Endoscopic Bariatric Surgery
For those who don’t fit into surgical guidelines (moderate and severe obesity), and those who don’t want bariatric surgery – endoscopic surgery is recommended. With the technique most suited for specific obese condition, will give desirable results with regard to weight loss and resolution of disease condition when combined along with a good diet and activity plan. Baros is the first team to start endoscopic bariatrics in India.
PRIMARY ENDOSCOPIC BARIATRIC PROCEDURES
Primary endoscopic bariatric therapy is recommended for patients with moderate to severe obesity ( 10 to 25 kg overweight). It is also useful for morbidly obese patients who defer or is not fit for surgery. Though various newer modalities are under experimentation, two procedures made it to regular clinical use. Though gastric balloon is available for the past 30 years, recent addition of refillable one year ballon has made endoscopic therapy famous. With the introduction of Sleeve Gastroplasty,, this non-surgical therapy is gaining immense popularity. Team BAROS of Apollo Hospitals, Chennai is the first center in Asia to introduce ESG in 2012.
ENDOSCOPIC INTRAGASTRIC BALLOON (EGB)
ENDOSCOPIC SLEEVE GASTROPLASTY (ESG)
Endoscopic placement of the balloon is temporary and reversible without surgical incisions. It is an inflatable medical device that is placed into the stomach to reduce weight. It provides weight loss when diet and exercise have failed and surgery is not wanted or not recommended. The balloon limits the amount of food the stomach can hold and thereby creates an early feeling of fullness and satiety. After six months (or up to twelve months with some newer devices), the device is removed using Endoscopy again. The use of the balloon is complemented with counseling and nutritional support or advice.
Endoscopic Sleeve Gastroplasty is a newer type of weight-loss procedure where the size of your stomach is reduced using an endoscopic suturing device without the need for surgery, this reduces the risk of complications. This procedure may be an option if you have a body mass index of 27 or more — and diet and exercise haven’t worked for you. The end result mimics a Laparoscopic Sleeve Gastrectomy, however, the volume of the stomach will be more. Like other weight-loss procedures, Endoscopic Sleeve Gastroplasty requires a commitment to a healthier lifestyle.
REVISIONAL ENDOSCOPIC SURGERY
With more than 4 decades of bariatric surgery in practice and increasing volume of surgery across the globe, there are growing incidence of weight regain and inadequate weight loss. Eventually obesity related diseases reappear as well. Studies have reported incidence as high as 30% of weight recidivism after bariatric surgery. With increased risk of intra-operative and post-operative complications following revision bariatric surgery and just moderate outcome with regards to excess weight loss and resolution of co-morbidities, endoscopic therapy has come as a great option as first step in revision for weight regain.
ENDOSCOPIC RE-SLEEVE GASTROPLASTY
Endoscopic Re-Sleeve Gastroplasty is a revisional bariatric procedure. ERS is an ideal alternative to surgery for patients who regain weight after sleeve gastrectomy. A dilated sleeve is a major predictor of weight regain. An endoscopic suturing system is used to plicate the dilated vertical sleeve and reduce its size to 100 cc, thus restoring the restrictive component. This can be added with or without a second layer of reinforcing stay sutures. The entire procedure avoids the need for surgery, thus reducing the risk of revision surgical complications.
ENDOSCOPIC STOMAL REDUCTION
Endoscopic stomal reduction or transoral outlet reduction (TORe) is a revisional bariatric procedure. ESR is an ideal alternative to surgery for patients who regain weight after Roux-N-Y gastric bypass. A dilated gastrojejunal anastomosis (stoma) is a major predictor of weight regain. An endoscopic suturing system is used to plicate the stoma and reduce its size to 1.5 cm, thus restoring the restrictive component of the gastric bypass. This can be added with or without a reduction in the size of the pouch if they have been found to be dilated. The entire procedure avoids the need for surgery, thus reducing the risk of revision surgical complications.
ENDOSCOPIC THERAPY FOR BARIATRIC COMPLICATIONS
Endoscopic Surgery is also a very effective mode to treat certain complications that arise out of Laparoscopic Bariatric procedures like stapler/anastomotic leak, intraluminal bleeding, luminal/stomal stricture, Gastroesophageal reflux, and eroded bands. In selected cases, it avoids the need for a re-laparoscopy/open procedure and thus reducing the high-risk of complications and its consequences.
Bariatric surgery is known to be associated with risk of gastric staple line leak or anastomotic leak. A long mega stent is considered a strong alternative to re-laparoscopy for an early leak. A fully covered Mega oesophageal stent will be placed under fluoroscopic (continuous x-ray) guidance with the proximal end in the food pipe (esophagus) and the distal end in the small bowel (duodenum) using markers, thus covering the entire stomach sleeve. Repeat abdominal fluoroscopy or CT is done to rule out the collection at 8 weeks and the stent will be removed. This may avoid reoperation and its complications in selective cases.
Complications of laparoscopic adjustable gastric band, including erosion, have been well described. Once endoscopic examination confirms erosion of the gastric band (both adjustable and non-adjustable), a metal wire was passed through the scope around the band and then passed out of scope through a special device and tightened to cut the band. The cut edge of the band was grasped, and by gentle traction removed transorally. In case of an adjustable band, an incision will be made over the subcutaneous band port site; the port dissected free and removed. A check fluoroscopy (continuous X-ray) is performed to rule out any leak before the procedure is complete. This avoids unnecessary risk of surgical complications if performed laparoscopically.
It facilitates a full-thickness tissue closure by “teeth” arranged in a “bear-trap” fashion like those used in hunting. The clip is applied to an over the scope applicator and introduced transorally. Once in front of the defect, suction is applied to suck the defect into the scope and the clip is deployed and applied over the defect. With the addition of a grasping device, (used primarily for larger defects) which may be used to pull the defect and/or mucosa into the cap before clip deployment. This feature, along with suction, maximizes the potential for effective closure.
Stretta is an endoscopic device that improves symptoms of reflux (GERD) after Sleeve gastrectomy. The incidence of de novo GERD and the effect of Sleeve on patients with preexisting GERD are well documented. Stretta allows an alternative for treatment in patients who are not willing or able to undergo surgery for intractable reflux. The Stretta catheter consists of an inflatable and flexible balloon—basket with four electrode needle sheaths. The operator inflates the balloon at the appropriate area in the food pipe and RF energy was subsequently delivered for 60 seconds through the needle into the muscles of the lower oesophageal sphincter. The needles are then withdrawn, and the balloon is deflated. This process is repeated every 0.5 cm in 6 places around the lower oesophageal sphincter region. This helps in the growth and strengthening of muscles thus reducing reflux.
Endoscopic dilatation of sleeve / anastomotic strictures is an alternative to surgical resection in selected patients. Though less efficient, endoscopic balloon dilatation can be first-line therapy for symptomatic strictures. EBD allows the doctor to dilate, or stretch, a narrowed area of the sleeved stomach or anastomosis through the inflated balloon of various sizes which are placed across the stricture area. The patient may need a few repeated sittings of dilatation for effectiveness.
Intraluminal bleeding is a rare but difficult complication to manage after bariatric surgery. Endoscopic haemoclips are an effective way of arrest bleeding which commonly will clinically present as blood spitting / vomiting on the day of surgery. A simple clip applied over the are of sputter will ensure arrest of bleeding. This can be combined with sclerotherapy for more effective results.