Post written by Vincenzo Bove, MD, from the Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and the Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy.

This video shows the first case of endoscopic sleeve gastroplasty (ESG) with Apollo Overstitch 2 years after a previous modified primary obesity surgery (endoluminal {POSE-2]). The patient is an obese female with hypertension and dyslipidaemia who underwent POSE-2, with initial total body weight loss of 21%. After about 1 year, she experienced loss of satiety and weight regain up to BMI 31.6 kg/m² and had gastroscopic evidence of almost complete opening of the stitches of the POSE-2 procedure.

After a new multidisciplinary evaluation, a redo ESG with Apollo Overstitch was planned. The procedure was done with the Apollo Overstitch suturing device loaded at the tip of a double-channel gastroscope (2TGIF-180, Olympus, Tokyo, Japan), with CO2 inflation, endotracheal intubation, and the patient in a supine position. The stitches of the POSE-2 were left in place. Sutures were placed on intact gastric mucosa starting from the gastric incisura toward the fundus, being careful to not suture over the previous stitches of POSE-2 to avoid needle engagement. We placed 5 sutures with 4 bites each in a straight line, with the last suture line about 4 cm distal to the cardia. The final aspect of the gastric sleeve was similar to a primary ESG. No adverse events occurred. After 6 months, the patient achieved a BMI of 26.4 kg/m² and reported an excellent feeling of satiety.

This is the first reported case of a redo ESG with Apollo Overstitch after an endoscopic gastroplasty performed with a different stapling device, with satisfactory medium-term weight loss outcomes. In our video, we showed the technical aspects for performing a safe procedure. We emphasized the importance of a straight line of sutures with up to 4 bites to avoid excessive stirring of the stomach, along with using CO2 and avoiding hyperinflation.      

This video shows that redo ESG with Apollo is a safe, feasible, and effective procedure when performed after failed POSE-2 procedure. Our experience suggests the opportunity to offer a minimally invasive therapeutic option for patients with unsatisfactory results after POSE-2.

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