Introduction

Endoscopic suturing offers a novel minimally invasive technique for deploying full thickness sutures in the gastrointestinal (GI) tract. Indications range from defect closure, post operative leaks, fistula repair, stent fixation and tissue plication for endoscopic sleeve gastroplasty.
Here we report our updated experience of endoscopic suturing for non-bariatric applications in the upper GI tract using the Apollo OverStitch^TM device (Apollo Endosurgery, Austin, Texas). This represents the largest and most diverse case series in a UK cohort of patients.

Aims & Methods

We retrospectively evaluated cases where the Apollo OverStitch^TM device was used at our tertiary upper GI centre. The primary outcomes were immediate technical and clinical success. Technical success was defined as the successful application of sutures. Immediate clinical success was defined according to indication. For defect closure this was evaluated using on the table fluoroscopy/endoscopic visualisation. For stent fixation it was determined by the absence of stent migration at follow up endoscopy.
Secondary outcomes included defect recurrence at follow up investigation. We also evaluated long term clinical success by assessing for resolution of the index clinical issue at the time of latest follow up.

Results

The Apollo OverStitch ^TM device was used 56 times across 35 patients (57% female) between August 2018 and March 2023. The mean age of patients at the time of the index procedure was 58 (+/-17.3 years). Outcomes according to indication are highlighted below (Table 1).
There were five cases (5/56, 8.9%) of technical failure. Three (3/5, 60%) involved iatrogenic perforations at the junction between D1/D2. Three cases (3/37, 8.1%) of immediate clinical failure were reported for the defect closure cohort. In the defect closure cohort there was a recurrence rate of 61.8% (21/34), with a long term clinical success rate of 68.2% (15/22). 14 cases of stent fixation were conducted with a stent migration rate of 35.7% (5/14).
There were two (2/56, 3.6%) cases of bleeding following endoscopic suturing. In both cases bleeding was stemmed endoscopically on the table and prior to the end of the procedure.

Conclusion

Our case series suggests that the Apollo OverStitch^TM device can be used for a diverse range of indications with high rates of immediate technical and clinical success.
We note a high recurrence rate reflecting that many defects require repeat suturing attempts to achieve durable long term closure. We postulate that this may be related tissue epithelisation and/or friability impacting opposition. Furthermore, technical failure occurred most with perforations at the D1/D2 junction. This is likely related to acute angulation which impedes the ability to deploy sutures.
The heterogenous follow up data from this case series impacts the ability to draw firm conclusions regarding long term outcomes. There is an ongoing prospective multicentre registry which will assist in evaluating long term outcomes.

Introduction

Obesity, one of the most common co-morbidities in women of reproductive age, contributes to infertility and obesity-related pregnancy complications. On the other hand, pregnancy is a condition in which, physiologically, the pregnant woman undergoes weight gain. Endoscopic Sleeve Gastroplasty (ESG), an organ-sparing bariatric procedure aimed to reduce gastric volume and modify gastric motility with full-thickness endoscopic sutures, may be used for the treatment of obesity in women of childbearing age.

Aims & Methods

A retrospective analysis of a prospective database was conducted to evaluate weight trajectories, the evolution of obesity-related comorbidities, and lifestyle modification in women who became pregnant after ESG.
A comparison was made between childbearing-age women who became pregnant after ESG and non-pregnant women who reached at least the 6-month follow-up after ESG.

Results

Between January 2018 and December 2021, a total of 150 childbearing-age women underwent ESG at a large Italian tertiary medical center. Out of the total, 18 patients (12,0 %) reported a desire for pregnancy associated with unsuccessful attempts in the 12 months preceding ESG.
Eleven patients (mean age 33,4±6,2 years) became pregnant after the procedure, following a mean time interval of 5,5±3,9 months. The mean preconception BMI was 31,9±4,0 kg/m² (with a mean reduction of 7,24±4,0 kg/m² after ESG). Three patients were affected by hyperinsulinemia (H-INS), while an additional patient had both H-INS and high blood pressure (HBP). Three women reported difficulty in becoming pregnant before the ESG: two were affected by PCOS.
Total body weight loss (TBWL) of at least 5% was achieved before pregnancy in all patients (73% reached a TBWL ≥ 10%).
Six out of eleven (55%) patients had weight gain in the ranges recommended by the Institute of Medicine (IOM) during pregnancy. Among the 18 women with a reported desire for maternity associated with difficult attempts in the previous 12 months, 16,6 % (3/18) managed to start and carry out a pregnancy.
TBWL (%) was 18,08±8,00, 10,35±11,53, and 12,08±8,49, at the beginning of pregnancy, at the delivery, and at the first follow-up (mean interval, 5,18±3,57 months).
No significant differences in WL, TBWL, EWL, BMI, BAROS, and QoL were found between the pregnancy and non-pregnancy groups (99 childbearing-age women) up to 24 months after ESG.

Conclusion

ESG produces adequate weight loss before pregnancy in patients with obesity and is potentially a useful treatment option for women who have difficulty becoming pregnant, such as those with PCOS. Pregnancy after ESG does not adversely affect weight loss outcomes after delivery as lifestyle changes induced by ESG are maintained after pregnancy and allow for a gradual loss of weight gained during pregnancy.

Introduction

Endoscopic sleeve gastroplasty (ESG) is a safe and effective procedure in class 1 and 2 obese subjects.The effects of menopause on weight are well known. However, given that this patient population is inherently weight-concerned, understanding the effects of ESG on women in menopause is essential to guiding clinicians in counselling this patient population.

Aims & Methods

A prospective dataset collecting data on all ESG procedures performed in a tertiary referral centre was assessed retrospectively. Data on fertility status (menopause and non-menopause women) were collected. A comparison was performed using the Mann-Whitney U test.

Results

Between May 2017 and October 2021, 209 women underwent ESG. Out of the total, fertility status was available for 204 women: 79 menopause (M; 38,7%) and 125 non-menopause women (NM; 61,3%).At baseline, non-menopause women were younger, whereas there were no differences in BMI and weight.
Adherence to follow-up was 92,4%, 87,3% and 80,0% for menopause, 88,8%, 90,4% and 72,9% for non-menopause, at 6,12 and 24 months, respectively.
Six months after the procedure, non-menopause women showed significantly higher TBWL, WL and BAROS score compared to the menopausal group. In contrast, EWL showed no significant difference between the groups.Average TBWL, WL and EWL were not significantly different between the groups at 12 and 24 months (as shown in Table below).
Seven menopausal women needed revision procedures (5 Re-ESG, 1 Surgery), whereas ten non-menopausal women underwent revision (8 Re-ESG, two surgery).

Table. Weight loss trajectories of subjects who underwent Endoscopic Sleeve Gastroplasty, based on menopausal status. Data are reported as median (Interquartile range).

Conclusion

Non-menopausal women who undergo ESG show better outcomes in the short term. However, this advantage does not persist in the medium and long term.

Introduction

Double-headed capsules enable the non-invasive one-step endoscopic evaluation of both the small bowel and colon (pan-intestinal capsule endoscopy, PCE).

Aims & Methods

We aim to evaluate the diagnostic accuracy and safety of PCE vs. the current standard of care (conventional colonoscopy) as the first-line examination in patients with iron deficiency anaemia (IDA) and/or overt bleeding after a non-diagnostic upper endoscopy (suspected mid or lower gastrointestinal bleeding, MLGIB).
We conducted a prospective, single-centre, single-blinded cohort study including consecutive patients with suspected MLGIB. All patients were submitted to PCE, followed by same-day colonoscopy under deep sedation. The physicians performing PCE and conventional colonoscopies were independent and blinded to each other’s observations. The diagnostic yield for potentially haemorrhagic lesions (PHL) was compared for efficacy analysis, and adverse events were assessed for both examinations. The gold standard diagnosis was defined by consensus panel. This trial has been registered in ClinicalTrials.gov (ID NCT04782986).

Results

We included 100 consecutive patients with suspected MLGIB, mean age 66.5 (18-92) years, 65% female gender, presenting with IDA (81%) or overt bleeding (19%). Mean haemoglobin level was 8.4 (4.1-12.8) g/dL and 40% were inpatients. For PCE, the PillCam Crohn’s® capsule was used in 88 patients, and PillCam COLON® 2 in the remaining. Patients with overt bleeding performed PCE within 2 weeks in 70% of cases, 15% in the first 72h after the bleeding episode. PCE was complete in 76% of cases, vs. colonoscopy 95% (p<0.01). The quality of bowel preparation was adequate in 72% of PCE vs. 85% of colonoscopies (p=0.012). Overall, PHL were diagnosed, based on the combination of PCE + colonoscopy, in 46% of patients, corresponding to small bowel and/or colon angioectasias in more than two-thirds (69.6%) of cases. PHL were detected by both examinations in 13/46 (28.3%), only by colonoscopy in 3/46 (6.5%), and only by PCE in 30/46 (65.2%) of cases (p<0.01). Overall, colonoscopy detected PHL in 23% of the entire cohort, which means 50% (23/46) of all patients with PHL according to the consensus panel, while for PCE the overall diagnostic yield was 44%, meaning 95.7% (44/46) of all PHL (p<0.01). Considering the gold standard diagnosis for PHL, colonoscopy had a sensitivity of 23/46=50%, specificity 54/54=100%, positive predictive value (PPV) 23/23=100% and negative predictive value (NPV) 54/77=70,1%, while for PCE the sensitivity was 44/46=95.7%, specificity 54/54=100%, PPV 44/44=100% and NPV 54/56=96.4%. Thirty-one percent of patients had PHL accessible to ileocolonoscopy; in those cases, the PCE was able to make the diagnosis in 29/31 (93.5%) vs. conventional colonoscopy in 23/31 (74.2%) of cases, p<0.01. Regarding safety, no significant adverse events occurred with PCE, vs. 2% (cardiopulmonary) with conventional colonoscopy.

Conclusion

PCE is safe and more effective than conventional colonoscopy in identifying PHL both in the small bowel and the colon, and could be considered as a first-line examination in patients with IDA or overt bleeding after a non-diagnostic upper endoscopy. In more than half of patients with suspected MLGIB, PCE does not detect any PHL either in the small bowel or the colon, dismissing any further invasive endoscopic investigations.

Disclosure

Medtronic provided financial support to the acquisition of some of the capsules which were used in the trial

Introduction

The global burden of overweight and obesity-related diseases has been a growing public health concern over the past few decades. These conditions contribute significantly to morbidity and mortality worldwide and are associated with a wide range of chronic diseases. Understanding the trends and sex differences in disease burden attributable to overweight and obesity is essential for developing effective prevention and intervention strategies. This study aims to assess the burden of overweight and obesity-related diseases in males and females.

Aims & Methods

We analyzed data from the Global Burden of Diseases (GBD) study, covering overweight and obesity-related disease burdens in 26 diseases across 204 countries and territories. Key disease burden indicators, including mortality and disability-adjusted life years (DALYs), were studied. Linear regression analysis was applied to the natural logarithm of age-standardized outcomes to determine the annual percent change.

Results

In 2019, the global burden of overweight and obesity-related diseases reached 160.2 million DALYs, and the number of deaths associated with these conditions was approximately 5.02 million in males and females. The age-standardized death rates in males showed an increase from 58.19 per 100,000 person-years in 1990 to 66.55 per 100,000 person-years in 2019 (APC =0.36%, 95% CI 0.30% to 0.42%, P <.001), while in females it decreased from 59.31 per 100,000 person-years in 1990 to 58.14 per 100,000 person-years in 2019 (APC =-0.22%, 95% CI -0.29% to -0.14%, P <.001). There was a higher increase in age-standardized DALY rates in males, from 1632.5 per 100,000 years in 1990 to 2070.34 per 100,000 years in 2019 (APC =0.74%, 95% CI 0.70% to 0.78%, P <.001), while females experienced a smaller increase from 1618.26 per 100,000 years in 1990 to 1789.67 per 100,000 years in 2019 (APC =0.24%, 95% CI 0.19% to 0.29%, P <.001). These trends resulted in a higher male-to-female rate ratio in deaths and DALYs in 2019, which did not exist in 1990. The higher male-to-female rate ratio in deaths and DALYs were found in more than half of countries and territories. A large proportion of the higher burden in males compared to females can be explained by an increase in development.

Conclusion

The study uncovers a significant increase in the burden of overweight and obesity-related diseases, with a marked disparity between males and females. These findings underscore the need for further research to investigate the underlying causes of this gender difference in overweight and obesity-related deaths and DALYs. Identifying the contributing factors will facilitate the development of targeted interventions and public health policies to address and resolve these disparities. It is crucial to ensure that both genders benefit equitably from efforts to combat the global burden of overweight and obesity-related diseases.

Introduction

Capsule endoscopy is the first-line examination for digestive bleeding with likely origin in the small bowel, in hemodynamically stable patients. In the 2022 update, ESGE guidelines recommend that, in the context of overt bleeding, capsule enteroscopy should be performed as soon as possible, ideally within the first 48 hours. In the previous guidelines, published in 2015, the recommended window was 14 days.

Aims & Methods

This study aimed to evaluate the improvement in yield offered by the new recommendations regarding the timing of urgent capsule enteroscopy. Patients with suspected overt middle gastrointestinal bleeding between January 2005 and November 2022 were retrospectively analyzed. Diagnostic and therapeutic yield, rebleeding rate, and mortality were compared when capsule enteroscopy was performed within the first 48 hours, within the first 14 days, or between the 3rd and 14th day after admission.

Results

A total of 138 patients were included (58.7% men, median age 66 years), 87 of whom (63.0%) underwent capsule enteroscopy within the first 48 hours after hospital admission. The median follow-up was 55 months (5-180). The diagnostic yield (presence of blood or lesions with bleeding potential) was slightly higher when capsule enteroscopy was performed within the first 48 hours (81.6% versus 76.5%, p=0.349). On the other hand, capsule enteroscopy within the first 48 hours was significantly associated with higher therapeutic yield (endoscopic, radiologic, or surgical treatment) - 54.0% versus 39.2%, p=0.02. The rebleeding rate was significantly lower in patients undergoing enteroscopy within 48 hours after admission (19.5% versus 29.4%, p=0.04). On the other hand, overall mortality at 36 months did not differ between strategies (21.8% and 25.5%, p=0.401).

Conclusion

Performing capsule endoscopy within the first 48 hours, as recommended by recently published guidelines, is associated with favourable short- and long-term clinical outcomes.