Introduction

Since 2006 at our hospital, lifestyle modification for obese patients has been provided through a team approach with a physician, dietician, nurse, physical therapist and psychologist. From 2016, a surgeon and anesthesiologist were added to the team for metabolic/bariatric surgery (laparoscopic sleeve gastrectomy: LSG).

Aims & Methods

The aim of this study is to clarify the characteristics of obese patients with NAFLD for whom LSG was effective. Of 40 obese patients who were received LSG between 2017 and 2021 with follow-up period of more than 1 year, 19 were male and 21 were female, 24 were with diabetes, 16 with other complications. The diagnosis of NAFLD was made by liver imaging for fat deposit and stiffness by Fibroscan, and liver biopsy in some cases.

Results

The mean preoperative BMI was 43, the mean Fib-4 index was 0.98, and the postoperative insulin resistance (CPI) of diabetic patients improved significantly, with 15 patients in complete remission and 6 in incomplete remission after surgery. One year after surgery, the mean weight loss was 18.3%, the Fib-4 index did not decrease significantly, but the mean AST (U/L) improved from 38 to 18, ALT (U/L) from 55 to 15, GGT (U/L) from 78 to 40, CAP (dB/m) from 348 to 279, and liver stiffness (kPa) from 12.1 to 7.6, significantly. In patients who underwent follow-up biopsy, there was a trend toward improvement in liver fibrosis.

Conclusion

Since LSG significantly improves hepatic markers in obese patients with NAFLD, metabolic/bariatric surgery should be positively considered.

Introduction

Since 2006 at our hospital, lifestyle modification, such as diet and exercise, for obese patients has been provided through a team approach with a physician, dietician, nurse, physical therapist and psychologist. From 2016, a surgeon and anesthesiologist were added to the team for metabolic/bariatric surgery (laparoscopic sleeve gastrectomy: LSG).

Aims & Methods

The aim of this study is to clarify the characteristics of obese patients with diabetes mellitus (DM) for whom LSG was effective according to body mass index (BMI). Of 24 diabetic patients who were received LSG between January 2017 and December 2021 with follow-up period of more than 1 year, 4 were with a BMI of < 35, 7 were with a BMI of 35 - 40, and 13 were with a BMI of 40 or more. The mean age was 51, 49 and 45 years. respectively. Complete remission of postoperative DM was defined as HbA1c < 6% without drug therapy, and incomplete remission was defined as a decrease in the amount of drug therapy among the other patients.

Results

Preoperative HbA1c (%) was 8.6, 7.0 and 8.0, and preoperative serum c-peptide (CPR) (ng/ml) was 1.9, 3.1 and 3.1, and preoperative ABCD score was 2.0, 4.4 and 6.0, respectively. There were no differences of preoperative complications, preoperative weight loss rate, postoperative weight loss rate, and postoperative body composition change rate. The postoperative complete DM remission rate (%) was 25, 71 and 69, respectively, and the drug dose was reduced in all patients, even in those with incomplete remission.

Conclusion

Regardless of BMI, complete remission of DM was achieved by performing LSG when CPR was maintained, even in patients with poorly controlled DM. On the other hand, even in patients with decreased CPR, benefits such as postoperative weight loss and drug reduction were observed. LSG should be actively considered in obese patients with DM.

Introduction

Endoscopic sleeve gastroplasty (ESG) is established as effective and mini-invasive procedure for obesity. Patients undergoing bariatric procedures in 80% of the cases are females. It is known that gender plays a role in several metabolic networks related to obesity; however no studies have investigated the gender impact on obesity after ESG.

Aims & Methods

To evaluate the gender impact on long-term weight loss outcomes after ESG in patients treated in our bariatric unit. We analyzed 160 patients that underwent ESG at Fondazione Policlinico Gemelli IRCCS from mese 2017 to mese 2021. A matched-pair analysis between the two groups for baseline BMI, age, and timing of the procedure was done. Weight loss outcomes were described in terms of total body weight (TBWL%) and excess weight loss (EWL%) at 12, 24 and 30 months.

Results

We found that men presenting for ESG had a higher body mass index (BMI) than women (40,7 kg/m² vs 39,8 kg/m²). After ESG the TBWL% in female at 12, 24, and 30 months was 17,2%, 14,0% and 15,2% compared to 14,9%, 14,3% and 9,6% in men, respectively. The EWL% was 48,4%, 39,6% and 41,7%, compared to 41,9%, 39,5% and 24,3% in men, respectively.

Conclusion

Women have more durable weight loss compared to men. More in depth studies are needed to understand the cause of this difference.

Introduction

The National Institute of Health and Care Excellence (NICE) recently endorsed Endoscopic Sleeve Gastroplasty (ESG) in combination with lifestyle modifications as a therapeutic modality to bariatric surgery in patients with body mass index > 30. Darlington Memorial Hospital was the first NHS Endobariatric Centre offering ESG to patients since 2022.

Aims & Methods

This is a retrospective analysis of the clinical outcomes and safety of ESG for the management of obesity in patients with BMI >30 between 2022-2024 at a single centre. A total of 21 procedures have been performed at this centre in the last 24 months, 2 procedures were performed in 2022, 4 procedures in 2023, and 15 procedures were carried out in 2024. We analysed procedural safety and total body weight loss (TBWL) at 6, 12 and 24 months.

Results

All patients were discussed in a multi-disciplinary team prior to being enlisted for ESG. Appropriate lifestyle modifications were initiated with Specialist Dietitian support. The average age of patients was 50.75 years (range 25 – 72), average BMI was 44.317 (range 35.37 - 57.4) and 75% of patients were women. None of the patients were receiving medications for weight loss (GLP-1 agonists). 3 patients were diabetic, 11 were hypertensive, 3 dyslipidemic and 4 had fatty liver. Other obesity related morbid conditions included Obstructive sleep apnoea in 5 patients and Osteoarthritis in one.
A total of 13 patients have at least 6 months follow up since the time of their procedure. Average total body weight loss in 6, 12 and 24 months was 17.78%, 36% and 26.7% respectively. Patient satisfaction scores have been consistently high.
The average time to completion of ESG was 88.26 minutes. The average length of stay in hospital was 2.24 days (range 1-11). All sutures were made in a U shape. The average number of sutures was 4.24 (range 1- 7). There were only 3 minor complications in this period: 1 post operative upper gastrointestinal bleed, 1 subphrenic collection and 1 minor pharangeal perforation. All of these complications occurred in the early phase of the service, and were managed conservatively, with full recovery.

Conclusion

Our initial 24 month experience with ESG shows excellent TBWL, similar to the MERIT Study. Procedural time is less than conventional bariatric procedures, with no major complications. These outcomes are similar to other international publications from larger centres.

References

Abu Dayyeh BK, Bazerbachi F, Vargas EJ, Sharaiha RZ, Thompson CC, Thaemert BC, Teixeira AF, Chapman CG, Kumbhari V, Ujiki MB, Ahrens J, Day C; MERIT Study Group; Galvao Neto M, Zundel N, Wilson EB. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet. 2022 Aug 6;400(10350):441-451. doi: 10.1016/S0140-6736(22)01280-6. Epub 2022 Jul 28. PMID: 35908555.
Kmietowicz Z. Endoscopic sleeve gastroplasty can be used to treat obesity, says NICE. BMJ. 2023 Sep 28;382:2240. doi: 10.1136/bmj.p2240. PMID: 37770095.
Alqahtani AR, Alqahtani O, Abdurabu H, Amro N, Al Qahtani A, Bokhari A, Elahmedi M, Aldarwish A. Endoscopic Sleeve Gastroplasty in Those With a Body Mass Index of 27-30. Am J Gastroenterol. 2023 Oct 1;118(10):1807-1811. doi: 10.14309/ajg.0000000000002476. Epub 2023 Aug 17. PMID: 37589499.

Introduction

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive restrictive bariatric procedure associated with significant weight loss, obesity-related comorbidities improvement, and a favorable safety profile. The suturing devices, available today, are often tricky and operator-dependent. A novel automated endoluminal-sutured gastroplasty system (EndoZip™, Nitinotes Ltd. based in Israel), has been developed to simplify and standardize ESG. The device is positioned in the gastric body under endoscopic vision and is connected to an external vacuum pump that captures the gastric wall segments into the distal end of the device. The activation of a motor system makes a custom-designed needle pass through the tissue and allows stitching, tightening, clipping, and cutting of suture wire. The suturing actions are done automatically in approximately 2 minutes, by just pressing on the operation button.

Aims & Methods

This multicenter, prospective, single-arm study aimed to assess the safety and efficacy of the ESG using EndoZip™ for the treatment of obesity. Patients with a BMI of 30 to 40 kg/m² unable to lose weight with non-invasive approaches and deemed suitable for bariatric endoscopic according to the multidisciplinary team were enrolled in 3 centers (Spain, Italy and Israel). The efficacy of the EndoZip™ system was assessed. %TBWL, and % of patients with %TBWL ≥5% were evaluated via ANCOVA model. Safety data and physician's satisfaction with device use, were evaluated via descriptive statistics.

Results

Forty-five patients underwent robotic endoscopy-assisted gastric volume reduction. The mean +SD age was 44 +8 years, and BMI was 34.6 +2.9 kg/m², respectively. The majority of the patients were female (89%). the average procedure time was 30 minutes. We used an average of 3.9 sutures; At 12 months, the mean +SD %TBWL was 13.5 + 10.4%. We observed >5% TBWL in 79.4% of the patients (Table 1). All endoscopists found the device easy to use. Serious adverse events occurred in 2 patients (bleeding and gastric perforation). The bleeding was stopped with endoscopic clipping, and the gastric perforation required surgical closure. No mortality occurred.

Conclusion

EndoZip™ system is an operator-friendly and reproducible procedure with promising efficacy and safety results.

Disclosure

Ivo Boskoski is a consultant for Apollo Endosurgery, Cook Medical, Boston Scientific, and Nitinotes.