Technical aspects of endoscopic sleeve gastroplasty

Kumbhari_headshotPost written by Vivek Kumbhari, MD, from the Department of Medicine, Division of Gastroenterology and Hepatology, at the Johns Hopkins Medical Institutions in Baltimore, Maryland, USA.

Endoscopic sleeve gastroplasty (ESG) is an emerging weight loss technique. However, it is highly operator dependent and there is some variability in technique. In ESG, the volume of the stomach is reduced by approximately 70% through the creation of a small-diameter sleeve by use of an endoscopic suturing device (OverStitch, Apollo Endosurgery, Austin, Tex).

A 35-year-old woman underwent an ESG. Eight plications were used for the procedure and the procedure took approximately 75 minutes to complete. Clinical review at 24 weeks revealed that the patient had lost 20% of her total body weight corresponding to a BMI reduction of 34 kg/m2 to 28 kg/m2.

ESG is a technique in evolution. It is yet to be determined a) what the ideal suture pattern is to optimize durability of the sleeve; b) how many sutures should one use; c) how much fundus should remain; and d) what is the mechanism of action, etc.

This video demonstrates a technique that is now commonly used by high volume providers. Leaving the fundus unsutured is now accepted as the optimal technique (as opposed to closing the fundus as was initially performed and published).

We have found that durability of the sleeve appears to be improved when the bites are full-thickness, when spaced closer together, when a greater number of bites are taken per suture (6-9), and when less ground is covered by each suture. This needs to be balanced with efficiency and the need to shorten the stomach during the suturing process.

Sutures should be placed until the endoscope starts to become uncomfortably retroflexed. At this point, the fundus is likely to be small (10-20cc).

During the process of cinching, the suture must be tight but not under too much tension. If too tense, then there is a high likelihood of the suture cutting through tissue over the next few weeks (“cheese-wire effect”).

One should avoid using suction to aid with taking the bites. The helix alone should be used to take each bite. By using suction, there is a high likelihood that you preferentially bring mucosa and submucosa (as occurs in cap assisted banding) to the scope tip as opposed to the entire gastric wall.

This procedure is very effective in those who have has gastric dilation corresponding to weight gain after a laparoscopic sleeve gastrectomy. It is a great way to gain experience with the procedure.

Read the full article here.

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