51
|
Personalized Approach for Obese Patients Undergoing Endoscopic Sleeve Gastroplasty. J Pers Med 2021; 11:jpm11121298. [PMID: 34945770 PMCID: PMC8704248 DOI: 10.3390/jpm11121298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 12/03/2022] Open
Abstract
Obesity is a chronic, relapsing disease representing a major global health problem in the 21st century. Several etiologic factors are involved in its pathogenesis, including a Western hypercaloric diet, sedentariness, metabolic imbalances, genetics, and gut microbiota modification. Lifestyle modifications and drugs often fail to obtain an adequate and sustained weight loss. To date, bariatric surgery (BS) is the most effective treatment, but only about 1% of eligible patients undergo BS, partly because of its negligible morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, endoscopic, bariatric procedure, which proved to be safe and effective. In this review, we aim to examine evidence supporting the role of a personalized and multidisciplinary approach, guided by a multidisciplinary team (MDT), for obese patients undergoing ESG, from patient selection to long-term follow-up. The cooperation of different health professionals, including an endocrinologist and/or obesity medicine physician, a bariatric surgeon, an endoscopist experienced in bariatrics, a registered dietitian, an exercise specialist, a behaviour coach, a psychologist, and a nurse or physician extender, aims to induce radical and sustained lifestyle changes. We also discussed the relationship between gut microbiota and outcomes after bariatric procedures, speculating that the characterization of gut microbiota before and after ESG may help develop new tools, including probiotics, to optimize weight loss outcomes.
Collapse
|
52
|
Endoscopic sleeve gastroplasty - minimally invasive treatment for non-alcoholic fatty liver disease and obesity. Indian J Gastroenterol 2021; 40:572-579. [PMID: 34914039 DOI: 10.1007/s12664-021-01202-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 05/24/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Adequate weight loss can lead to reduction in steatosis, inflammation, and fibrosis in patients with obesity and non-alcoholic fatty liver disease (NAFLD). We evaluated the role of endoscopic sleeve gastroplasty (ESG) in patients with obesity and NAFLD. METHODS In this single-center prospective study, consecutive adult patients with NAFLD who underwent ESG between November 2018 and May 2019 were included. The primary outcome was the impact of ESG on hepatic parameters: change in alanine aminotransferase (ALT), hepatic steatosis index (HSI), NAFLD fibrosis score (NFS), fibrosis-4 index (FIB-4), and aspartate aminotransferase (AST)-to-platelet ratio index (APRI) from baseline to 6 and 12 months. Secondary outcomes included change in glycated hemoglobin (HbA1c), percentage weight loss, and safety. Analysis of variance with repeated measures was used for statistical analysis. RESULTS A total of 26 patients (mean age [SD] 41.5 [9.58] years; 16 females) with mean (SD) weight of 99.43 (21.89) kg at baseline were included. There was significant improvement in ALT (mean ± SD) from baseline of 59.54 ± 17.02 IU/L to 49.50 ± 11.72 IU/L and 48.42 ± 13.22 IU/L at 6 and 12 months (p = 0.001). Mean (SD) NFS was significantly improved from 0.228 (1.00) at baseline to -0.202 (1.16) and -0.552 (1.08) at 6 and 12 months (p 0.001). Mean (SD) HSI, FIB-4, and APRI scores significantly reduced from baseline to 6 and 12 months (p = 0.001). There was 18.07% total body weight loss at 12 months, with significant improvement in HbA1c. There were no major adverse events. CONCLUSION ESG is a safe and effective treatment option for patients with NAFLD and obesity causing significant weight loss. Rigorous randomized trials are required to incorporate ESG in NAFLD treatment algorithm.
Collapse
|
53
|
Katakwar A, Lakhtakia S, Rao GV. Response to Five-Year Outcomes of Endoscopic Sleeve Gastroplasty for the Treatment of Obesity. Clin Gastroenterol Hepatol 2021; 19:2685. [PMID: 33278576 DOI: 10.1016/j.cgh.2020.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Abhishek Katakwar
- AIG Hospitals (Unit of Asian Institute of Gastroenterology), Hyderabad, India
| | - Sundeep Lakhtakia
- AIG Hospitals (Unit of Asian Institute of Gastroenterology), Hyderabad, India
| | - Guduru Venkat Rao
- AIG Hospitals (Unit of Asian Institute of Gastroenterology), Hyderabad, India
| |
Collapse
|
54
|
Dials J, Demirel D, Halic T, De S, Ryason A, Kundumadam S, Al-Haddad M, Gromski MA. Hierarchical task analysis of endoscopic sleeve gastroplasty. Surg Endosc 2021; 36:5167-5182. [PMID: 34845547 DOI: 10.1007/s00464-021-08893-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic weight loss procedure used to treat obesity. The long-term goal of this project is to develop a Virtual Bariatric Endoscopy (ViBE) simulator for training and assessment of the ESG procedure. The objectives of this current work are to: (a) perform a task analysis of ESG and (b) create metrics to be validated in the created simulator. METHODS We performed a hierarchical task analysis (HTA) by identifying the significant tasks of the ESG procedure. We created the HTA to show the breakdown and connection of the tasks of the procedure. Utilizing the HTA and input from ESG experts, performance metrics were derived for objective measurement of the ESG procedure. Three blinded video raters analyzed seven recorded ESG procedures according to the proposed performance metrics. RESULTS Based on the seven videos, there was a positive correlation between total task times and total performance scores (R = 0.886, P = 0.008). Endoscopists expert were found to be more skilled in reducing the area of the stomach compared to endoscopists novice (34.6% reduction versus 9.4% reduction, P = 0.01). The mean novice performance score was significantly lower than the mean expert performance score (34.7 vs. 23.8, P = 0.047). The inter-rater reliability test showed a perfect agreement among three raters for all tasks except for the suturing task. The suturing task had a significant agreement (Inter-rater Correlation = 0.84, Cronbach's alpha = 0.88). Suturing was determined to be a critical task that is positively correlated with the total score (R = 0.962, P = 0.0005). CONCLUSION The task analysis and metrics development are critical for the development of the ViBE simulator. This preliminary assessment demonstrates that the performance metrics provide an accurate assessment of the endoscopist's performance. Further validation testing and refinement of the performance metrics are anticipated.
Collapse
Affiliation(s)
- James Dials
- Department of Computer Science, Florida Polytechnic University, 4700 Research Way, Lakeland, FL, 33805, USA
| | - Doga Demirel
- Department of Computer Science, Florida Polytechnic University, 4700 Research Way, Lakeland, FL, 33805, USA.
| | - Tansel Halic
- Department of Computer Science, University of Central Arkansas, Conway, USA
| | - Suvranu De
- Department of Mechanical, Aerospace and Nuclear Engineering, Rensselear Polytechnic Institute, Troy, USA
| | - Adam Ryason
- Department of Mechanical, Aerospace and Nuclear Engineering, Rensselear Polytechnic Institute, Troy, USA
| | - Shanker Kundumadam
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, USA
| |
Collapse
|
55
|
Abstract
The field of endoscopic bariatric and metabolic therapy has rapidly evolved from offering endoscopic treatment of weight regain following bariatric surgery to providing primary weight loss options as alternatives to pharmacologic and surgical interventions. Gastric devices and remodeling procedures were initially designed to work through a mechanism of volume restriction, leading to earlier satiety and reduced caloric intake. As the field continues to grow, small bowel interventions are evolving that may have some effect on weight loss but focus on the treatment of obesity-related comorbidities. Future implementation of combination therapy that utilizes both gastric and small bowel interventions offers an exciting option to further augment weight loss and alleviate metabolic disease. This review considers gastric devices and techniques including space-occupying intragastric balloons, aspiration therapy, endoscopic tissue suturing, and plication interventions, followed by a review of small bowel interventions including endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically delivered devices to create incisionless anastomoses. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Collapse
Affiliation(s)
- Russell D Dolan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA;
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan 48109, USA; .,Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
| |
Collapse
|
56
|
Chua TY, Kyanam Kabir Baig KR, Leung FW, Ashat M, Jamidar PA, Mulki R, Singh A, Yu JX, Lightdale JR. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020. Gastrointest Endosc 2021; 94:441-451. [PMID: 34147512 DOI: 10.1016/j.gie.2021.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.
Collapse
Affiliation(s)
- Tiffany Y Chua
- Division of Digestive Diseases, Harbor-University of California Los Angeles, Torrance, California, USA
| | - Kondal R Kyanam Kabir Baig
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Felix W Leung
- VA Sepulveda Ambulatory Care Center, North Hills, California, USA
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, Indiana School of Medicine, Indianapolis, Indiana, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ramzi Mulki
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ajaypal Singh
- Division of Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Jessica X Yu
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jenifer R Lightdale
- Division of Pediatric Gastroenterology and Nutrition, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| |
Collapse
|
57
|
Abstract
PURPOSE OF REVIEW To provide updated evidence on the endoscopic procedures for weight loss and to bring personal insights on the future of endobariatrics. RECENT FINDINGS Intragastric balloons promote significant improvement in histologic and radiologic aspects of non-alcoholic steatohepatitis; the endoscopic sleeve gastroplasty is effective up to 5 years and seems particularly beneficial to patients with BMI≤40kg/m2; distal POSE is a promising technique but still lacks adequate clinical data; aspiration therapy triggers remarkable weight loss, but data on weight trends after removal of the device are still lacking; the satiety-inducing device, the sleeveballoon, the gastric mucosal devitalization, and the endoscopic magnetic partial jejunal diversion are promising procedures still under study and refinements. Several therapeutic options are necessary during obesity's natural history. Therefore, endobariatrics should act in harmony with lifestyle interventions, diet modification, psychological treatment, pharmacotherapy, and bariatric surgery seeking the best outcome in the long term.
Collapse
Affiliation(s)
- Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, Eneas de Carvalho Aguiar Av. 255, São Paulo, SP, 05304-000, Brazil.
- Surgery and Anatomy Department, Division of Gastrointestinal Surgery, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil.
| | - Manoel Galvao Neto
- Department of Surgery, ABC Faculty of Medicine, Santo Andre, Brazil
- Endovitta Institute, Sao Paulo, Brazil
| |
Collapse
|
58
|
Mehta A, Sharaiha RZ. Bariatric and metabolic endoscopy: impact on obesity and related comorbidities. Ther Adv Gastrointest Endosc 2021; 14:26317745211019156. [PMID: 34179778 PMCID: PMC8193659 DOI: 10.1177/26317745211019156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/16/2021] [Indexed: 12/26/2022] Open
Abstract
The global obesity pandemic is among the most significant public health crises today. Furthermore, obesity remains a major risk factor for many weight-related comorbid conditions including cardiovascular disease, type 2 diabetes mellitus, liver disease, and cancer. Endoscopic bariatric therapies are currently on the rise as a new tool in the fight against the obesity epidemic, offering patients an alternative to more invasive surgery and a more effective option than diet and lifestyle modifications. The aim of this review article is to summarize the current literature regarding endoscopic bariatric therapies and their impact on obesity and its associated metabolic complications.
Collapse
Affiliation(s)
- Amit Mehta
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Reem Z Sharaiha
- Associate Professor of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine and NewYork-Presbyterian Hospital, New York, NY 10021, USA
| |
Collapse
|
59
|
Li R, Veltzke-Schlieker W, Adler A, Specht M, Eskander W, Ismail M, Badakhshi H, Galvao MP, Zorron R. Endoscopic Sleeve Gastroplasty (ESG) for High-Risk Patients, High Body Mass Index (> 50 kg/m 2) Patients, and Contraindication to Abdominal Surgery. Obes Surg 2021; 31:3400-3409. [PMID: 33905069 DOI: 10.1007/s11695-021-05446-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/18/2021] [Accepted: 04/21/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND For high-risk classified patients, patients with superobesity and in cases of contraindication to abdominal surgery, traditional bariatric surgery might lead to potential morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a novel and effective bariatric therapy for morbidly obese patients. Our research group initially evaluated the safety, feasibility, and efficacy of ESG for high-risk, high body mass index (BMI) patients, and patients contraindicated to abdominal surgeries. METHODS Eligible patients characterized as high-risk for bariatric surgery due to high-BMI, severe comorbidities, or impenetrable abdomen were prospectively documented. ESG was performed by using Overstich® (Apollo Endosurgery, Austin, TX, USA). Primary outcomes included technical success, post-procedure adverse events and mortality, and the change of weight and BMI. RESULTS ESG was successfully performed for all patients (N = 24, mean age was 55.6 (± 9.2) years old, 75% male). Baseline weight and BMI were 157.9 (± 49.1) kg and 49.9 (± 14.4) kg/m2. According to Edmonton Obesity Staging System (EOSS), 8 (33.3%), 14 (58.3%), and 2 (8.3%) patients were respectively classified as EOSS 2, 3, and 4. Mean operation time was 114.7 (± 26.0) min, without intraoperative complication. Weight loss, BMI reduction, %total weight loss (%TWL), and %excess weight loss (%EWL) were 17.5 (± 14.6) kg, 5.6 (± 4.6) kg/m2, 12.2% (± 8.9%), and 29.1% (± 17.9%) at post-ESG 12-month, respectively. One (4.2%) moderate post-procedure adverse event (gastric mucosal bleeding) was observed. CONCLUSIONS ESG can be used as a safe, feasible, and effective option for the therapy of patients with superobesity, high-risk patients, and patients contraindicated to abdominal surgery. Graphical Abstract.
Collapse
Affiliation(s)
- Renjie Li
- Center for Bariatric and Metabolic Surgery, Klinikum Ernst von Bergmann, Charlottenstraße 72, 14467, Potsdam, Germany
| | - Wilfried Veltzke-Schlieker
- Division Interdisciplinary Endoscopy, Department for Hepatology and Gastroenterology, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Adler
- Division Interdisciplinary Endoscopy, Department for Hepatology and Gastroenterology, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Specht
- Center for Bariatric and Metabolic Surgery, Klinikum Ernst von Bergmann, Charlottenstraße 72, 14467, Potsdam, Germany
| | - Wael Eskander
- Center for Bariatric and Metabolic Surgery, Klinikum Ernst von Bergmann, Charlottenstraße 72, 14467, Potsdam, Germany
| | - Mahmoud Ismail
- Department for Thoracic Surgery, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Harun Badakhshi
- Clinic for Radiooncology and Radiotherapy, Klinikum Ernst von Bergmann, Potsdam, Germany
| | | | - Ricardo Zorron
- Center for Bariatric and Metabolic Surgery, Klinikum Ernst von Bergmann, Charlottenstraße 72, 14467, Potsdam, Germany.
| |
Collapse
|
60
|
Platt KD, Schulman AR. Endoscopic sleeve gastroplasty: the "cable" technique. VideoGIE 2021; 6:207-208. [PMID: 34027248 PMCID: PMC8118129 DOI: 10.1016/j.vgie.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Video 1Video demonstration of endoscopic sleeve gastroplasty performed using a novel suture pattern termed the "cable" technique.
Collapse
Affiliation(s)
- Kevin D Platt
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Allison R Schulman
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan.,Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
61
|
Katakwar A, Lakhtakia S, Talukdar R. Comments on "Endoscopic sleeve gastroplasty, laparoscopic sleeve gastrectomy, and laparoscopic greater curve plication: do they differ at 2 years?". Endoscopy 2021; 53:339. [PMID: 33631832 DOI: 10.1055/a-1308-1998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Abishek Katakwar
- Department of Bariatric Surgery, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| |
Collapse
|
62
|
Kähler G. Endoskopische Magenverkleinerung – Alternative zur Sleeve Gastrectomy? Zentralbl Chir 2021; 146:9-12. [PMID: 33588503 DOI: 10.1055/a-1200-6300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
63
|
Yoon JY, Arau RT. The Efficacy and Safety of Endoscopic Sleeve Gastroplasty as an Alternative to Laparoscopic Sleeve Gastrectomy. Clin Endosc 2021; 54:17-24. [PMID: 33478194 PMCID: PMC7939770 DOI: 10.5946/ce.2021.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/05/2021] [Indexed: 12/13/2022] Open
Abstract
Endoscopic sleeve gastroplasty (ESG) is a therapeutic endoscopic technique for reducing the size of the gastric reservoir in obese patients, using a full-thickness endoscopic suturing device. The effectiveness of ESG in weight loss is significantly greater than that of high-intensity diet and lifestyle therapy and lower than that of laparoscopic sleeve gastrectomy (LSG). The efficacy at 12 months after ESG in terms of percentage of total body weight loss and excess body weight loss was approximately 16% and 60%, respectively. The well-known predictive factors for increased weight loss by ESG are good compliance with regular monitoring and post-procedure care involving a multidisciplinary team approach. Although the underlying mechanism of weight loss induced by ESG is debatable, delayed gastric emptying and early satiation are some of the proposed mechanisms. The pooled rate of adverse events after ESG reported in several meta-analysis studies ranged from 1.5% to 2.3% and the incidence of new-onset gastroesophageal reflux disease after ESG was negligible, indicating that ESG has a superior safety profile to LSG. Moreover, ESG reduced the risk of obesity-related metabolic comorbidities, evidenced by the reduction in HbA1c level, systolic blood pressure, triglyceride level, and risk of hepatic steatosis and fibrosis; it even improved the quality of life. ESG could be considered safe and qualify as an alternative treatment to LSG.
Collapse
Affiliation(s)
- Jin Young Yoon
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Román Turró Arau
- Department of Bariatric Endoscopy, Centro Medico Teknon, Barcelona, Spain
| | | |
Collapse
|