Training in bariatric and metabolic endoscopy

Practice patterns and outcomes of endoscopic sleeve gastroplasty based on provider specialty

Background and study aims Endoscopic sleeve gastroplasty (ESG) is performed in clinical practice by gastroenterologists and bariatric surgeons. Given the increasing regulatory approval and global adoption, we aimed to evaluate real-world outcomes in multidisciplinary practices involving bariatric surgeons and gastroenterologists across the United States. Patients and methods We included adult patients with obesity who underwent ESG from January 2013 to August 2022 in seven academic and private centers in the United States. Patient and procedure characteristics, serious adverse events (SAEs), and weight loss outcomes up to 24 months were analyzed. SPSS (version 29.0) was used for all statistical analyses. Results A total of 1506 patients from seven sites included 235 (15.6%) treated by surgeons and 1271 (84.4%) treated by gastroenterologists. There were no baseline differences between groups. Gastroenterologists used argon plasma coagulation for marking significantly more often than surgeons ( P <0.001). Surgeons placed sutures in the fundus in all instances whereas gastroenterologist placed them in the fundus in less than 1% of the cases ( P <0.001>). Procedure times were significantly different between groups, with surgeons requiring approximately 20 minutes more during the procedure than gastroenterologists ( P <0.001). Percent total body weight loss (%TBWL) and percent responders achieving >10 and >15% TBWL were similar between the two groups at 12, 18, and 24 months. Rates of SAEs were low and similar at 1.7% for surgeons and 2.7% for gastroenterologists ( P >0.05). Conclusions Data from a large US cohort show significant and sustained weight loss with ESG and an excellent safety profile in both bariatric surgery and gastroenterology practices, supporting the scalability of the procedure across practices in a multidisciplinary setting.

Transoral outlet reduction: Outcomes of endoscopic Roux-en-Y gastric bypass revision in 284 patients at a community practice

BACKGROUND

Transoral outlet reduction (TORe) is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass (RYGB) for weight recurrence; however, little has been published on its clinical implementation in the community setting.

AIM

To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB.

METHODS

This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022. Patients were provided longitudinal nutritional support via virtual visits. The primary outcome was total body weight loss (TBWL) at twelve months from TORe. Secondary outcomes included TBWL at three months and six months; excess weight loss (EWL) at three, six, and twelve months; twelve-month TBWL by obesity class; predictors of twelve-month TBWL; rates of post-TORe stenosis; and serious adverse events (SAE). Outcomes were reported with descriptive statistics.

RESULTS

Two hundred eighty-four adults (91.9% female, age 51.3 years, body mass index 39.3 kg/m2) underwent TORe an average of 13.3 years after RYGB. Median pre- and post-TORe outlet diameter was 35 mm and 8 mm, respectively. TBWL was 11.7% ± 4.6% at three months, 14.3% ± 6.3% at six months, and 17.3% ± 7.9% at twelve months. EWL was 38.4% ± 28.2% at three months, 46.5% ± 35.4% at six months, and 53.5% ± 39.2% at twelve months. The number of follow-up visits attended was the strongest predictor of TBWL at twelve months (R2 = 0.0139, P = 0.0005). Outlet stenosis occurred in 11 patients (3.9%) and was successfully managed with endoscopic dilation. There was one instance of post-procedural nausea requiring overnight observation (SAE rate 0.4%).

CONCLUSION

When performed by an experienced endoscopist and combined with longitudinal nutritional support, purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB.

Perception of Bariatric Surgery and Endoscopic Bariatric Therapies Among Primary Care Physicians

INTRODUCTION

In the USA, less than 1% of eligible patients who qualify for bariatric surgery ultimately undergo surgery. Perceptions of endoscopic bariatric therapies (EBTs) for weight management remain unknown.

METHODS

A 22-question survey was distributed to primary care physicians (PCPs) across the Mayo Clinic healthcare system. Survey invitations were sent via email, and all surveys were unanimously conducted electronically.

RESULTS

A total of 130 PCPs participated in the survey (40% response rate). Twenty-four PCPs were between 20 and 24 years out of training (18.5%), and 71 (54.6%) were female. Most providers had a body mass index (BMI) between 18.5 and 24.9 kg/m² (n = 62, 47.7%). Among the weight loss options discussed during clinic visits, PCPs discussed lifestyle modification including diet and exercise (n = 129; 99.2%), and 68 PCPs (52.3%) were not aware of EBTs as weight loss interventions. While 46.2% of the PCPs agreed that a bariatric endoscopy is an effective option for weight loss, only 24.6% of PCPs were familiar with the indications for EBTs. Most of the cohort (n = 69, 53.1%) experienced barriers in referring their patients. Moreover, most of the patients referred to bariatric clinics were from PCPs who had a BMI between 18.5 and 24.9 kg/m² (n = 62, 47.7%) as compared to PCPs with a BMI of 40 kg/m² and greater (n = 5, 3.8%).

CONCLUSIONS

Due to the rise of bariatric therapies in recent years, PCPs are increasingly involved in the referral and management of patients with obesity and obesity-related comorbidities. However, knowledge gaps regarding weight loss options, including EBTs, could limit optimal care to patients desiring medically monitored weight loss.

The Development of a Novel Bariatric Laparoscopic Simulator

Bariatric surgery presents a specific challenge in surgical education; simulators need to take into account the specific technical difficulties related to the patient population but also to various types of surgery. We interviewed several leaders in the fields of bariatric and general surgery with experience in laparoscopic surgery and developed a bariatric-specific laparoscopic simulator. This novel simulator was constructed using a variety of silicone-based materials and 3D printing techniques to be reusable and adjustable for a variety of procedures, with no essential components being disposed of following each use. Expert surgeons (n=4) with knowledge on bariatric procedures were recruited and asked to perform a simple simulated laparoscopic procedure. Following testing, participants were asked to complete a survey and rate the simulator based on its physical attributes, global realism, usefulness in improving surgical skills, and overall surgical experience. Face and content validation outcomes based on the questionnaire evaluations completed by expert surgeons showed very good results, with an overall mean score of 4.3 out of 5 (86%). These preliminary results highlight the potential for the simulator's application as a tool to improve bariatric surgical education and patient outcomes.