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Antecedentes: la obesidad es una enfermedad con alta prevalencia a nivel mundial, y su incidencia está en aumento, especialmente en los países de ingresos medios a altos. Su fisiopatología se encuentra relacionada con la regulación hormonal intestinal y diversas afecciones gastrointestinales. Introducción: el gastroenterólogo desempeña un papel importante en el tratamiento de esta enfermedad por medio de intervenciones especializadas como la endoscopia bariátrica, que contribuyen con la pérdida de peso y la disminución de las comorbilidades asociadas a esta condición. Además, debido a que cada vez más pacientes se someten a procedimientos para la pérdida de peso, es esencial comprender el tratamiento médico coadyuvante en los procedimientos bariátricos. En esta revisión se presentan los elementos clave que debe tener en cuenta el gastroenterólogo para el manejo de la obesidad con base en la literatura más reciente. Conclusiones: existen necesidades de tratamiento insatisfechas para los pacientes con obesidad, dentro de las cuales el abordaje con procedimientos endoscópicos bariátricos son una realidad considerando que se realicen en conjunto con otros abordajes de carácter multidisciplinario.

Abstract Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Background: Bariatric endoscopy has emerged for non-surgical treatment of obesity, providing a treatment option for weight loss and associated comorbidities. Outcomes of endoscopic sleeve gastroplasty (ESG) of 12 months have been published by our team and there is a need for longer follow-up period understanding the effects of ESG techniques. Aim: This report emphasises on weight loss pattern in follow-up time points and monitors the post-procedure improvement in comorbidities with minimum 4-year follow-up of patients undergoing ESG at a single academic centre in India. Subjects and Methods: This was a prospective cohort study. All procedures were performed by the same surgeon. Patients with a body mass index of >30 kg/m2 (or >27 with comorbidities) underwent ESG for treatment of obesity. Patients were systematically followed yearly after their procedure. Data collected on the primary outcome and secondary outcomes were analysed and presented. Results: 612 patients (69.3% female) with a mean age of 40.70 ± 12.66 years and mean body mass index of 34.30 ± 5.05 kg/m2 underwent ESG. Out of 612 patients, follow-up rates for a 1-2-3 and 4 years were 93.1%, 90.2%, 81.7% and 81.9%, respectively. The mean percentage total body weight loss was 18.19% (95% confidence interval [CI]: 17.72–18.57) and %EWL was 49.30% (95% CI: 48.91–49.68) with 90% of participants-maintaining a percentage of total weight loss of ≥5% and 70% of patients maintaining an EWL of ≥25% at 4 years, respectively. Resolution/improvement of comorbidities was 51.2% cases of T2DM, 65.8% cases of hypertension, 73.6% cases of dyslipidaemia and 89.9% remission were in obstructive sleep apnoea. No patient required an emergency intervention, and there was no mortality or significant morbidity. Conclusions: This study shows acceptable results with ESG at 4 years in our unit. Regular monitoring by a multidisciplinary nurtures weight loss, resolution or improvement of comorbidities and improvement of quality of life with low perioperative complications. There is a need for more reports with this approach to determine the amount and duration of weight loss outcome and medical intervention.

Abstract The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term ‘digital surgery’. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and

Abstract. Since its first description in 2013, robust evidence supporting the efficacy and safety of the endoscopic sleeve gastroplasty (ESG) has been on the rise. A large case series and meta-analysis report supported results up to 24 months, while some other studies already described 5-year data. If associated with pharmacotherapy, the ESG may help one to achieve weight loss similar to that of surgical sleeve gastrectomy. Though the results of the ongoing randomized trials on ESG are awaited, currently available data support the clinical use of the ESG, especially for patients who are refusing or unfit for bariatric surgery.

It is known that the rapid weight loss is a predisposing factor to develop biliary lithiasis. The physiopathology is related with an oversaturation of bile with cholesterol, bile stasis, and increase in mucin concentration in bile. The incidence of cholelithiasis post gastric bypass is estimated around 37%. Almost 50% developed disease in the first year of monitoring, and 60% in the first 6 months. Meanwhile the patients undergoing sleeve gastrectomy have an incidence of cholelithiasis of 27%. Diverse kinds of protocols exist: prophylactic surgery (simultaneous cholecystectomy and gastric bypass in every patients, whether they have or not cholelithiasis), elective (simultaneous cholecystectomy with conventional gastric bypass in the patients with asymptomatic cholelithiasis), and conventional cholecystectomy only in the presence of cholelithiasis with symptoms. Which way to go is still a topic of discussion among surgeons but the majority agree that prophylactic surgery shouldn’t be an option because the number of patients that will develop symptomatic cholelithiasis is low (around 6% to 8% of them) and this leads to an elevated number of patients exposed to an unnecessary procedure with potential complications. The presence of gallstones in the common bile duct (CBD) although is a rare complication after Roux-en-Y gastric bypass (around 0.2% of the bariatric patients) represents an important challenge due to the anatomical modifications of the gastrointestinal tract. This leads to having to pursue other methods to reach the papillae for the resolution of choledocholithiasis: laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP), balloon enteroscopy assisted ERCP, percutaneous biliary drainage with subsequent trans fistula treatment and laparoscopic exploration of CBD. Which of these methods should we choose must be based on the surgeon experience, the equipment available and the location of the stone. But whatever the method, a special training is needed on endoscopy, percutaneous surgery and laparoscopy.

RESUMEN Introducción: muchos de los pacientes sometidos a cirugía bariátrica (bypass gástrico en Y-de-Roux [RYGB]), con el tiempo, pueden recuperar parte del peso perdido. La reducción transoral del vaciamiento gástrico (TORe) con sutura endoscópica podría ser una alternativa válida en estos pacientes. Métodos: serie inicial retrospectiva que incluye a 13 pacientes consecutivos remitidos por reganancia ponderal tras RYGB y con anastomosis gastroyeyunal dilatada (> 15 mm). El TORe fue realizado mediante un dispositivo endoscópico de suturas transmurales (OverStitch-Apollo(r)), reduciendo el diámetro de la anastomosis y del reservorio gástrico. Se describen los datos iniciales de viabilidad técnica, seguridad y eficacia, con un seguimiento limitado a seis meses. Resultados: tras el RYGB, existía una pérdida media máxima de 37,69 kg y una posterior reganancia media de 21,62 kg. Se redujo el diámetro medio de la anastomosis de 36 mm (rango 20-45) a 9 mm (rango 5-12) (reducción del 75%) con una media de 2,5 suturas y el del reservorio de 7,2 cm (rango 2-10) a 4,7 cm (rango 4-5) (reducción del 34,72%) con una media de 2,7 suturas. La pérdida media de peso a los seis meses tras el TORe fue de 12,29 kg (pérdida del 56,85% del peso reganado tras RYGB). No se registraron complicaciones relacionadas con el procedimiento. Conclusiones: la reducción mediante sutura endoscópica de la anastomosis gastroyeyunal dilatada y del reservorio gástrico parece una opción viable y segura según nuestra limitada experiencia inicial. Dentro de un abordaje multidisciplinar y en un seguimiento a corto plazo, se presenta como una opción mínimamente invasiva y eficaz para controlar la reganancia ponderal tras RYGB.

Background and study aims A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.

The use of digital technology is increasing rapidly across surgical specialities, yet there is no consensus for the term 'digital surgery'. This is critical as digital health technologies present technical, governance, and legal challenges which are unique to the surgeon and surgical patient. We aim to define the term digital surgery and the ethical issues surrounding its clinical application, and to identify barriers and research goals for future practice. 38 international experts, across the fields of surgery, AI, industry, law, ethics and policy, participated in a four-round Delphi exercise. Issues were generated by an expert panel and public panel through a scoping questionnaire around key themes identified from the literature and voted upon in two subsequent questionnaire rounds. Consensus was defined if >70% of the panel deemed the statement important and