Post written by Christopher McGowan, MD, MSCR, AGAF, ABOM, FASGE, from True You Weight Loss, Cary, North Carolina, USA.

In this video, we describe our technique for the endoscopic removal of an AspireAssist weight-loss device (Aspire Bariatrics, King of Prussia, Penn, USA) with simultaneous prophylactic stoma closure. The device was approved by the U.S. Food and Drug Administration in 2016 for the treatment of adults with obesity and provided a long-term mechanism for patients to aspirate or eliminate gastric contents to facilitate weight loss.

For patients uninterested in or ineligible for traditional bariatric surgery, this device offered the potential for significant weight loss and the ability to maintain control over their weight-loss efforts. Unfortunately, amid economic pressures related to the COVID-19 pandemic, Aspire Bariatrics withdrew its device from the U.S. market in 2022. Patients with the indwelling device were notified of this market withdrawal and advised to seek device removal on a nonurgent basis.

Considering that the AspireAssist device is designed to remain in place chronically, the majority of patients who present for tube removal have had the device in place for more than 1 year and potentially up to 3 or more years. Although tube removal is easily performed via endoscopic retrieval, careful consideration must be paid to the closure of the resulting stoma. The risk of a persistent gastrocutaneous fistula (GCF) increases proportionately to gastrostomy tube dwell time.

In fact, the risk of a chronic GCF is approximately 30% to 40% if tube removal occurs after 2 years. Subsequent closure often requires surgical intervention, which is unideal. Therefore, we recommend prophylactic closure at the time of tube removal. Although numerous methods—including through-the-scope clips, over-the-scope clips, and argon plasma coagulation—have been described, these methods have a high fail rate.

Therefore, our preferred method is a through-the-scope suturing device, X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery, Austin, Tex, USA). This efficient technique can be performed during gastrostomy tube removal and provides durable closure in our experience.

This video offers unique technical insight into the treatment of a very specific scenario–removal and closure of an AspireAssist tube and stoma–which may benefit the number of patients who still require tube removal. Furthermore, the techniques herein potentially inform about the removal of chronic gastrostomy tubes used for other indications.

The key takeaways that I would emphasize are (1) the risk of a chronic GCF increases in proportion to the duration of gastrostomy tube dwell time because of the formation of a neoepithelium within the stoma tract; (2) prophylactic closure is recommended for any stoma tract of more than a 2-year duration and should be considered in “younger” tracts as well, given the risks of a persistent fistula; (3) traditional methods such as endoscopic clips, argon plasma coagulation, and cytology brush agitation are prone to failure; and (4) the X-Tack Endoscopic HeliX Tacking System may provide a more durable closure without the need for specific training in full-thickness endoscopic suturing.

Endoscopic view of the AspireAssist tube removal and stoma closure. A, A-tube within anterior gastric wall. B, A-tube secured by endoscopic snare after device is cut externally. C, Stoma after A-tube extraction. D, Tissue ablation of stoma using argon plasma coagulation. E, X-Tack placement of tack 1 and tack 2. F, Stoma closure with X-Tack cinching.

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