ENDOSCOPIC SLEEVE GASTROPLASTY FOR OBESITY TREATMENT: TWO YEARS OF EXPERIENCE

Success Predictors of Endoscopic Sleeve Gastroplasty

OBJECTIVE

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that proved to be safe and effective in obesity treatment. However, not all subjects respond to treatment in the same way, and, with a view to personalized care, it is essential to identify predictors of success or failure.

METHODS

A retrospective 2-year followed-up cohort of ESG subjects was analyzed to investigate the presence of any baseline or early indicators of long-term optimal or suboptimal ESG outcomes.

RESULTS

A total of 315 subjects (73% women) were included, with 73% of patients exhibiting an Excess weight loss percentage (%EWL) >25% at the 24 months. Neither demographic parameters (age and sex), smoking habits, and menopause in women nor the presence of comorbidities proved potential predictive value. Interestingly, the %EWL at 1 month after ESG was the strongest predictor of 24-month therapeutic success. Subsequently, we estimated an "early threshold for success" for 1 month-%EWL by employing Youden's index method.

CONCLUSIONS

ESG is a safe and effective bariatric treatment that can be offered to a wide range of subjects. Early weight loss seems to impact long-term ESG results significantly and may allow proper early post-operative care optimization.

Machine learning models to predict success of endoscopic sleeve gastroplasty using total and excess weight loss percent achievement: a multicentre study

BACKGROUND

The large amount of heterogeneous data collected in surgical/endoscopic practice calls for data-driven approaches as machine learning (ML) models. The aim of this study was to develop ML models to predict endoscopic sleeve gastroplasty (ESG) efficacy at 12 months defined by total weight loss (TWL) % and excess weight loss (EWL) % achievement. Multicentre data were used to enhance generalizability: evaluate consistency among different center of ESG practice and assess reproducibility of the models and possible clinical application. Models were designed to be dynamic and integrate follow-up clinical data into more accurate predictions, possibly assisting management and decision-making.

METHODS

ML models were developed using data of 404 ESG procedures performed at 12 centers across Europe. Collected data included clinical and demographic variables at the time of ESG and at follow-up. Multicentre/external and single center/internal and temporal validation were performed. Training and evaluation of the models were performed on Python's scikit-learn library. Performance of models was quantified as receiver operator curve (ROC-AUC), sensitivity, specificity, and calibration plots.

RESULTS

Multicenter external validation: ML models using preoperative data show poor performance. Best performances were reached by linear regression (LR) and support vector machine models for TWL% and EWL%, respectively, (ROC-AUC: TWL% 0.87, EWL% 0.86) with the addition of 6-month follow-up data. Single-center internal validation: Preoperative data only ML models show suboptimal performance. Early, i.e., 3-month follow-up data addition lead to ROC-AUC of 0.79 (random forest classifiers model) and 0.81 (LR models) for TWL% and EWL% achievement prediction, respectively. Single-center temporal validation shows similar results.

CONCLUSIONS

Although preoperative data only may not be sufficient for accurate postoperative predictions, the ability of ML models to adapt and evolve with the patients changes could assist in providing an effective and personalized postoperative care. ML models predictive capacity improvement with follow-up data is encouraging and may become a valuable support in patient management and decision-making.

A pilot study of implementation of endoscopic sleeve gastroplasty (ESG) in Norway

BACKGROUND AND AIM

Bariatric surgery is the most effective treatment for obesity but is invasive and associated with serious complications. Endoscopic sleeve gastroplasty (ESG) is a less invasive weight loss procedure to reduce the stomach volume by full-thickness sutures. ESG has been adopted in many countries, but implementation at Scandinavian centres has not yet been documented. We performed a clinical pilot trial at a Norwegian centre with the primary objective to assess the feasibility of the ESG procedure.

PATIENTS AND METHODS

We included the first 10 patients treated with ESG at a Norwegian centre in a single-arm pilot study. The eligibility criteria were either a body mass index (BMI) of 40-49.9 kg/m2, BMI 35-39.9 kg/m2 and at least one obesity-related comorbidity, or BMI 30-34.9 kg/m2 and type 2 diabetes. Patient follow-up resembled the scheme used for bariatric surgery at the center, including dietary plans and outpatient visits.

RESULTS

All procedures were technically successful except for one patient who had adhesions between the stomach and anterior abdominal wall, related to a prior hernia repair, resulting in less-than-intended stomach volume reduction. Mean total body weight loss (TBWL) after 26 and 52 weeks was 12.2% (95% CI 8.1-16.2) and 9.1% (95% CI 3.3 - 15.0). One patient experienced a minor suture-induced diaphragmatic injury, which was successfully managed conservatively.

CONCLUSIONS

This first Scandinavian clinical trial of ESG, documenting the implementation of the procedure at a Norwegian center, demonstrated acceptable feasibility and safety, with large variations in individual weight loss during the 52-week follow-up period.

Future of Metabolic Endoscopy

Obesity has been escalating as one of the worst public health epidemics. Conservative therapies including lifestyle modifications and weight loss medications have limited efficacy and long-term sustainability. Bariatric surgeries, although effective, remain underutilized due to their cost, safety concerns, and patient acceptance. In the past two decades, endoscopic bariatric and metabolic therapies (EBMTs) have emerged as safe, effective, and less invasive options for the treatment of obesity and its comorbidities, with recent studies reporting favorable outcomes in terms of weight loss and metabolic parameters. This article reviews the major and newly developed EBMTs, with emphasis on their metabolic effects and potential use in the management of metabolic conditions.

Outcomes of Endoscopic Sleeve Gastroplasty in the Elder Population

Purpose

With the aging of the population and the epidemic spread of obesity, the frequency of older individuals with obesity is steadily growing. To date, no data evaluating the use of endoscopic sleeve gastroplasty (ESG) in the elderly have been published. In this case series, we evaluate the short- and medium-term outcomes of ESG in patients with obesity aged 65 years and older.

Materials and Methods

A retrospective analysis was done on a prospective database; patients aged 65 years and older were included in our analysis. EWL%, TBWL%, the Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire, and the presence of comorbidities were assessed.

Results

Eighteen patients aged 65 years and older underwent ESG between November 2017 and July 2021. The median age was 67 years and the mean baseline BMI was 41.2 kg/m². After ESG, the median TBWL% was 15.1%, 15.5%, and 15.5% at 6, 12, and 24 months, while the median %EWL was 39%, 37%, and 41% at 6, 12, and 24 months, respectively. The median BAROS score was 3.0, 3.4, and 2.5 at 6, 12, and 24 months, respectively. Six out of twelve patients with hypertension and 3/4 diabetic patients reduced or removed their medications within 12 months following ESG. Two out of six patients with OSA stopped therapy with CPAP. No adverse events were recorded.

Conclusion

According to our experience, ESG is a promising therapeutic option for elder individuals with obesity who fail non-invasive methods, and who refuse or are deemed not suitable for bariatric surgery because of age and comorbidities.

Graphical abstract

Safety of Endoscopic Sleeve Gastroplasty with a Single-Channel Endoscope

PURPOSE

Less invasive endoscopic bariatric procedures are under development for the management of class I of obesity. The purpose of our study is to evaluate the safety of endoscopic sleeve gastroplasty (ESG) using the new suturing device OverStitch Sx™.

MATERIALS AND METHODS

This is a retrospective single-center study over 191 patients using the ESG under general anesthesia with overnight inpatient observation between January 2019 and December 2020. The analyzed variables were adverse effects and change in body weight at 6 and 12 months of follow-up.

RESULTS

A total of 191 patients underwent ESG for primary obesity. There were 173 female (90.6%) with a mean age of 36.9 years. The mean BMI was 33.7 kg/m² (range: 28.9-54). There were no major intra-procedure adverse events. There were two postprocedural complications (1.04%), a transparietal suturing of falciform ligament which needed laparoscopic exploration for severe abdominal pain and a perigastric collection with antibiotic treatment, both with favorable outcome. Considering the weight loss results, the %TWL recorded was 22.4% for 84 patients (43.9%, 6 months' follow-up) and 18.7% for 69 patients (36.1%, 12 months' follow-up) with the mean EWL of 41.6% and respectively 34.7%. A total of 59 patients (30.9%) were lost follow-up and 12 patients underwent revisional bariatric procedure. According to ASGE definition, 53.8% (n = 71) reached > 25% of EWL.

CONCLUSION

Endoscopic gastroplasty represents a safe minimal invasive approach with the new device OverStitch Sx™ that can be considered an effective and well-tolerated procedure especially for primary obesity treatment.

OverStitch Sx Endoscopic suturing system in minimally invasive endoscopic procedures: overview of its safety and efficacy and comparison to oversticthTM

INTRODUCTION

OverStitch endoscopic suturing enables advanced closure by tissue approximation via endoscopically placed sutures with the ability to customize suture patterns. Newer OverStitch generation also known as OverStitch Sx overcame the limitation of the previous generation and is compatible with 20 single channel scopes over four platforms with greater maneuverability and visibility.

AREAS COVERED

In this article we will focus on the differences between three generations of OverStitch. In addition, we will review existing literature on the efficacy of OverStitch in the management of full thickness defect closure, fistula and leaks repair, stent fixation, and bariatric surgeries along with its complications and limitations.

EXPERT OPINION

Assembling overstitch takes less than five minutes and the correct sequence of system assembly is the key for a successful procedure. Transition from the second-generation OverStitch to OverStitch Sx may require three to five cases for learning curve.

Personalized Approach for Obese Patients Undergoing Endoscopic Sleeve Gastroplasty

Obesity is a chronic, relapsing disease representing a major global health problem in the 21st century. Several etiologic factors are involved in its pathogenesis, including a Western hypercaloric diet, sedentariness, metabolic imbalances, genetics, and gut microbiota modification. Lifestyle modifications and drugs often fail to obtain an adequate and sustained weight loss. To date, bariatric surgery (BS) is the most effective treatment, but only about 1% of eligible patients undergo BS, partly because of its negligible morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, endoscopic, bariatric procedure, which proved to be safe and effective. In this review, we aim to examine evidence supporting the role of a personalized and multidisciplinary approach, guided by a multidisciplinary team (MDT), for obese patients undergoing ESG, from patient selection to long-term follow-up. The cooperation of different health professionals, including an endocrinologist and/or obesity medicine physician, a bariatric surgeon, an endoscopist experienced in bariatrics, a registered dietitian, an exercise specialist, a behaviour coach, a psychologist, and a nurse or physician extender, aims to induce radical and sustained lifestyle changes. We also discussed the relationship between gut microbiota and outcomes after bariatric procedures, speculating that the characterization of gut microbiota before and after ESG may help develop new tools, including probiotics, to optimize weight loss outcomes.

Endoscopic Treatment of Obesity and Nutritional Aspects of Bariatric Endoscopy

Obesity is a significant problem worldwide. Several serious diseases that decrease patient quality of life and increase mortality (high blood pressure, dyslipidaemia, type 2 diabetes etc.) are associated with obesity. Obesity treatment is a multidisciplinary and complex process that requires maximum patient compliance. Change of lifestyle is fundamental in the treatment of obesity. While pharmacotherapeutic options are available, their efficacy is limited. Surgical treatment though highly effective, carries the risk of complications and is thus indicated mostly in advanced stages of obesity. Endoscopic treatments of obesity are less invasive than surgical options, and are associated with fewer complications and nutritional deficits. Currently, there is a large spectrum of endoscopic methods based on the principles of gastric volume reduction, size restriction and gastric or small bowel bypass being explored with only few available in routine practice. The aim of this publication is to present an up-to-date summary of available endoscopic methods for the treatment of obesity focusing on their efficacy, safety and nutritional aspects.

Intragastric Balloon Versus Endoscopic Sleeve Gastroplasty for the Treatment of Obesity: a Systematic Review and Meta-analysis

BACKGROUND

We aimed to individually evaluate IGB and ESG procedures and compare the efficacy, durability, and safety of these procedures.

METHODS

Bibliographic databases were systematically searched for studies investigating the use of IGB and ESG for the treatment of obesity. Studies reporting percent total weight loss (%TWL) or percent excess weight loss (%EWL) with at least 12 months of follow-up were included.

RESULTS

A total of 28 studies were included in the final analysis. Only 1 study directly compared ESG to IGB, 9 studies evaluated ESG alone, while 18 studies evaluated IGB. At 12-month follow-up after ESG, mean %TWL was 17.51 (95% CI 16.44-18.58), and %EWL was 60.51 (95% CI 54.39-66.64). Mean %TWL and %EWL after IGB at 12 months was 10.35 (95% CI 8.38-12.32) and 29.65 (95% CI 25.40-33.91), respectively. Mean %TWL and %EWL after IGB were significantly decreased at 18 or 24 months compared to 6 months indicating weight regain after IGB removal. ESG achieved significantly superior weight loss compared to IGB, the difference in mean %TWL was 7.33 (95% CI 5.22-9.44, p value = 0.0001) at 12 months. Serious adverse events were observed in < 5% for both procedures.

CONCLUSION

Although ESG and IGB are safe and effective for weight loss, our study suggests that ESG results in more significant and sustained weight loss. Nevertheless, a variety of approaches are essential to care for this underserved population, and there are several factors other than weight loss that should be considered in selecting the ideal therapy for individual patients.

Endoscopic assessment of morphological and histopathological upper gastrointestinal changes after endoscopic sleeve gastroplasty

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a promising bariatric endoluminal procedure. Restriction and shortening of the stomach are obtained by means of non-resorbable full-thickness sutures, thus inducing the formation of several endoluminal pouches in which food can stagnate. The effect of ESG on the upper gastrointestinal tract has never been investigated.

OBJECTIVES

This study objectively evaluates endoscopic macroscopic and histopathologic changes within 12-month follow-up (FU) in patients who underwent ESG.

SETTING

Retrospective study on a prospective database of patients who underwent ESG at our tertiary referral center between October 2016 and March 2019.

METHODS

All consecutive patients undergoing upper endoscopy (EGD) preoperatively and 6 and 12 months after ESG were included. The upper gastrointestinal tract was evaluated for mucosal abnormalities and biopsies were systematically taken.

RESULTS

Eighty-six patients were included. EGD results were as follows: esophagitis decreased from 14% preoperatively to 3.6% and 1.2% at 6- and 12-month FU, respectively (P = .001); 19.8% of patients presented preoperatively a type I hiatal hernia <4 cm and showed no size increment or de novo hiatal hernia at 6- and 12-months. The rate of preoperative hyperemic (23.2%) and erosive (3.5%) gastropathy decreased to 9.5% and 1.2% at 6 months and 17.4% and 1.2% at 12 months, respectively. Gastric ulcer (4.7%), duodenal hyperemic mucosa (1.2%) and duodenal micro-ulcerations (2.3%) detected preoperatively were not present at 6- and 12-month EGD. The rate of histopathological disease, which was 68.1% preoperatively, dropped to 29.2% at 12 months, chronic gastritis decreased from 40.3% to 26.4%, acute gastritis from 9.7% to 0%, and acute inflammation on chronic gastritis from 18% to 2.8% (P < .001).

CONCLUSION

ESG is a safe procedure that does not promote the new onset of macroscopic and histopathologic abnormalities within 1-year follow-up.

Systematic Review of Innovation Reporting in Endoscopic Sleeve Gastroplasty

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic procedure used to treat obesity-related comorbidities. Whilst its use is increasing in clinical practice, there is comparatively little understanding about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of ESG in the context of guidelines for evaluating innovative surgical devices and procedures.

METHODS

Systematic searches were used to identify all published studies reporting ESG insertion. Data collected included patient selection, governance arrangements, proceduralist expertise, technique description and outcome reporting.

RESULTS

Searches identified 2289 abstracts; 37 full-text papers were included (one prospective comparative cohort study, 16 retrospective cohort studies, 17 prospective cohort studies and three case reports). No randomized trials were identified. Eighteen studies were conducted prospectively. The number of patients in the included studies ranged from 1 to 1000. The lower BMI limit ranged from 27 to 35 kg/m². Research approvals were reported in 26 studies. Two studies reported on the learning curve. All studies reported some aspect of technical implementation, but many variations were noted. Suturing device used and suture pattern were the most commonly reported aspects (32 studies). Follow-up ranged from 1 to 24 months, but was 12 months or less in 28 studies. Forty-eight different outcomes were reported across all studies.

CONCLUSION

The literature on ESG has demonstrated some progression in reporting and analysis and the next stage of assessment should be a randomized controlled trial to demonstrate efficacy.

Endobariatric procedures for obesity: clinical indications and available options

Obesity remains a growing public health epidemic that has increased healthcare costs and related comorbidities. Current treatment guidelines encourage a multidisciplinary approach starting from patient selection, interventions, and long-term follow-up to maintain weight loss. However, these conservative interventions are largely ineffective at reducing body weight due to low adherence to the treatment regimen. Recently, endoscopic bariatric therapies have become an attractive alternative to traditional invasive bariatric surgeries due to their improved efficacy, safety, and cost-effectiveness. Endoscopic bariatric therapies include intragastric balloon placement, endoscopic sleeve gastroplasty, gastric bypass revision, and aspiration therapy. These procedures fall into two separate categories depending on the primary mechanism involved: restrictive or malabsorptive. Restrictive methods, such as the Orbera® and ReShape™ intragastric balloons, increase satiation and delay gastric emptying while decreasing the amount of food that can be ingested. In contrast, malabsorptive devices, such as the EndoBarrier®, interfere with the small intestine's ability to absorb food while restoring normal gastrointestinal hormone levels regulating satiation. Together, these techniques provide useful alternatives for patients in whom pharmacological or lifestyle modifications have proven ineffective. Despite these advantages, the long-term effects of these procedures on metabolic changes remain to be studied. Furthermore, the management of complications from these procedures continues to evolve. In this review, we aim to elaborate on the clinical indications and efficacy of the endobariatric procedures, together with various types of available endoscopic bariatric therapy procedures.

Endobariatrics and Metabolic Endoscopy: Can We Solve the Obesity Epidemic with Our Scope?

PURPOSE OF REVIEW

Obesity is a chronic relapsing disease that results in cardiovascular disease, diabetes mellitus, and non-alcoholic fatty liver disease. Currently, surgery represents the most effective treatment. However, the advent of minimally invasive endoscopic bariatric therapy (EBT) has shifted the treatment paradigm to less invasive, cost-effective procedures with minimal complications and recovery time that are preferred by patients. In this review, we will describe current and future EBTs, focusing on outcomes and safety.

RECENT FINDINGS

The endoscope has provided an incisionless portal into the gastrointestinal tract for placement of space-occupying devices and intraluminal procedures. EBTs are no longer solely manipulating anatomic alterations; instead, they aim to improve metabolic parameters such as glycated hemoglobin, low-density lipoprotein, cholesterol, and hepatic indices by targeting the mucosal layer of the gastrointestinal tract. The endoscope has succeeded in facilitating clinically meaningful weight loss and improvement of metabolic parameters. Future, solutions to the obesity epidemic will likely entail genetic testing, evaluation of the microbiome, and delivery of personalized therapy, utilizing combination endoscopic modalities that change the anatomy and physiology of individual patients, with new targets such as the abnormal metabolic signal.

Overview of bariatric and metabolic endoscopy interventions

The rise of endoscopic techniques allowing weight loss offers an attractive alternative to surgical interventions in Western countries where the obesity epidemic has risen dramatically. Endoscopists are well positioned to manage obesity given their broad-based medical knowledge, understanding of gastrointestinal physiology, and training in endoscopic technique. The field of bariatric and metabolic endoscopy has permitted the development of several efficacious and safe technologies. This review focuses on techniques and devices used for endoscopic management of obesity, as well as the fundamental justifications to offer those therapies to obese patients.

New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review

Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.

[Opportunities and challenges of endoscopic sleeve gastroplasty]

Obesity and its complications, such as type 2 diabetes, hypertension, hyperlipidemia, nonalcoholic fatty liver, are serious global public health problems. Endoscopic sleeve gastroplasty (ESG) can reduce the length and width of the stomach by simulating the anatomical structure of surgical sleeve gastrectomy to reduce the capacity of the stomach, and is safe and effective to reduce weight. ESG has the advantages of non- invasiveness, no gastrectomy, repeatability, simple operation, no incision scar, few complications, short hospital stay and quick postoperative recovery. As an intermediate means of medical treatment and surgery, ESG provides a new method for weight loss for obese patients who cannot tolerate or are unwilling to undergo surgery. Herein we trace the origin of ESG, analyze the unique advantages of ESG suture, explore the technical improvement in the development of ESG, and briefly describe the weight reduction effect of ESG and compare the curative effect of ESG with laparoscopic sleeve gastrectomy. ESG has undergone rapid development and maturity but also faces such challenges as the lack of established standard procedures, unclear weight reduction mechanism, and clarification of the indications for operation. Still, ESG is expected to become the mainstream technique for weight reduction.

Procedures and devices for bariatric and metabolic endoscopy

Obesity is a leading cause of preventable death in developed countries, with a rising incidence over time. Lifestyle modification, pharmacotherapy, and bariatric surgery are the mainstays of bariatric therapy, even though burdened by several limitations in terms of efficacy or safety. Bariatric endoscopy has been developed in the last decades as a minimally invasive alternative, aimed to bridge the gap between conservative and interventional conventional therapies. This review aims to provide an updated overview of the bariatric and metabolic available endoscopic procedures and to drive the choice of the right procedure for the right patient.

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

BACKGROUND

Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery.

METHODS

A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards.

RESULTS

Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure.

CONCLUSION

This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.

Reinforced POSE: the 18-Plication Solution

BACKGROUND

Obesity is one of the main challenges in the first world nowadays. New alternatives are needed and endoscopic endoluminal approaches are gaining importance against the risky surgery and the non-efficient pharmacological treatments. Nevertheless, these techniques seem to be inefficient in obese III patients. The aim of the study is to demonstrate the safety and efficiency of the new reinforced POSE 18-plication protocol.

METHODS

Mean body mass index (BMI) ≈ 47 kg/m² obese type III patients were treated in different Spanish centers with the new POSE method consisting of 18 plications in the stomach body. On the other hand, 15 lower body mass patients BMI ≈ 40 kg/m² were treated with the standard POSE method previously described.

RESULTS

Three months follow-up shows an overall % total weight loss (TWL) and % excess weight loss (EWL) of 15% and 41% respectively for standard POSE and 17% and 36% for the new reinforced POSE18. Both are equally safe and the endpoint weight loss objectives are reached. Endoluminal procedures have been demonstrated to be useful in overweight and obese type I/II. However, bariatric surgery is recommended for higher BMI > 40 kg/m². We successfully applied a non-standard POSE protocol and the patients reached 17%TWL in 3 months.

CONCLUSIONS

Our study shows that reinforced POSE 18 can be successfully applied in obese type III; it is safer than bariatric surgery and there are no associated risks when compared with standard endoscopic surgery.

Efficacy and Safety of Endoscopic Sleeve Gastroplasty: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Bariatric surgery is the most successful treatment for obesity. However, many patients avoid surgery due to its perceived invasive nature and fear of complications. Endoscopic sleeve gastroplasty (ESG) is a seemingly less invasive option for patients with obesity. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of ESG in adults.

METHODS

We searched MEDLINE, Embase, Web of Science, and Cochrane Library through July 2019. Investigated outcomes included the percent total body weight loss (TBWL), body mass index reduction, percent excess weight loss (EWL), and adverse events.

RESULTS

We extracted data from 8 original studies, published from 2016 through 2019, which included a total of 1772 patients. At 6 months, mean TBWL was 15.1% (95% CI, 14.3-16.0), mean decrease in body mass index was 5.65 kg/m2 (95% CI, 5.07-6.22), and mean excess weight loss was 57.7% (95% CI, 52.0-63.4). Weight loss was sustained at 12 months and 18-24 months with a TBWL of 16.5% (95% CI, 15.2-17.8) and 17.2% (95% CI, 14.6-19.7), respectively. The pooled post-ESG rate of severe adverse events was 2.2% (95% CI, 1.6%-3.1%), including pain or nausea requiring hospitalization (n = 18, 1.08%), upper gastrointestinal bleeding (n=9, 0.56%), and peri-gastric leak or fluid collection (n = 8, 0.48%).

CONCLUSIONS

In a systematic review and meta-analysis, we found ESG to produce clinically significant weight loss that was reproducible among independent centers and to have a low rate of severe adverse events. ESG appears to be an effective intervention for patients with obesity, although comparative studies and randomized controlled trials are necessary. PROSPERO Identifier: CRD42019121921.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Outcomes of endoscopic sleeve gastroplasty; how does it compare to laparoscopic sleeve gastrectomy? A systematic review and meta-analysis

Background and study aims Endoscopic sleeve gastroplasty (ESG) is a novel moderately invasive technique in endo-bariatrics as compared to laparoscopic sleeve gastrectomy (LSG). Data is limited as to its efficacy and safety.

Methods We searched multiple databases from inception through August 2019 to identify studies that reported on ESG in the treatment of obesity. Our goals were to calculate the pooled rates of total weight loss (%TWL), excess weight loss (%EWL), and body mass index (BMI) at 1 month, 6 months, and 12 months with ESG. We included studies that reported on LSG, in a similar time frame as ESG, and compared the 12-month outcomes.

Results From eight studies on ESG (1815 patients), the pooled rates of %TWL at 1 month, 6 months, and 12 months were 8.7 (7.2–10.2), 15.3 (14.1–16.6) and 17.1 (15.1–19.1), respectively. The pooled rates of %EWL at 1 month, 6 months, and 12 months were 31.7 (29.3–34.1), 59.4 (57–61.8) and 63 (51.3–74.6), respectively. The pooled rates of BMI at 1 m, 6 m, and 12 m were 32.6 (31–34.3), 30.4 (29–31.8) and 30 (27.7–32.3, I2 = 97), respectively. At 12 months, the pooled %TWL, %EWL and BMI with LSG (7 studies, 2179 patients) were 30.5 (27.4–33.5), 69.3 (60.1–78.4) and 29.3 (27.1–31.4) respectively. On comparison analysis, %TWL with LSG was superior to ESG (P = 0.001). %EWL and BMI were comparable. All adverse events, bleeding and gastro-esophageal reflux disease were significantly lower with ESG when compared to LSG.

Conclusion ESG demonstrates acceptable weight loss parameters and seems to have a better safety profile when compared to LSG.

Gallbladder perforation due to endoscopic sleeve gastroplasty: A case report and review of literature

BACKGROUND

The healthcare impact of obesity is enormous, and there have been calls for new approaches to containing the epidemic worldwide. Minimally invasive procedures have become more popular, with one of the most widely used being endoscopic sleeve gastroplasty (ESG). Although major adverse events after ESG are rare, some can cause considerable mortality. To our knowledge, there has been no previous report of biliary ascites after ESG.

CASE SUMMARY

A 48-year-old female with obesity refractory to lifestyle changes and prior gastric balloon placement underwent uncomplicated ESG and was discharged on the following day. On postoperative day 3, she developed abdominal pain, which led to an emergency department visit the following day. She was readmitted to the hospital, with poor general health status and signs of peritoneal irritation. Computed tomography imaging showed fluid in the abdominal cavity. Laparoscopy revealed biliary ascites and showed that the gallbladder was sutured to the gastric wall. The patient underwent cholecystectomy and lavage of the abdominal cavity and was admitted to the intensive care unit post-operatively. After 7 d of antibiotic therapy and 20 d of hospitalization, she was discharged. Fortunately, 6 mo later, she presented in excellent general condition and with a 20.2% weight loss.

CONCLUSION

ESG is a safe procedure. However, adverse events can still occur, and precautions should be taken by the endoscopist. In general, patient position, depth of tissue acquisition, location of stitch placement, and endoscopist experience are all important factors to consider to mitigate procedural risk.

Redo endoscopic sleeve gastroplasty: technical aspects and short-term outcomes

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a restrictive endoscopic bariatric procedure providing promising results. In this short case series, we analyze the technical aspects and short-term outcomes of the redo ESG.

METHODS

A retrospective analysis was done on a prospective database of all patients that were selected by a multidisciplinary team that underwent ESG between March 2017 and May 2019. Patients that underwent a redo ESG because of a progressive loss of satiety, weight regain, or insufficient weight loss due to high baseline body mass index were included. Percentage of excess weight loss (%EWL), percentage of total body weight loss (%TBWL), and the Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire were evaluated during follow-up.

RESULTS

A total of 120 ESG procedures were performed with mean %EWL of 44.4% (± 19.5), mean %TBWL of 18.3% (± 6.7), and mean BAROS of 4.5 (± 1.7) at 12 months. Of those, four patients that underwent a redo ESG were identified. A total of three of them had a redo ESG after 12 months from the first ESG, whereas one of them had a redo ESG after 7 months. During the second procedure, old threads were removed with scissors and new stitches were positioned following a triangular pattern and avoiding overlap with the previous stitches. No adverse events were reported during the redo ESG. Six month follow-up was available for three patients, mean %EWL and %TBWL were 44.2% and 20.4%, respectively; BAROS questionnaire mean score was 6.3. One patient had only 1 month follow-up with a mean %EWL and %TBWL of 33.3% and 12.2%, respectively; BAROS questionnaire reported score was 6. All included patients reported excellent satiety feeling after redo ESG.

CONCLUSIONS

The redo ESG short-term outcomes are completely satisfying in terms of safety and efficacy. The need to perform a redo ESG should not be considered as a failure of the previous procedure, but it can be considered as a second step of the endoscopic treatment strategy.

The Use of the Overstitch for Bariatric Weight Loss

Obesity is a public health pandemic and leading contributor to morbidity and mortality. Endoscopic bariatric therapies have emerged as a viable minimally invasive treatment option to fill the therapeutic gap between conservative and surgical approaches. The ability to reliably place full-thickness sutures throughout the gastrointestinal tract has opened the door to novel endoscopic gastric restrictive procedures. A growing body of literature supports endoscopic sleeve gastroplasty as a safe, effective, and reproducible endoscopic treatment of obesity and metabolic syndrome. In addition, endoscopic sutured revision procedures following gastric bypass and sleeve gastrectomy are now first-line with demonstrable safety and long-term efficacy.

The Development of the Overstitch System and Its Potentials

Endoscopic suturing device for flexible endoscopy was conceptualized by Apollo Group in collaboration with Olympus Optical Ltd. The first modification of suturing device for flexible endoscopy (Eagle Claw) was manufactured by Olympus engineers and extensively used by members of Apollo Group in numerous bench-top experiments on isolated pig stomachs and in live porcine model. The suturing system for flexible endoscopy in humans (Overstitch) was cleared for general clinical use in the United States in 2008. The latest model is compatible with more than 20 single-channel flexible endoscopes with diameters ranging from 8.8 mm to 9.8 mm made by major endoscope manufacturers.

The Use of the OverStitch for Bariatric Weight Loss in Europe

Technological advances have permitted minimally invasive treatment of many gastrointestinal diseases. With the advent of endoscopic full-thickness suturing, it has become possible to replicate some of the surgical procedures. Endoluminal bariatric procedures to remodel and reduce the gastric volume similar to surgery is evolving as a treatment option for obesity. Some of these methods also have been extended to treat weight regain after gastric bypass surgery. There is a steep learning curve to gaining proficiency with different endoscopic gastric remodeling or gastroplasty techniques. This article describes a simplified technique of endoscopic sleeve gastroplasty using the OverStitch suturing device.

Safety and efficacy of endoscopic sleeve gastroplasty worldwide for treatment of obesity: a systematic review and meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) has gained momentum as a promising, minimally invasive bariatric therapy worldwide.

OBJECTIVE

We performed the first comprehensive systematic review and meta-analysis of studies to evaluate the efficacy, safety, and procedural technique of ESG.

METHODS

Bibliographic databases were systematically searched for studies assessing patients who underwent ESG for the treatment of obesity. Studies were included if they reported percent total weight loss or percent excess weight loss and the incidence of serious adverse events. Studies with <15 patients, follow-up period <6 months, and overlapping patients were excluded.

RESULTS

Eight observational studies with 1859 patients were included. Pooled mean percent total weight loss at 6, 12, and 24 months was 14.86 (95% confidence interval [CI]: 13.83-15.90), 16.43 (95%CI: 15.23-17.63), and 20.01 (95%CI:  16.92-23.11), respectively. Pooled mean percent excess weight loss at 6, 12, and 24 months was 55.75 (95%CI: 50.61-60.89), 61.84 (95%CI: 54.75-68.93), and 60.40 (95%CI: 48.88-71.92), respectively. The pooled incidence of serious adverse events was 2.26% (95%CI 1.25-4.03) and no mortality was reported. Gastrointestinal bleeding and perigastric fluid collection were the most common reported serious adverse events; however, the pooled incidence of both was <1%. Variations in procedural technique were seen, but the full-thickness nature of suturing was reported in all studies. A layer of reinforcement sutures was performed in the majority of studies (n = 6). Limitations include the lack of controlled studies, long-term follow-up data, and standardization of technique.

CONCLUSION

ESG, a minimally invasive bariatric therapy, is reproducible among centers worldwide with effective weight loss and favorable safety profile outcomes. Controlled studies would be valuable to further corroborate these findings.

Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study

BACKGROUND AND AIMS

Obesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform "U" stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. This also uniquely assessed outcomes in all body mass index (BMI) categories and changes in metabolic rate, lean body mass, and adipose tissue composition.

METHODS

This is a multicenter analysis of prospectively collected data from 7 centers including patients with overweight and obesity who underwent ESG. Primary outcomes included absolute weight loss, percent total body weight loss (%TWL), change in BMI, and percent excess weight loss (%EWL) at 6 and 12 months in overweight and obese classes I, II, and III. Secondary outcomes included adipose tissue, lean body mass reduction, and metabolic rate analyzed by bioimpedance. Additionally, immediate or delayed adverse events (AEs) were analyzed. Clinical success was defined as achieving ≥25% EWL at 1 year with ≤5% serious AE (SAE) rate following the American Society for Gastrointestinal Endoscopy (ASGE)/American Society for Metabolic and Bariatric Surgery (ASMBS) threshold.

RESULTS

A total of 193 patients underwent ESG during the study period. All groups had >10% TWL and >25% EWL at 6 months of follow-up. On average, %TWL was 14.25% ± 5.26% and 15.06% ± 5.22% and the %EWL 56.15% ± 22.93% and 59.41% ± 25.69% at 6 months and 1 year of follow-up, respectively. %TWL was 8.91% ± .3%, 13.92% ± 5.76%, 16.22% ± 7.69%, and 19.01% ± .95% and %EWL 56.21% ± 2.0%, 62.03% ± 27.63%, 54.13% ± 23.46%, and 46.78% ± 2.43% for overweight and obesity classes I, II, and III, respectively, at 1 year. Male sex, age <41 years, and higher BMI were predictors of achieving a TWL ≥10% at 1-year follow-up. There was a significant reduction in adipose tissue from baseline. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery.

CONCLUSIONS

ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds.

Resuturing of Stomach in Endoscopic Sleeve Gastroplasty 8 Months After Original Procedure

Endoluminal treatments such as endoscopic gastroplasty have been gaining ground in obesity treatment. A 52-year-old woman gained weight 5 months after endoscopic gastroplasty. Thus, it was decided to resuture the greater curvature of the stomach 8 months after the initial procedure by reducing the gastric pouch even further. The patient lost 16% of her total body weight with this procedure. Endoscopic gastroplasty, which can be reperformed in patients who regain weight, reach a plateau, or do not achieve the initial planned weight loss, is an effective and safe first-line obesity treatment.

Endoscopic sleeve gastroplasty: a modified technique with greater curvature compression sutures

Background  Endoscopic sleeve gastroplasty (ESG) is rapidly becoming established as a safe and effective means of achieving substantial weight loss via the transoral route. New ESG suture patterns are emerging. Our aim was to investigate whether superior weight loss outcomes can be achieved by using a unique combination of longitudinal compression sutures and "U"-shaped sutures. Methods  This is a retrospective review of prospectively collected data of all patients undergoing ESG by a single operator in a single UK center. Results  Between January 2016 and December 2017, 32 patients (23 female) underwent ESG; n = 9 cases were completed utilizing a commonly used triangular suture pattern ("no longitudinal compression") and n = 23 cases were completed using our unique "longitudinal compression" suture pattern. In the no compression and compression groups, the mean ages were 45 ± 12 years and 43 ± 10 years, the median baseline weights were 113.6 kg (range 82.0 - 156.4) and 107 kg (range 74.0 - 136.0), and the median baseline body mass indexes (BMIs) were 35.9 kg/m ² (range 30.9 - 43.8) and 36.5 kg/m ² (range 29.8 - 42.9), respectively. After 6 months, body weight had decreased by 21.1 kg (range, 12.2 - 34.0) in the compression group (n = 7) versus 10.8 kg (range, 7.0 - 25.8) in the no compression group (n = 5) ( P  = 0.042). Correspondingly, BMI decreased by 7.8 kg/m ² (range, 4.9 - 11.2) and 4.1 kg/m ² (range, 2.6 - 7.2) in each group, respectively ( P  = 0.019). Total body weight loss (%TBWL) was greater in the compression group at 19.5 % (range, 12.9 - 30.4 %) compared to 13.2 % (range, 6.2 - 17.1 %) in the non-compression group ( P  = 0.042). No significant adverse events were reported in this series. Conclusion  The technique of ESG is evolving and outcomes from endoscopic bariatric therapies continue to improve. We provide preliminary evidence of superior weight loss achieved through a modified gastroplasty suture pattern.

Endoscopic Sleeve Gastroplasty (ESG) Is a Reproducible and Effective Endoscopic Bariatric Therapy Suitable for Widespread Clinical Adoption: a Large, International Multicenter Study

OBJECTIVE

Endoscopic sleeve gastroplasty (ESG), an incisionless endoscopic bariatric procedure, has shown impressive results in case series. This study examines the reproducibility, efficacy, and safety in three centers across two countries, and identifies key determinants for procedural success.

DESIGN

Patients who underwent ESG between February 2016 and May 2017 at one of three centers (Australia and USA) were retrospectively analyzed. All procedures were performed on an outpatient basis using the Apollo OverStitch device (Apollo Endosurgery, Austin, TX). Primary outcomes included absolute weight loss (ΔWeight, kg), change in body mass index (∆BMI, in kg/m²), total body weight loss (TBWL, %), excess weight loss (EWL, in %), and immediate and delayed adverse events.

RESULTS

In total, 112 consecutive patients (male 31%, age 45.1 ± 11.7 years, baseline BMI 37.9 ± 6.7 kg/m²) underwent ESG. At 1, 3, and 6 months, Δweight was 9.0 ± 4.6 kg (TBWL 8.4 ± 4.1%), 12.9 ± 6.4 kg (TBWL 11.9 ± 4.5%), and 16.4 ± 10.7 kg (TBWL 14.9 ± 6.1%), respectively. The proportion of patients who attained greater than 10% TBWL and 25% EWL was 62.2 and 78.0% at 3 months post-ESG and 81.0 and 86.5% at 6 months post-ESG. Weight loss was similar between the three centers. Multivariable analysis showed that male sex, greater baseline body weight, and lack of prior endoscopic bariatric therapy were predictors of greater Δweight at 6 months. Three (2.7%) severe adverse events were observed.

CONCLUSIONS

ESG is an effective, reproducible, and safe weight loss therapy that is suitable for widespread clinical adoption.

Efficacy and safety of endoscopic sleeve gastroplasty for obesity patients: a meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, effective, and safe technique for weight loss intervention. Since a relatively small number of cases were present in previous studies, this study aimed to elucidate the efficacy and safety of ESG.

METHODS

Relevant publications were identified through searching PubMed, EMBASE, Cochrane, and Web of Science before March 1, 2019. The percentage of total body weight loss (%TBWL), percentage of excess weight loss (%EWL), and the adverse event rate in each follow-up session were extracted, pooled, and analyzed. Forest plots were graphed based on random effects models.

RESULTS

A total of 1542 patients from nine studies were eligible for analysis. The pooled results of %TBWL at 1, 3, 6, and 12 months were 8.78% (p = 0.000), 11.85% (p = 0.000), 14.47% (p = 0.024), and 16.09% (p = 0.063), respectively. The pooled results of %EWL at 1, 3, 6, and 12 months were 31.16% (p = 0.000), 43.61% (p = 0.000), 53.14% (p = 0.000), and 59.08% (p = 0.015), respectively. Finally, the pooled rate of mild adverse events was 72% (p < 0.01), and the pooled estimate of severe adverse events was only 1% (p = 0.08).

CONCLUSION

Although the conventional surgical sleeve gastrectomy is the gold standard for bariatric surgery, ESG could be a promising minimally invasive alternative for treating obesity with satisfactory efficacy and low risk.

Endoscopic sleeve gastroplasty: From whence we came and where we are going

The most effective and durable treatment for obesity is bariatric surgery. However, less than 2% of eligible patients who fulfill the criteria for bariatric surgery undergo the procedure. As a result, there is a drive to develop less invasive therapies to combat obesity. Endoscopic bariatric therapies (EBT) for weight loss are important since they are more effective than pharmacological treatments and lifestyle changes and present lower adverse event rates compared to bariatric surgery. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive EBT that involves remodeling of the greater curvature. ESG demonstrated favorable outcomes in several centers, with up to 20.9% total body weight loss and 60.4% excess weight loss (EWL) on 2-year follow-up, with a low rate of severe adverse events (SAE). As such, it could be considered safe and effective in light of ASGE/ASMBS thresholds of > 25% EWL and ≤ 5% SAE, although there are no comparative trials to support this. Additionally, ESG showed improvement in diabetes mellitus type 2, hypertension, and other obesity-related comorbidities. As this procedure continues to develop there are several areas that can be addressed to improve outcomes, including device improvements, technique standardization, patient selection, personalized medicine, combination therapies, and training standardization. In this editorial we discuss the origins of the ESG, current data, and future developments.

Endoscopic gastroplasty to treat medically uncontrolled obesity needs more quality data: A systematic review

Endoscopic gastroplasty (EG) has been used in clinical practice to treat obesity. This systematic review has the objective of assessing if there is an acceptable level of scientific evidence on the safety and effectiveness of EG. A thorough search strategy was used up to October 2018, including the 2 most common techniques: endoscopic suturing and the primary obesity surgery endolumenal procedure. The quality of the studies was evaluated through the Joanna Briggs Institute Critical Appraisal tools for use in Systematic Reviews-"Checklist for Case Series"-and summarized using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Only 1 randomized controlled trial (moderate GRADE evidence) was found, and the remaining were case reports or small case series (very low GRADE evidence). The literature has low scientific quality. All studies, with 1 exception, are small case series with short follow-up. One of the randomized controlled trials did not meet the primary endpoint for weight loss in both groups (EG × sham) after 1-year follow-up. The case series reported from 16% to 19% total weight loss, but few had more than 6 months of follow-up. Serious adverse events ranged from 2% to 10%. Based on current literature, there is not enough quality scientific evidence regarding long-term weight loss and the procedure's safety to recommend the use of EG in current clinical practice.