Evolution of Endoscopic Bariatric Devices: From Development to Practice

Valuing innovative endoscopic techniques: endoscopic suturing to prevent stent migration for benign esophageal disease

BACKGROUND AND AIMS

Reimbursement often presents a significant barrier to widespread adoption of innovative endoscopic devices. We aimed to determine the value (defined as cost savings to a payer) of endoscopic suturing devices in preventing the migration of esophageal stents placed for benign esophageal diseases.

METHODS

A decision-analytic model was constructed from a payer perspective evaluating fully covered metal stent placement for benign esophageal diseases (fistula, leak, perforation, or stricture) in a hospital outpatient setting. The model compared 2 strategies: endoscopic suturing to anchor the stent or no suture. Health care outcomes and costs were derived from published systematic reviews and national databases (U.S. Food and Drug Administration Manufacturer and User Facility Device Experience [MAUDE] for safety data; 2018 Medicare Physician Fee Schedule and Provider Utilization and Payment Data databases for reimbursement data).

RESULTS

From a payer perspective, reimbursement for care increased by US$1487.98 without endoscopic suturing per patient, compared with US$621.06 with endoscopic suturing, to cover the risk of stent migration in addition to usual professional and facility reimbursement for stent placement. Thus, an average cost saving of US$866.92 per patient was achieved with endoscopic suturing to reduce stent migration risks. Cost savings associated with suturing ranged from US$147.48 to US$1586.36 per patient, based on the indication for the procedure in sensitivity analysis. Cost savings increased with higher rates of technical success in suture placement.

CONCLUSIONS

Creating a defined reimbursement pathway for endoscopic suture fixation of a stent for the treatment of benign esophageal diseases appears to be justified from a payer perspective.

Safety and Feasibility of a Novel Endoscopic Suturing Device (EndoZip TM) for Treatment of Obesity: First-in-Human Study

INTRODUCTION

Endoscopic gastroplasty and gastric volume reduction techniques have been shown to achieve significant weight loss and improvement in comorbid conditions. The objective of this study is to assess the feasibility and safety of a novel fully automated, operator-independent endoscopic suturing system (EndoZip™) for minimally invasive treatment of obesity.

DESIGN

Single-center pilot feasibility study.

PATIENTS

Eleven patients with a body mass index (BMI) of 30 to 40 kg/m² with or without obesity-associated comorbidity.

INTERVENTIONS

Gastric volume reduction with EndoZip™ system.

MAIN OUTCOME MEASUREMENTS

Primary outcome was to assess the technical feasibility and safety. The secondary outcome was to determine %total body weight loss (TBWL) and %excess weight loss (EWL) at 6 months.

RESULTS

The mean ± SD age was 42.7 ± 5.6 years, and the mean ± SD BMI was 36.9 ± 2.8 kg/m². A majority (64%) were men. The procedure was technically successful (100%) in all patients. A median of 3 (range, 2-4) full-thickness sutures were placed, and the mean procedure time was 54.6 ± 23.9 (23-100) min. No immediate complications occurred, and all were discharged in 24 h. One patient developed respiratory infection 3 days after the procedure and required hospitalization. The infection was mild and resolved with antibiotic treatment. At 6-month follow-up, the mean ± SD TBWL, %TBWL, and %EWL were 17.8 ± 6.7 kg, 16.2 ± 6.0%, and 54.3 ± 28.4%, respectively (p < 0.001).

LIMITATIONS

Limited number of patients.

CONCLUSION

Our first-in-human study showed that the Endozip™ device could be safely used for the treatment of obesity. The early weight loss results are promising. An extended feasibility study on a larger sample size is being planned (Clinicaltrials.gov. NCT03472196).

Malnutrition in obesity before and after bariatric surgery

Bariatric surgeries are considered the only effective way of weight loss therapy in morbidly obese patients, i.e. body mass index ≥ 35. However, micronutrient deficiencies and malnutrition are common after most bariatric procedures and thus, pre- and postoperative nutritional assessment and corrections are advised. The present review is presented in an effort to describe in some detail about prevalence, and mechanisms of macro- and micronutrient deficiencies in obese and post-bariatric surgery individuals. We also aimed to summarize the data on screening and supplementation of macro- and micronutrients before and after bariatric surgeries.