Search

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m 2 , or with a BMI of 27.0-29.9 kg/m 2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population., Competing Interests: Disclosure The following authors disclosed financial relationships: P. Jirapinyo: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Erbe, and Spatz Medical; advisory board for Apollo Endosurgery; research support from Apollo Endosurgery, Boston Scientific Corporation, GI Dynamics, Fractyl, and USGI Medical. A. Hadefi: Research support from Endo Tools Therapeutics. C. C. Thompson: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Medtronic, Endoquest Robotics, Fractyl, FujiFilm, GI Dynamics, EnVision Endoscopy, Olympus/Spiration, Softac, USGI Medical, Xenter, Enterasense Ltd, and Lumendi; research support from Apollo Endosurgery, Boston Scientific Corporation, Endoquest Robotics, Erbe, Fractyl, FujiFilm, GI Dynamics, Olympus/Spiration, USGI Medical, and Lumendi; advisory board for Fractyl and USGI Medical; founder of Bariendo, BlueFlame Healthcare Venture Fund, ELLES, EnVision Endoscopy, GI Windows, Society for Metabolic and Bariatric Endoscopy Inc, and Enterasense Ltd, and GI Windows; board member for Bariendo, ELLES, EnVision Endoscopy, GI Windows, and Enterasense Ltd; ownership in Bariendo, ELLES, EnVision Endoscopy, GI Windows, Society for Metabolic and Bariatric Endoscopy Inc, Softac, Xenter, and Enterasense Ltd; partner in BlueFlame Healthcare Venture Fund; president of the Society for Metabolic and Bariatric Endoscopy Inc; Scientific Advisory Board for Xenter. R. Pannala: Research support from Fractyl Labs; general payments from Boston Scientific Corporation; consultant for HCL Technologies; advisory board for Nestle Healthsciences and Bluestar Genomics. S. K. Goelder: Travel compensation from Apollo Endosurgery. V. Kushnir: Consultant for BSCI, Noah Medical, Steres, and ConMed. M. Barthet: Consultant for Boston Scientific Corporation, Endotools, and Taewoong. C. M. Apovian: Advisory board for Altimmune, Inc, CinFina Pharma, Inc, Cowen and Company, LLC, Currax Pharmaceuticals, LLC, EPG Communication Holdings Ltd, Form Health, Inc, Gelesis, Srl, L-Nutra, Inc, NeuroBo Pharmaceuticals, Inc, Novo Nordisk, Inc, OptumRx, Inc, Pain Script Corporation, Palatin Technologies, Inc, Pursuit By You, ReShape Lifesciences Inc, Riverview School, and Xeno Biosciences; research support from the National Institutes of Health, Patient-Centered Outcomes Research Institute, and GI Dynamics, Inc. I. Boskoski: Consultant for Boston Scientific Corporation (Apollo Endosurgery), Nitinotes, and EndoTools. C. G. Chapman: Consultant for Boston Scientific Corporation, Olympus, Steris, and Apollo Endosurgery; speaker for Apollo Endosurgery. V. Kumbhari: Consultant for Boston Scientific Corporation. J. Esker: Consultant for Pendulum Therapeutics. A. D. Pryor: Speaker for Gore, Medtronic, and Stryker. R. Maselli: Consultant for Apollo Endosurgery. A. R. Schulman: Consultant for Apollo Endosurgery, Boston Scientific Corporation, Olympus, and MicroTech; research support from GI Dynamics and Fractyl. N. Thosani: Consultant for Boston Scientific Corporation, Ambu, and Pentax America; royalties from UpToDate; ownership in ROSEAId. V. Huberty: Shareholder in, board member for, and research support from EndoTools Therapeutics. S. Sullivan: Consultant for Allurion Technologies, Biolinq, BariaTek, Pentax, Fractyl, and Endo Tools Therapeutics; research support from Allurion Technologies, ReShape Medical/Obalon Therapeutics, and Rebiotix; stock ownership in Biolinq. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy. Published by Elsevier Inc on behalf of American Society for Gastrointestinal Endoscopy and by Georg Thieme Verlag KG Stuttgart on behalf of European Society of Gastrointestinal Endoscopy. All rights reserved. Published by Elsevier Inc. All rights reserved.)

Background: Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass., Method: A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass., Conclusions: The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting., (© 2022. The Author(s).)

Background and Aims: Endoscopy is effective in management of bariatric surgery (BS) adverse events (AEs) but a comprehensive evaluation of long-term results is lacking. Our aim is to assess the effectiveness of a standardized algorithm for the treatment of BS-AE., Patients and Methods: We retrospectively analyzed 1020 consecutive patients treated in our center from 2012 to 2020, collecting data on demographics, type of BS, complications, and endoscopic treatment. Clinical success (CS) was evaluated considering referral delay, healing time, surgery, and complications type. Logistic regression was performed to identify variables of CS., Results: In the study period, we treated 339 fistulae (33.2%), 324 leaks (31.8%), 198 post-sleeve gastrectomy twist/stenosis (19.4%), 95 post-RYGB stenosis (9.3 %), 37 collections (3.6%), 15 LAGB migrations (1.5%), 7 weight regains (0.7%), and 2 hemorrhages (0.2%). Main endoscopic treatments were as follows: pigtail-stent positioning under endoscopic view for both leaks (CS 86.1%) and fistulas (CS 77.2%), or under EUS-guidance for collections (CS 88.2%); dilations and/or stent positioning for sleeve twist/stenosis (CS 80.6%) and bypass stenosis (CS 81.5%). After a median (IQR) follow-up of 18.5 months (4.29-38.68), complications rate was 1.9%. We found a 1% increased risk of redo-surgery every 10 days of delay to the first endoscopic treatment. Endoscopically treated patients had a more frequent regular diet compared to re-operated patients., Conclusions: Endoscopic treatment of BS-AEs following a standardized algorithm is safe and effective. Early endoscopic treatment is associated with an increased CS rate., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Due to the large number of laparoscopic sleeve gastrectomy (LSG) performed over the last decade, the management of the leak following LSG has been increasingly reported. The role of covered Self Expandable Metal Stents (cSEMS) for the treatment of the leak is still controversial because of the poor tolerance and high risk of complications., Objectives: The aim of the present study was to analyze the foregut wall perforation and aorta injuries, a very rare but potentially fatal complication, related to the treatment of the leak following LSG using cSEMS., Setting: Private hospital, France., Methods: An audit was conducted in 2 French tertiary bariatric endoscopic centers focusing on aortic injuries after cSEMS use for leak. We examined and classified the initial procedure, leak characteristics, primary endoscopic treatment, and outcome of endoscopic complication for each eligible case., Results: A total of 5 patients were identified with foregut wall perforation and aorta injuries. All stents were deployed for staple line leak following LSG. The recorded mortality in case of esophageal-aortic injuries related to cSEMS use was 80%., Conclusion: cSEMS are potentially effective tools for the management of foregut leaks in bariatric surgery. The biggest challenges with this approach are stent migration and poor quality of life. Caution is required due to the risk of fatal complications such as foregut wall perforation and aortic injury., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Submucosal tumors (SMTs) of the gastrointestinal tract are a rare pathological entity comprising a wide variety of neoplastic and non-neoplastic lesions. Even if most SMTs are benign tumors (e.g., leiomyomas), a smaller portion may have a malignant potential (e.g., gastrointestinal stromal tumor (GIST)). Preoperative diagnosis of SMT in bariatric patients may arise challenging clinical dilemmas. Long-term surveillance may be difficult after bariatric surgery. Moreover, according to SMT location, its presence may interfere with planned surgery. Submucosal tunneling endoscopic resection (STER) has emerged as an effective approach for minimally invasive en bloc excision of SMTs. This is the first case series of STER for SMTs before bariatric surgery., Methods: Seven female patients underwent STER for removal of SMTs before bariatric surgery. All lesions were incidentally diagnosed at preoperative endoscopy. STER procedural steps comprised mucosal incision, submucosal tunneling, lesion enucleation, and closure of mucosal defect., Results: En bloc removal of SMT was achieved in all cases. Mean procedural time was of 45 min (SD 18.6). No adverse event occurred. Mean size of the lesions was 20.6 mm (SD 5.8). Histological diagnoses were 5 leyomiomas, 1 lipoma, and 1 low grade GIST. Bariatric procedure was performed after a mean period of 4.1 months (SD 1.6) from endoscopic resection., Conclusion: STER is a safe and effective treatment for the management of SMT even in bariatric patients awaiting surgery. Preoperative endoscopic resection of SMTs has the advantages of reducing the need for surveillance and removing lesions that could interfere with planned surgery. STER did not altered accomplishment of bariatric procedures.

Background: Laparoscopic sleeve gastrectomy (LSG) is a widely accepted, stand-alone bariatric operation. Data on elderly patients undergoing LSG are scarce., Objectives: The aim of this study was to demonstrate that LSG is safe and effective for patients>65 years old with severe obesity., Setting: Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Paris-Saclay University, France., Methods: Prospectively collected data from consecutive patients undergoing LSG were retrospectively analyzed. Patients with>1-year follow-up were included in the analysis for weight loss and co-morbidities evaluation. Quality of life was evaluated using the Short-Form 36 questionnaire., Results: Fifty-four patients>65 years old (range, 65-75 yr) underwent LSG. Median weight was 119 kg, and median body mass index was 43 kg/m 2 . Median duration of surgery was 86.5 minutes. Two patients (3.7%) suffered a gastric staple-line leak, 1 treated by pure endoscopic internal drainage and 1 by relaparoscopy with subsequent endoscopic internal drainage. Mortality was null. Median length of hospital stay was 5 days. Six, 12, and 24 months after LSG, median body mass index decreased significantly to 35, 32.9, and 30.7 kg/m 2 , respectively (P<.0001), with mean excess weight loss of 76.3% at 2 years. Type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea syndrome, and arthralgia showed statistically significant remission at 1- and 2-year follow-up, while 6 of 8 SF-36 scale scores of quality of life assessment improved significantly., Conclusions: This study suggests that LSG is effective for patients>65 years old, resulting in significant weight loss, co-morbidities remission, and quality of life improvement. Careful patient selection after adequate risk versus benefit evaluation by an expert multidisciplinary team is essential for patient safety and optimal results., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Post-operative collections are a recognized source of morbidity after abdominal surgery. Percutaneous drainage is currently considered the standard treatment but not all collections are accessible using this method. Since the adoption of EUS, endoscopic transmural drainage has become an attractive option in the management of such complications. The present study aimed to assess the efficacy, safety and modalities of endoscopic transmural drainage in the treatment of post-operative collections., Methods: Data of all patients referred to our dedicated multidisciplinary facility from 2014 to 2017 for endoscopic drainage of symptomatic post-operative collections after failure of percutaneous drainage or when it was deemed impossible, were retrospectively analyzed., Results: Thirty-two patients (17 males and 15 females) with a median age of 53 years old (range 31-74) were included. Collections resulted from pancreatic (n = 10), colorectal (n = 6), bariatric (n  = 5), and other type of surgery (n  = 11). Collection size was less than 5 cm in diameter in 10 (31%), between 5 and 10 cm in 17 (53%) ,and more than 10 cm in 5 (16%) patients. The median time from surgery to endoscopic drainage was 38 days (range 6-360). Eight (25%) patients underwent endoscopic guided drainage whereas 24 (75%) patients underwent EUS-guided drainage. Technical success was 100% and clinical success was achieved in 30 (93.4%) after a mean follow-up of 13.5 months (1.2-24.8). Overall complication was 12.5% including four patients who bled following trans-gastric drainage treated with conservative therapy., Conclusions: The present series suggests that endoscopic transmural drainage represents an interesting alternative in the treatment of post-operative collection when percutaneous drainage is not possible or fails.

Background: A large number of patients who undergo laparoscopic sleeve gastrectomy present with surgical complications. Stenosis, in particular, occurs in .7%-4% of cases., Objectives: To report our experience, results, and long-term follow-up after pneumatic dilation of late functional helix stenosis after laparoscopic sleeve gastrectomy., Setting: Multicenter study led by an endoscopic tertiary referral center., Methods: Thirty-five patients were dilated initially at 30 mm. Thirteen out of 35 patients underwent a second dilation up to 35 mm. Only 8 patients underwent a third pneumatic dilation up to 40 mm. The stricture was localized in the mid-body of the sleeve in 32 patients overall; 3 had narrowing adjacent to the cardia. Eleven twists formed an acute angle between the 2 segments of the stomach, whereas 24 angles were obtuse. Seven out of 35 patients presented with persistent dilated pouch above the twist. Two patients were lost to follow-up. Overall outcome at an average follow-up of 15.5 months after primary surgery (range 7-49 mo) was as follows: 12 clinical failures and 1 technical failure (40%) and 60% (20 out of 33) clinical success., Conclusion: Pneumatic dilation of late functional helix stricture is an effective technique for treatment of dysphagia in the majority of patients treated. Complete helix stricture, defined in function of the angle within twist, as well as the presence of a persistently dilated gastric pouch above the kinking, seems to be correlated with higher failure rates., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Symptomatic intra-abdominal collection after bariatric surgery occurs in up to 5% of cases. Surgical, percutaneous, or endoscopic drainage are the feasible approaches., Materials and Methods: In this video, we show the case report of a 50-year-old woman who underwent to gastric omega bypass on a previous sleeve gastrectomy. After 3 weeks, she presented a well-organized liquid collection just behind the longitudinal staple line of the gastric pouch. No passage of contrast from the gastrointestinal tract to the collection was highlighted. Endoscopic ultrasound drainage approach failed due to tightness of the gastric pouch. Therefore, direct endoscopic drainage was successfully performed using CT scan images as guidance and according to fluoroscopic visualization of the staple line., Results: The patient fully recovered, and she was discharged 48 h after endoscopy with complete normalization of inflammatory markers (CRP and leukocytosis). Upper GI endoscopy has been scheduled in 3 months in order to plan the removal of the stents., Conclusions: We managed such surgical complication creating a fistula between the gastric remnant and the collection achieving an internal drainage of the intra-abdominal fluid collection. The concept of internally drain any fluid collection with endoscopically delivered double pigtails plastic stents is gaining momentum and has been demonstrated effective in the management of leak following bariatric and upper GI surgery too.

Background: Prompt management of laparoscopic sleeve gastrectomy (LSG) complications is essential in avoiding prolonged hospital stay and associated mortality. The value of routine computed tomography (CT) scan examination in early diagnosis of postoperative complications after LSG has not been studied., Objectives: To prospectively assess the impact of postoperative day (POD) 2 CT scan after LSG., Setting: Department of Minimally Invasive Digestive Surgery, Antoine-Beclere Hospital, AP-HP, Paris-Saclay University, France., Methods: Data were prospectively gathered for 1000 patients undergoing single-incision LSG and POD 2 CT scan. Complications were identified and treatment modalities decided according to the severity of complications. Sensitivity, specificity, and positive and negative predictive values were calculated for the diagnosis of surgical complications on POD 2 CT scan., Results: Mean age was 40.1 years and median BMI 42.6 kg/m². Early postoperative surgical complications occurred in 66 patients (6.6%). Intraabdominal bleeding/hematoma occurred in 38 patients, with 3 requiring emergent reoperation on POD 1. POD 2 CT scan detected this complication in 32 patients (sensitivity: 91.4%). Twenty-four (63.1%) patients were treated with relaparoscopy and drainage while 14 (36.9%) received conservative management. Postoperative transfusion was required in 7 patients. Twenty-eight patients suffered a gastric staple line leak, 13 (sensitivity: 46.4%) detected on POD 2 CT scan. Three patients (10.7%) received pure surgical treatment, 16 (57.1%) combined relaparoscopy and endoscopic treatment, and 9 (32.2%) had pure endoscopic treatment., Conclusion: POD 2 abdominal CT scan is an efficient diagnostic tool for detecting active bleeding/hematoma, but shows less impressive results with gastric staple line leak detection. A combination of clinical surveillance and early imaging allowed prompt management of complicated cases, avoiding further morbidity., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Residual arterial supply of the gastric tube after sleeve gastrectomy (SG) can be damaged by surgery, which can reduce gastric tube perfusion and could promote postoperative leakage. To compare the postoperative vascularization of the gastric tube using early computed tomography (CT) scanning after SG in patients with or without postoperative staple-line leak. University hospital. A retrospective analysis of a prospective database was performed in consecutive patients undergoing SG. Patients who presented with a staple-line leak were matched (1:3) with a control group of patients who underwent surgery without postoperative morbidity during the same period. Gastric tube vascularization was studied on a postoperative day 2 CT scan in both groups of patients. During the study period, 1826 patients underwent SG , including 42 patients (2.3%) who presented with a staple-line leak. Those 42 patients were successfully matched to 126 control patients. Global identification of residual gastric arterial supply in early postoperative CT scans was similar in patients with or without staple-line leak after SG. However, residual vascular supply of the gastroesophageal junction (i.e., terminal and anterior cardiotuberosity branches of the left gastric artery or left inferior phrenic artery) was more frequently interrupted by the staple line in the group of patients who developed a gastric leak. This study suggests a correlation between interruption of the main arteries supplying the gastroesophageal junction by the staple line on early postoperative CT scans and the development of gastric leak after SG. These results support the vascular theory as one of the causes of leak after SG. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Operative management of acute abdomen after bariatric surgery in the emergency setting."

Introduction: Achalasia after bariatric surgery is a rare pathological entity. Nonetheless, several cases have been described in literature. Per oral endoscopic myotomy has recently emerged as the preferred approach for the management of esophageal motility disorders. Material and Methods: We report a video case of POEM performed in a female patient with prior multiple bariatric surgical procedures. In her past medical history, she underwent to laparoscopic lap band, sleeve gastrectomy, and Roux-Y-gastric bypass. Results: POEM was carried out without complication. Myotomy was performed only for 1 cm below the cardias due to the presence of the gastro-jejunal anastomosis. Post-operative course was uneventful and oral diet was restarted after one day. At 2 months follow-up, the patient is asymptomatic with no weight regain. Conclusion: We report the first case of POEM after three different bariatric surgical procedure. Fibrosis due to prior interventions did not hampered POEM procedure, and the shorter myotomy due to the presence of small gastric pouch did not reduced its efficacy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Fully covered self-expanding metal stent (SEMS) placement has been successfully described for the treatment of malignant and benign conditions. The aim of this study is to evaluate our experience of fully covered SEMS placement for post-operative foregut leaks. MATERIALS AND METHODS: Retrospective analysis was done for indications, outcomes and complications of SEMS placed in homogeneous population of 15 patients with post-operative foregut leaks in our tertiary-care centre from December 2008 to December 2010. Stent placement and removal, clinical and radiological evidence of leak healing, migration and other complications were the main outcomes analyzed. RESULTS: Twenty-three HANAROSTENT® SEMS were successfully placed in 14/15 patients (93%) with post-operative foregut leaks for an average duration of 28.73 days (range=1-42 days) per patient and 18.73 days per SEMS. Three (20%) patients needed to be re-stented for persistent leaks ultimately resulting in leak closure. Total 5/15 (33.33%) patients and 7/23 (30.43%) stents showed migration; 5/7 (71.42%) migrated stents could be retrieved endoscopically. There were mucosal ulceration in 2/15 (13.33%) and pain in 1/15 (6.66%) patients. CONCLUSIONS: Stenting with SEMS seems to be a feasible option as a primary care modality for patients with post-operative foregut leaks. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative collections are an important cause of morbidity following obesity surgery. Surgical revision is most often required if general sepsis is present. Conservative treatment consists of broad spectrum antibiotics and percutaneous drainage of any collection. EUS drainage is a new technique that is gaining momentum allowing an easy access to collections close to the GI tract. Materials and Methods: We present the case report of a 39-year-old woman who underwent to robotic Roux-en-Y gastric bypass for morbid obesity. She developed a jejuno-jejunal dehiscence treated with revision surgery. Afterward, a pelvic collection/hematoma was highlighted; however, neither percutaneous approach nor surgery succeeded in draining it. Results: EUS-guided deployment of a fully covered lumen-apposing metal stent was performed. Subsequently, two necrosectomies were required to remove necrotic tissue and clots from the perirectal cavity. Finally, three double pigtail stents were deployed to promote healing. The patient spontaneously expelled the stents with the stool, and she is asymptomatic after a follow-up of 3 months. Conclusion: EUS transmural rectal drainage may represent a sound option for the treatment of pelvic postoperative collections. FCLAMS deployment guarantees a rapid drainage allowing to perform an endoscopic necrosectomy. [ABSTRACT FROM AUTHOR]