharmacotherapy and more disruptive bariatric surgery. In this Review, we examine the range of gastrointestinal medical devices that are available in clinical practice to treat obesity, as well as those that are in advanced stages of development. We focus on the mechanisms of action as well as the efficacy and safety profiles of these devices. Many of these devices are placed endoscopically, which provides gastroenterologists with exciting opportunities for treatment.

Outcomes following 50 consecutive endoscopic gastrojejunal revisions for weight gain following Roux-en-Y gastric bypass: a comparison of endoscopic suturing techniques for stoma reduction

BACKGROUND

Approximately 20-30 % of morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGB) will experience significant weight regain in the years following surgery. Endoscopic gastrojejunal revision (EGJR) has been shown to be a safe, effective and less invasive alternative to revisional surgery, with promising weight loss outcomes. However, minimal data exist regarding how to perform the procedure most effectively and what factors may predict good outcomes. We compared weight loss outcomes between patients undergoing endoscopic stoma revision by one of two full-thickness suturing techniques.

METHODS

A retrospective review of patients undergoing EGJR between 06/2012 and 09/2015 was performed. Included patients were adults 18-74 years of age who had experienced weight regain ≥2 years after initial RYGB with stoma dilation ≥15 mm in diameter. Revision was done with either an interrupted (IRT) or purse-string (PST) suture technique. A linear mixed effects model was constructed to predict postoperative weight loss.

RESULTS

Fifty revisions (IRT = 36, PST = 14) were performed in 47 patients (92 % female, mean age of 50.9 ± 10.9 years and body mass index of 41.4 ± 7.1 kg/m²). Technical success (stoma diameter ≤10 mm) was achieved in all cases. Final diameter was significantly smaller in the PST group, 6.6 ± 2.2 mm versus 4.8 ± 1.8 mm (p < 0.01), resulting in a significantly greater % stoma reduction (76.8 ± 8.5 % vs. 84.2 ± 5.1 %, p < 0.01) versus the IRT group. PST resulted in greater % excess weight loss over time compared to IRT. Sixteen comorbid conditions resolved among 12 patients. No major complications occurred.

CONCLUSION

Endoscopic revision of the gastric outlet results in meaningful weight loss and comorbidity resolution in select patients experiencing weight regain following RYGB. A PST revision likely results in higher and more sustainable weight loss when compared to IRT.

Endoscopic revision of gastric bypass: Holy Grail or Epic fail?

BACKGROUND

Approximately 20-30 % of patients who undergo Roux-en-Y gastric bypass (RYGB) will not meet the goals of weight loss surgery. Revisional surgery is associated with higher morbidity compared to initial operative management, and results in terms of weight loss have been inconsistent. Endoscopic plication has been seen as a less invasive option, with encouraging initial results. The objective was to analyze the outcomes after Restorative Obesity Surgery, Endolumenal (ROSE) procedure.

METHODS

We retrospectively analyzed patients who underwent ROSE between 5/2008 and 11/2013. All patients had failure of weight loss or regain weight after RYGB. Demographics, operative data, and follow-up were recorded.

RESULTS

Twenty-seven patients underwent ROSE. One patient was excluded due to lack of follow-up. Twenty-five (96 %) patients were female. Mean time since initial RYGB was 11.9 ± 4.3 years. Mean initial weight and BMI were 236 ± 47 lb and 40.6 ± 8.1 kg/m(2), respectively. Mean OR time was 77 ± 30 min. Preoperative average pouch length and stoma diameter were 6.8 ± 2.3 and 2.1 ± 0.7 cm, respectively. On average, 4 ± 1.6 stitches were placed. Final pouch length and stoma diameter were 3.4 ± 1.6 (50 % reduction) and 0.86 ± 0.4 cm (61 % reduction). A total of 12 (46 %) and seven (28 %) patients underwent EGD at 3 and 12 months postoperatively. The mean pouch length and stoma diameter were 5 ± 1.9 (26.5 % reduction) and 1.2 ± 0.7 cm (42.9 % reduction) at 3 months and 6.14 ± 1.6 (10 % reduction) and 2.2 ± 1.2 cm (4.7 % increase) at 12 months, respectively. The %EWL was 8.9, 9.3, 8, 6.7, -10.7, -13.5, -5.8, -4.5 at 3, 6, 12, 24, 36, 48, 60, and 72 months, respectively.

CONCLUSION

Although endoscopic plication achieved the intended reduction in the pouch and stoma diameter at 3 months, these tend toward the preoperative diameter at 12 months. This anatomical failure and the lack of follow-up may explain why most patients failed to achieve sustainable weight loss.

Six month outcomes in patients experiencing weight gain after gastric bypass who underwent gastrojejunal revision using an endoluminal suturing device

BACKGROUND

Weight gain after Roux-en-Y gastric bypass occurs in approximately 25 % of cases, and this may contribute to recurrence of comorbid conditions. Currently, adequate treatment strategies for this group of patients are limited. Endoscopic narrowing of the gastrojejunal anastomosis may result in a low-risk, minimally invasive treatment alternative compared to standard surgical revision. We assessed short-term outcomes in patients undergoing endoscopic gastrojejunal revisions (EGJR) using an endoluminal suturing device.

METHODS

We performed an institutional review board-approved retrospective analysis of 25 consecutive patients who underwent EGJR. Patients preoperatively presented with a dilated gastrojejunal anastomosis of greater than 15 mm and weight gain. An endoluminal suturing device (Overstitch(TM), Apollo Endosurgery, Austin TX) was used to reduce the diameter of the anastomosis. Follow-up occurred at 2 and 6 weeks, 3 and 6 months, and 1 year

RESULTS

Prior to EGJR, patients regained an average of 23.4 ± 13.2 kg from their weight loss nadir and had a mean body mass index of 42.2 ± 6.6 kg/m(2). At 6 weeks, 100 % of patients experienced weight loss (average 5.8 ± 4.4 kg; p < .001). At 3 months, 94 % had weight loss (average 7.0 ± 6.2 kg; p < .001). At 6 months, 91 % maintained weight loss (average 5.6 ± 6.2 kg; p = 0.013). Lastly, at 1 year following EGJR, 100 % of available cases maintained weight loss (average 7.5 ± 6.4 kg; p = 0.057). The average percent excess weight loss was 12.5, 15.4, 12.4, and 17.1 % at 6 weeks, 3 and 6 months, and 1 year, respectively. There was a negative time effect in the mixed effect model using both on-treatment and intent-to-treat analyses, illustrating a significant weight reduction over time. The average follow-up per patient was 146 days. There were no complications reported during the follow-up period.

CONCLUSIONS

Six month follow-up for EGJR patients demonstrated a low-risk, minimally invasive treatment option to reverse weight gain subsequent to a failed gastric bypass. Procedures presented no complications and may provide an attractive alternative to standard surgical revision.

Emerging technologies and procedures: results of an online survey and real-time poll

BACKGROUND

Many new techniques and bariatric endoluminal procedures are being developed and used for the treatment of obesity. Clear guidelines or opinions of the new techniques are not readily available. The aim of this study was to gauge the level of interest and opinions of bariatric surgeons regarding these new techniques, using online and real poll surveys.

METHODS

The American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technologies committee developed a questionnaire that was distributed among the membership and conducted a live poll of attendees at Obesity Week 2013. Opinions of new technologies and techniques by practitioners were assessed.

RESULTS

A total of 134 responses to the questionnaire were returned. Most responses (79%) expressed the belief that new bariatric techniques are needed to improve the practice of bariatric and metabolic surgery. The responses describing the effects of new procedures and technology as beneficial were (1) increased interest from patients or referring physicians (94%), (2) expanded indications for intervention (93%), and (3) lower risk intervention (96%). Nearly all respondents (90.2%) identified value in informational guidelines on new technologies and procedures, and most (88.7%) agreed that the ASMBS should coordinate clinical trials or registries to evaluate these therapies.

CONCLUSION

Although most bariatric and metabolic surgeons agree that new endoluminal surgical techniques are beneficial, most also are unable to offer the procedures to their patients without more clinical evidence and clear guidelines from the society.

Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery

BACKGROUND & AIMS

Weight regain or insufficient loss after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of RYGB. Endoluminal interventions for GJ reduction are being explored as alternatives to revision surgery. We performed a randomized, blinded, sham-controlled trial to evaluate weight loss after sutured transoral outlet reduction (TORe).

METHODS

Patients with weight regain or inadequate loss after RYGB and GJ diameter greater than 2 cm were assigned randomly to groups that underwent TORe (n = 50) or a sham procedure (controls, n = 27). Intraoperative performance, safety, weight loss, and clinical outcomes were assessed.

RESULTS

Subjects who received TORe had a significantly greater mean percentage weight loss from baseline (3.5%; 95% confidence interval, 1.8%-5.3%) than controls (0.4%; 95% confidence interval, 2.3% weight gain to 3.0% weight loss) (P = .021), using a last observation carried forward intent-to-treat analysis. As-treated analysis also showed greater mean percentage weight loss in the TORe group than controls (3.9% and 0.2%, respectively; P = .014). Weight loss or stabilization was achieved in 96% subjects receiving TORe and 78% of controls (P = .019). The TORe group had reduced systolic and diastolic blood pressure (P < .001) and a trend toward improved metabolic indices. In addition, 85% of the TORe group reported compliance with the healthy lifestyle eating program, compared with 53.8% of controls; 83% of TORe subjects said they would undergo the procedure again, and 78% said they would recommend the procedure to a friend. The groups had similar frequencies of adverse events.

CONCLUSIONS

A multicenter randomized trial provides Level I evidence that TORe reduces weight regain after RYGB. These results were achieved using a superficial suction-based device; greater levels of weight loss could be achieved with newer, full-thickness suturing devices. TORe is one approach to avoid weight regain; a longitudinal multidisciplinary approach with dietary counseling and behavioral changes are required for long-term results. ClinicalTrials.gov identifier: NCT00394212.

Endoluminal revision of gastric bypass for weight regain--a systematic review

BACKGROUND

Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a challenging problem for patients and bariatric surgeons alike. Traditional operative strategies to combat weight regain are technically challenging and associated with a high morbidity rate. Endoluminal interventions are thus an attractive alternative that may offer a good combination of results coupled with lower periprocedure risk that might one day provide a solution to this increasingly prevalent problem. The purpose of this article is to systematically review the available literature on endoluminal procedures used to address weight regain after RYGB, with specific attention to the safety profile, efficacy, cost, and current availability. This review focuses only on endoluminal procedures that are performed for weight regain after RYGB, as opposed to primary endoluminal obesity procedures.

METHODS

This study was a retrospective review.

RESULTS

Several methods of endoluminal intervention for weight regain are reviewed, ranging from injection of inert substances to suturing and clipping devices. The literature review shows the procedures on the whole to be well tolerated with limited efficacy. The majority of the literature is limited to small case series. Most of the reviewed devices are no longer commercially available.

CONCLUSIONS

Endoluminal therapy represents an intriguing strategy for weight regain after RYGB. However, the current and future technologies must be rigorously studied and improved such that they offer durable, repeatable, cost-effective solutions.

Transoral gastric volume reduction as intervention for weight management: 12-month follow-up of TRIM trial

BACKGROUND

The aim of the present pilot study was to evaluate the safety and weight loss efficacy of endoscopic transoral gastric volume reduction using an endoscopic suturing system.

METHODS

Patients with a body mass index (BMI) of 30-45 kg/m(2) were enrolled in the present institutional review board-approved study. Anterior to posterior gastric plications were placed in the gastric fundus and body using the suturing device. The endpoints were procedure time, adverse events, weight loss, and endoscopic findings at 1, 6, and 12 months after the procedure. The nominal P values are presented.

RESULTS

A total of 18 patients underwent the procedure (9 at each site). The mean age and BMI was 40 years and 38 kg/m(2), respectively. The average number of plications placed per patient was 6, and the mean procedure time was 2.1 hours (range 1.5-2.8). At 12 months of follow-up (n = 14), decreases in the mean weight (-11.0 ± 10.0 kg, P = .0006), mean BMI (-4.0 ± 3.5 kg/m(2), P = .0006), and mean waist circumference (-12.6 ± 9.5 cm, P = .0004) were observed. The mean excess weight loss at 12 months was 27.7% ± 21.9%. The proportion of patients with an EWL of ≥ 20% or ≥ 30% was 57% and 50%, respectively. The mean systolic and diastolic blood pressure decreased by 15.2 mm Hg (P = .0012) and 9.7 mm Hg (P = .0051), respectively. No device- or procedure-related serious adverse events. Endoscopy at 12 months of follow-up showed partial or complete release of plications in 13 patients.

CONCLUSION

Transoral gastric volume reduction procedure using the RESTORe Suturing System device proved to be safe and well tolerated. Procedural technical success was achieved for all subjects. Modest decreases in weight, BMI, and waist circumference were observed, as was a decline in the frequency of hypertension. Despite some overall positive clinical findings, the plications were not durable, and the effects of the procedure varied widely among the study participants. Additional research is needed to provide a more reproducible and durable effect.

A pathway to endoscopic bariatric therapies

The American Society for Gastrointestinal Endoscopy (ASGE) is dedicated to advancing patient care and digestive health by promoting excellence in gastrointestinal endoscopy. The American Society for Metabolic and Bariatric Surgery (ASMBS) is dedicated to improving public health and well-being by lessening the burden of the disease of obesity and related diseases. They are the largest professional societies for their respective specialties of gastrointestinal endoscopy and bariatric surgery in the world. The ASGE/ASMBS task force was developed to collaboratively address opportunities for endoscopic approaches to obesity, reflecting the strengths of our disciplines, to improve patient and societal outcomes. This white paper is intended to provide a framework for, and a pathway towards, the development, investigation, and adoption of safe and effective endoscopic bariatric therapies (EBT).

Endoscopic findings and outcomes of revisional procedures for patients with weight recidivism after gastric bypass

BACKGROUND

Significant weight regain occurs for 10% to 20% of patients after Roux-en-Y gastric bypass (RYGB). Potential causative factors include anatomic abnormalities such as enlargement of the gastric pouch and gastrojejunostomy (GJ). This report describes endoscopic findings for patients referred for investigation of weight regain and presents the outcomes of revisional therapy for patients with abnormal anatomy.

METHODS

To evaluate gastric pouch and stoma size, RYGB patients referred for weight regain underwent upper endoscopy. A GJ was defined as enlarged if it had a diameter greater than 2 cm in any dimension, and a pouch was defined as enlarged if its length exceeded 6 cm long or its width exceeded 5 cm. Patients with abnormal anatomy who subsequently underwent revisional procedures were arbitrarily categorized into three groups based on the interval from RYGB to endoscopic evaluation: less than 5 years (group 1), 5 to 10 years (group 2), longer than 10 years (group 3). The percentage of regained weight lost (%RWL) after revision was compared between the groups.

RESULTS

In this study, 205 RYGB patients (176 women with a mean age of 47 ± 10 years and a current body mass index [BMI] of 43.4 ± 8.4 kg/m(2)) were evaluated. The mean time from primary RYGB was 6.9 ± 3.7 years, and the increase in BMI from its nadir was 9.78 ± 5.80 kg/m(2). Abnormal endoscopic findings (n = 146, 71.2%) included large GJ (n = 86, 58.9%), large pouch (n = 42, 28.8%), or both (n = 18, 12.3%). Of the 205 patients, 51 (24.9%) underwent a revisional surgical or endoluminal procedure. At a mean follow-up assessment 13 months after revision, group 1 (n = 12) had a mean %RWL of 103% ± 89.3%, and 62% of these patients lost all their regained weight. The mean %RWL was 45% ± 12.6% in group 2 (n = 30) and 40% ± 13.6% in group 3 (n = 9).

CONCLUSION

Endoscopy is a valuable tool for evaluating weight regain after bariatric surgery that can identify abnormal post-RYGB anatomy in a majority of patients. Revisional procedures to restore normal RYGB anatomy appear to be most successful if performed within 5 years after the primary procedure.

Endolumenal revision obesity surgery results in weight loss and closure of gastric-gastric fistula

BACKGROUND

Approximately 20-50% of patients regain weight 3-5 years after Roux-en-Y gastric bypass (RYGB) surgery. Gastric-gastric fistulas and dilation of the gastrojejunostomy and gastric pouch have been reported in these patients. Traditional revision surgery after RYGB has greater morbidity and mortality compared with the index bariatric procedure. We studied our initial results with revision of obesity surgery using an endoscopic platform in a community hospital setting.

METHODS

A retrospective review was performed of patients who had undergone this endoscopic revisional procedure secondary to significant weight regain with or without gastric-gastric fistula. All patients underwent revision of the gastrojejunostomy and/or closure of the gastric-gastric fistula using this minimally invasive approach.

RESULTS

A total of 37 consecutive patients (36 women) with a mean age of 45 years and mean weight regain of 15.1 ± 10.0 kg were included in the present study. The mean interval between RYGB and revision was 5.2 years (range 1-11). The mean preoperative and postoperative stomal size was 21.5 and 10 mm, respectively. Anchors were successfully placed in all patients. The mean follow-up period was 4.69 months (range 2-10). The mean percentage of excess body weight loss was 23.5% ± 66.4%. No immediate complications developed. Two patients underwent endoscopic dilation of the stoma because of persistent meal intolerance. Three gastric-gastric fistulas were successfully closed.

CONCLUSION

Revision of gastrojejunostomy after RYGB can be safely undertaken using this endoscopic platform. The short-term follow-up results showed clinically significant weight loss. Long-term follow-up is needed. Closure of gastric-gastric fistulas can also be achieved using this procedure.

Transoral gastric volume reduction for weight management: technique and feasibility in 18 patients

BACKGROUND

Endoluminal suturing to reduce the gastric volume might provide an additional option for the treatment of obesity. Potential advantages of a nonoperative endoluminal intervention include less pain, the ability to perform it as an outpatient procedure, and a high level of patient acceptance. The purpose of the present pilot study was to demonstrate the feasibility and procedural safety of transoral gastric volume reduction (TRIM procedure) using the Restore Suturing System in patients with a body mass index of 30-45 kg/m(2). Successful completion of the procedure and adverse events were evaluated at academic/university hospitals.

METHODS

This was a nonrandomized feasibility study performed at 2 institutions. After institutional review board approval, the patients underwent the TRIM endoluminal gastric plication procedure with the Restore Suturing System (Restore device). Gastric plications were completed to approximate the anterior and posterior gastric walls to achieve restriction of the upper stomach. The number and location of successful plications were recorded, and patients were monitored for complications. The present report described the short-term procedural results (≤ 24 hours after the procedure) of the studied cohort.

RESULTS

A total of 18 patients were enrolled in the present study. The TRIM procedure was successfully completed in all patients, with placement of 4-8 plications (average 6 per patient). The average procedure time was 125 ± 23 minutes, and no serious or significant procedure-related complications occurred. After the procedure, common patient complaints were nausea, vomiting, and abdominal discomfort. The first 10 patients enrolled were kept overnight according to the study protocol, and the remaining 8 patients were discharged on the day of the procedure.

CONCLUSION

Endoluminal suturing using the TRIM procedure and the Restore device was technically feasible, and no serious or significant procedure-related complications were reported. Weight loss, co-morbidity improvement, and durability are under assessment.

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results

BACKGROUND

Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset.

METHODS

The patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up.

RESULTS

A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds.

CONCLUSIONS

Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009

BACKGROUND

Sleeve gastrectomy (SG) is a rapid and comparatively simple bariatric operation, which thus far shows good resolution of co-morbidities and good weight loss. The potential peri-operative complications must be recognized and treated promptly. Like other bariatric operations, there are variations in technique. Laparoscopic SG was initially performed for high-risk patients to increase the safety of a second operation. However, indications for SG have been increasing. Interaction among those performing this procedure is necessary, and the Second International Consensus Summit for SG (ICSSG) was held to evaluate techniques and results.

METHODS

A questionnaire was filled out by attendees at the Second ICSSG, held March 19-22, 2009, in Miami Beach, and rapid responses were recorded during the consensus part.

RESULTS

Findings are based on 106 questionnaires representing a total of 14,776 SGs. In 86.3%, SG was intended as the sole operation. A total of 81.9% of the surgeons reported no conversions from a laparoscopic to an open SG. Mean +/- SD percent excess weight loss was as follows: 1 year, 60.7 +/- 15.6; 2 years, 64.7 +/- 12.9; 3 years, 61.7 +/- 11.4; 4 years 64.6 +/- 10.5; >4 years, 48.5 +/- 8.7. Bougie size was 35.6F +/- 4.9F (median 34.0F, range 16F-60F). The dissection commenced 5.0 +/- 1.4 cm (median 5.0 cm, range 1-10 cm) proximal to the pylorus. Staple-line was reinforced by 65.1% of the responders; of these, 50.9% over-sew, 42.1% buttress, and 7% do both. Estimated percent of fundus removed was 95.8 +/- 12%; many expressed caution to avoid involving the esophagus. Post-operatively, a high leak occurred in 1.5%, a lower leak in 0.5%, hemorrhage in 1.1%, splenic injury in 0.1%, and later stenosis in 0.9%. Post-operative gastroesophageal reflux ( approximately 3 mo) was reported in 6.5% (range 0-83%). Mortality was 0.2 +/- 0.9% (total 30 deaths in 14,776 patients). During the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%.

CONCLUSION

SG for morbid obesity is very promising as a primary operation.