A recent publication in Gastrointesintal Endoscopy evaluated the endoscopic sleeve gsatroplasty (ESG) across seven centers. The study of 193 patients who underwent an ESG demonstrated that on average, the %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. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery. The authors concluded that ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds.
Barrichello S, Hourneaux de Moura DT, Hourneaux de Moura EG, Jirapinyo P, Hoff AC5, Fittipaldi-Fernandez RJ, Baretta G, Felício Lima JH, Usuy EN, de Almeida LS, Ramos FM, Matz F, Galvão Neto MDP, Thompson CC. Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study. Gastrointest Endosc. 2019 Jun 19.
We speak with one of the study authors, Manoel Galvao Neto, in more detail regarding the study and what role ESG will play in the treatment of obesity.
What has been your interest in evaluating and researching ESG?
We start performing the ESG in 2012 as one of the pioneers on the technique. Since them, our goal as a group is to develop and study the method, which we did in around 10 publications since then. Out of our group, more than 40 papers were published and/or presented in international congress being 4 of those meta-analysis studies with positive results. So in this short period, a considerable amount of useful data has been produced at a level that initial promising results allow it to be used in clinical practice
Dr. Manoel Neto also recommends the following the Merit trial which is a United States based trial gathering Level 1 evidence on the ESG. (https://clinicaltrials.gov/ct2/show/NCT03406975)
Who are the best candidates, in regards to BMI and co-morbidities for an endoscopic sleeve gastroplasty (ESG)?
Best candidates are the so-called low BMI obesity patients with in-between 30-40 that don't qualify for bariatric surgery. There is also data on using ESG as a bridge for bariatric surgery on high BMI (there are reports of the procedure on up to 100 BMI in Germany), situs inversus and "difficult" Abdomen. Bridge to non-bariatric procedures like liver and kidney transplantations and orthopedics are also reported
This particular study evaluated the use of a "U" stitch pattern. Can you explain the previous types of stitching patterns? What is the benefit of the "U" stitch pattern over previously used stitching patterns?
We had helped develop this pattern ("U" ) in ABC medical School in Brazil, and it seems that it is one of the most popular ones. Also, it was used to train around 200 colleagues in Brazil as their initial suture pattern due to its safety, reproducibility, and easiness to learn because it keeps a define and clear line avoiding the suture to be crossed. There are quite a different number of suture patterns around Like "Z", Square, "N" and so one. The advantages of one over the other are not clear and reside more in a personal or group option on the direction of a common goal that is to reduce the stomach greater curvature
The success of a bariatric endoscopic procedure has utilized ≥25% EWL at 1 year as the threshold for a successful procedure. Do you feel this an appropriate threshold, or should it be changed?
Actually, I do feel it is appropriate. Achieving ≥25 %EWL with no more than 5% of SAE are parameters have been defined by ASGE and FDA to evaluate the success of EndoBariatric therapies (EBT). I personally prefer %TWL to evaluate it, and we also report this parameter. Regarding follow-up timing, EBT is still evaluated on its short mid-term effect since they are being mainly used on less severe obese patients
What is the significance of the findings of this recent publication that readers should take away from in regards to ESG?
Take-home messages from this specific paper:
• Structured and stepwise training with didactics followed by suture “boot camp” and physician proctoring on the apprentice center as the training received by all participants on the study that provide cases seems to work
• ESG is safe and reproducible
This paper, a multicenter study, analyzed 193 patients which achieved 15.06% ± 5.22%TWL with 1.03% off SAE.
• Downsides are its retrospective, non-randomized structure
Concerns have been raised regarding patients who need to undergo a roux-en-y gastric bypass or a sleeve gastrectomy after an ESG. Are these concerns warranted? What do you suggest to surgeons performing these procedures after a previous ESG?
For these matters, we should not worry that much. The ones who raise those questions ignore that when we were developing this technique, those issues were addressed and contemplated. If one needs to convert an ESG to an RYGB, it can be easily done since we avoid suture most of the fundus and we also don't suture the smaller curvature, so it is a go. Regarding converting an ESG to a Sleeve Gastrectomy, we do recommend the use of intra-operative endoscopy so it can orient the positioning of the stapler out of previous metal needle tips and plastic clips. Alqahtani evaluated 20 patients who underwent a laparoscopic sleeve gastrectomy following an ESG (https://www.ncbi.nlm.nih.gov/pubmed/31214968).
What are some of the complications of an ESG?
Reported complications are bleedings (internal and external), chronic pain, abscess, perforations, inadvertent gallbladder suturing. Neither intra-operative conversion nor mortality were reported. SAE rates on meta-analysis papers range from 1.1 to 2.6%
We already have very effective bariatric surgical procedures. Why not simply expand the indications for a sleeve gastrectomy, for instance, to the lower BMI (such as BMI) or expand its use in patients with co-morbidities? What will be the future role of ESG in world of bariatric surgery?
Indeed. Bariatric Surgery is effective and safe but has complications that are by nature more severe and life-threatening than a less invasive method like EBT, and that can't be neglected so if bariatric surgery move on direction of lower BMI it has to prove to be as safe as EBT. On the other hand, we are on the verge of adding more effective weight loss drugs to EBT and to merge gastric EBT with bowel EBT amplifying results and durability. Being an effective EBT, ESG has a promising future. It is just the beginning, and with more endosuturing devices coming to the market it seems to be a solid EBT
What will be the future role of ESG in the world of bariatric surgery?
Gather momentum and achieve a larger scale in terms of market penetration. USA RCT trial was designed to get the payers on board and we should aim to reimbursement
What are you recommendations in regard to those individuals who want to begin doing ESG in their bariatric practice?
ESG is indeed an advanced endoscopic procedure and the ones aiming to perform it should have or should build advanced endoscopic skills. Both GI and Surgeons can perform the procedure with proper training as we demonstrated in this article. Attending Endosuturing courses and masterclasses are a good way to start
