Magnet and wire remodeling for the treatment of candy cane syndrome: first case series of a new approach (with video)

BACKGROUND AND AIMS

Candy cane syndrome (CCS) is an adverse event (AE) from gastrectomy or gastric bypass and end-to-side anastomosis to a jejunal loop. Preferential passage of food to the blind loop induces early satiety, pain, and regurgitation. An endoscopic device that combines 2 magnets and a self-retractable wire was designed to perform progressive septotomy with marsupialization. We evaluated the clinical safety and efficacy of this treatment in CCS.

METHODS

Consecutive patients presenting with symptoms associated with CCS after gastrectomy or Roux-en-Y gastric bypass were treated with the MAGUS (Magnetic Gastrointestinal Universal Septotome) system. Weight, dysphagia, pain scores, 12-item Short Form Survey quality of life physical and mental scores, GERD Health-Related Quality of Life, and Eckardt score were measured at baseline and 1 and 3 months postprocedure. Satisfaction with therapy and AEs were monitored during follow-up.

RESULTS

Fourteen consecutive patients with CCS were enrolled in the study. Thirteen MAGUS systems migrated within 28 days after achieving uneventful complete septotomy. In 1 patient the magnet had to be collected from the right-sided colon after 1 month. Treatment was completed in a single endoscopy session. Dysphagia score (2 [1-3] vs 1 [1-1], P = .02), pain score (7 [6-8] vs 1 [0-1], P = .002), Eckardt score (5 [3-8] vs 1 [0-2], P = .002), GERD Health-Related Quality of Life score (37 [29-45] vs 8 [6-23], P = .002), and quality of life physical and mental scores were all significantly improved at 3 months. No device or procedure-related serious AEs were observed. One patient died during follow-up from evolution of oncologic disease.

CONCLUSIONS

Endoluminal septotomy using a retractable wire and magnet system in CCS is feasible and safe, with rapid improvement of symptoms. (Clinical trial registration number: NCT04480216.).

Magnets and a self-retractable wire for endoscopic septotomies: from concept to first-in-human use

BACKGROUND

A medical device that allows simple and safe performance of an endoscopic septotomy could have several applications in the gastrointestinal (GI) tract. We have developed such a device by combining two magnets and a self-retractable wire to perform a progressive septotomy by compression of the tissues. We describe here the concept, preclinical studies, and first clinical use of the device for the treatment of symptomatic epiphrenic esophageal diverticulum (EED).

METHODS

The MAGUS (MAgnetic Gastrointestinal Universal Septotome) device was designed based on previous knowledge of compression anastomosis and currently unmet needs. After initial design, the feasibility of the technique was tested on artificial septa in pigs. A clinical trial was then initiated to assess the feasibility and safety of the technique.

RESULTS

Animal studies showed that the MAGUS can perform a complete septotomy at various levels of the GI tract. In two patients with a symptomatic EED, uneventful complete septotomy was observed within 28 and 39 days after the endoscopic procedure.

CONCLUSIONS

This new system provides a way of performing endoluminal septotomy in a single procedure. It appears to be effective and safe for managing symptomatic EED. Further clinical applications where this type of remodeling of the GI tract could be beneficial are under investigation.

Safety and feasibility of an endoluminal-suturing device for endoscopic gastric reduction (with video)

BACKGROUND AND AIMS

Obesity is a major pandemic disease. Surgical therapy is highly effective, but its availability will likely be overwhelmed by the burden of the disease. Endoscopic technologies that could reproduce some of the clinical effects of surgery may become part of the treatment armamentarium. A simple transoral restrictive procedure could play a role in first-line surgical management.

METHODS

We evaluated the safety and feasibility of transmural suturing using a simple triangulation platform for gastric volume reduction through the creation of multiple double plicatures.

RESULTS

Between May and July 2015, 11 obese (body mass index 34.6 ± 2.1 kg/m²) patients (mean age, 36 ± 10 years) underwent gastroplasty through transmural endoscopic sutures (performed using a triangulation platform and an endoscopic stitcher). The median duration of the procedure was 2.00 hours (range, 1.15-3.15 hours) and dramatically decreased after the first 5 cases. No severe adverse events were observed. Mean (standard deviation) weight loss and percentage of excess weight loss were 5.8 kg (2.7%) and 21% (9%) at 1 month (n = 11), 8.8 kg (4.9%) and 33% (22%) at 3 months (n = 10), and 10.9 kg (7.3%) and 41% (33%) at 6 months (n = 10).

CONCLUSIONS

Transoral endoscopic gastroplasty performed using a simple triangulation platform and a dedicated suturing device appears to be safe and effective at mid-term follow-up in creating gastric restriction and inducing weight loss in this first-in-humans experience. (Clinical trials registration number: NCT02534662.).

Swallowable Obalon® gastric balloons as an aid for weight loss: a pilot feasibility study

The goal of this study was to evaluate the safety and the impact on weight loss of a new swallowable gastric balloon. In this prospective pilot study, 17 overweight or obese patients were included. Up to three balloons were ingested under fluoroscopic control. All balloons were removed by upper GI endoscopy, 12 weeks after the ingestion of the first balloon. 43 out of 44 attempts (98 %) to swallow a balloon were successful. Nausea and stomach pain were the most frequent side effects. Endoscopic procedures for balloon removal were uneventful. Weight loss was significant at weeks 4, 8, and 12. This pilot study showed no significant side effects induced by up to three balloons, and a significant weight loss.

Endoscopic treatment of postoperative enterocutaneous fistulas after bariatric surgery with the use of a fistula plug: report of five cases

Anastomotic leaks frequently occur after bariatric surgery and their management includes different options. The present study describes the management of enterocutaneous fistulas in patients in whom surgical or endoscopic treatments have failed, by insertion of a biomaterial (Surgisis fistula plug) to facilitate healing of the gastrocutaneous fistula. Five patients with leaks after bariatric surgery were treated. All patients had undergone previous failed surgical or endoscopic attempt(s) at closure. Our technique entailed insertion of the Surgisis fistula plug into the fistula tract by a "rendezvous" procedure, via both percutaneous and endoscopic routes. The data were collected retrospectively. Initially, two patients were treated by fistula plug alone and three received fistula plug plus a self-expanding stent. In two patients, cutaneous fistula outflow ceased within a few days. The other three patients required one additional endoscopic procedure. At the end we observed healed leaks in four of the five patients (80 %). The median follow-up duration was 18 months. In conclusion, the combined therapy consisting of fistula plug implantation with optional stenting helps closure in these difficult refractory cases of gastrocutaneous fistula.

Transoral gastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study

BACKGROUND AND STUDY AIMS

Bariatric surgical treatments have been proven to induce long-term weight loss in morbidly obese patients, but complications are relatively frequent. We recently reported a first human multicenter trial assessing the safety, feasibility, and weight loss results of the Transoral Gastroplasty (TOGA) system (Satiety Inc., Palo Alto, CA) at 6 months. Here we report the 6-month results of the second phase of the pilot trial with the TOGA system, with technical improvements to the device.

PATIENTS AND METHODS

Patients met established criteria for bariatric surgery. The TOGA system, a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curvature of the stomach. Follow-up was at 1 week and at 1, 3, and 6 months. At 3 months, re-treatment consisting in additional distal restrictions was allowed if necessary.

RESULTS

Data were available for 11 patients in our center (7 female, mean age 44.2 years, mean body mass index 41.6). The procedure was completed safely in all patients. There were no serious adverse events. Mean excess weight loss was 19.2 %, 33.7 %, and 46.0 % at 1, 3, and 6 months, respectively. Average body mass index decreased from 41.6 before treatment to 33.1 at 6 months. Absolute mean weight loss was 9.9 kg, 17.5 kg, and 24.0 kg at 1, 3, and 6 months, respectively. A dramatic improvement in quality-of-life measures was observed in all patients.

CONCLUSIONS

This second pilot trial confirmed the feasibility and safety of transoral gastroplasty. The early results and technical improvements reported in the present study are encouraging in terms of safety, early weight loss, and quality of life, and clearly allowed multicenter trials, which are planned to start soon.

Safety, feasibility and weight loss after transoral gastroplasty: First human multicenter study

OBJECTIVE

To evaluate the safety and feasibility in human subjects of a new transoral restrictive procedure for the treatment of obesity.

METHODS

The protocol was approved by the institutional review boards (IRBs) of both centers involved, and all patients gave informed consent. Patients met established inclusion criteria for bariatric surgery. The TOGa system (Satiety Inc., Palo Alto, CA), a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curve of the stomach. Patients were hospitalized overnight for observation and underwent barium upper gastrointestinal (UGI) the next morning. Post procedure, all patients were placed on a liquid diet for 1 month and asked to begin an exercise program. Follow-up was carried out at 1 week and 1, 3, 4, 5, and 6 months.

RESULTS

Twenty one patients were enrolled [17 female, age 43.7 (22-57) years, BMI 43.3 (35-53) kg/m(2)]. Device introduction was completed safely in all patients. There were no serious adverse events (AEs). The most commonly reported procedure or device related adverse events were vomiting, pain, nausea, and transient dysphagia. At 6 month endoscopy, all patients had persistent full or partial stapled sleeves. Gaps in the staple line were evident in 13 patients. Patients lost an average 17.6 pounds at 1 month, 24.5 pounds at three months, and 26.5 pounds at 6 months post-treatment [excess weight loss (EWL) of 16.2%, 22.6%, and 24.4%, respectively].

CONCLUSIONS

There is great interest in new procedures for morbid obesity that could offer lower morbidity than current options. Early experience with the TOGa procedure indicates that this transoral approach may be safe and feasible. Further experience with the device and technique should improve anatomic and functional outcomes in the future. Additional studies are underway.