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Original article Clinical endoscopy: Editorial| Volume 93, ISSUE 1, P131-132, January 2021

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Revisional endoscopic sleeve gastroplasty: a new trick up our sleeves

      Abbreviations:

      EWL (excess weight loss), LSG (laparoscopic sleeve gastrectomy), R-ESG (revisional endoscopic sleeve gastroplasty), RYGB (Roux-en-Y gastric bypass)
      Laparoscopic sleeve gastrectomy (LSG) permanently restricts the total gastric volume to induce weight loss. Beyond restricting the gastric capacity, its effectiveness is also accomplished by metabolic changes through increased gastric emptying and through changes in the secretion of enteric hormones such as ghrelin and glucagon-like peptide-1.
      • Benaiges D.
      Laparoscopic sleeve gastrectomy: more than a restrictive bariatric surgery procedure?.
      It has been proved to be an effective bariatric surgery for many, although it is not without long-term failure.
      Weight recidivism after LSG (<50% excess weight loss [EWL]) can occur at an incidence range of 14% to 37% according to one of the few long-term meta-analysis by Clapp et al.
      • Clapp B.
      • Wynn M.
      • Martyn C.
      • et al.
      Long term (7 or more years) outcomes of the sleeve gastrectomy: a meta-analysis.
      Long-term failure after LSG with weight regain has been associated with sleeve dilatation.
      • Felsenreich D.M.
      • Langer F.B.
      • Kefurt R.
      • et al.
      Weight loss, weight regain, and conversions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy.
      These patients frequently require revisional bariatric surgery. Operative options include resizing of the gastric sleeve, conversion to Roux-en-Y gastric bypass (RYGB), or duodenal switch.
      • Felsenreich D.M.
      • Langer F.B.
      • Kefurt R.
      • et al.
      Weight loss, weight regain, and conversions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy.
      This is not without risks of adverse events, which include anastomotic leaks, bleeding, and stenosis. A novel bariatric procedure alternative to these revisions is the endoscopic sleeve gastroplasty that was first described by Abu Dayyeh et al.
      • Abu Dayyeh B.K.
      • Rajan E.
      • Gostout C.J.
      Endoscopic sleeve gastroplasty: a potential endoscopic alternative to surgical sleeve gastrectomy for treatment of obesity.
      As Maselli et al
      • Maselli D.B.
      • Alqahtani A.R.
      • Abu Dayyeh B.K.
      • et al.
      Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study.
      have described in this issue of Gastrointestinal Endoscopy, revisional endoscopic sleeve gastroplasty (R-ESG) has been attempted in a small series of patients. The authors conducted a retrospective review of prospectively collected data of 82 consecutive patients who received R-ESG from 9 different medical centers. These patients underwent E-RSG at a median of 5 years from index LSG. After R-ESG, mean total body weight loss was 6.6% ± 3.2% at 1 month and 15.7% ± 7.6% at 12 months, with follow-up percentages of 81.7% and 51.2%, respectively. Meanwhile, the average EWL at follow-up was 18.5% ± 10.7% at 1 month and 47.6% ± 26.6% at 12 months, with follow-up percentages of 68.3% and 47.6%, respectively. No specific variable analyzed was associated with an increased likelihood of achieving total body weight loss >15% at 12 months.
      Interestingly, the patient population in this study was 92.7% female and was pooled from 9 different institutions. The follow-up population at 12 months was only 47.6% of the initial 82 patients. The authors commented that 76.9% of this follow-up group had >25% EWL, which is considered a clinical success according to the American Society for Gastrointestinal Endoscopy task force. Given the infancy of this procedure, the small patient population is not unexpected. Unfortunately, the follow-up percentage is less than ideal.
      Although short-term outcomes point to fewer adverse events with adequate EWL at 12 months, the long-term outcomes are yet to be elucidated. An important question to answer concerns the durability of this revisional procedure. These patients did not undergo follow-up endoscopic evaluation during this follow-up period. As after an LSG, the endoscopically revised sleeve could theoretically dilate. Additionally, the endoscopic sutures may not have long durability in restricting the gastric volume. Will this procedure be just a bridge to a more permanent revisional surgery? These are some important points to clarify.
      Additionally, the authors acknowledged the lack of standardization of the endoscopic revision, given the study methods. With this multicenter study, it is unclear whether the endoscopists were all trained to perform the procedure similarly. Unlike LSG, where a bougie is used to help achieve more uniform sleeve volumes, the variability of suture patterns with this endoscopic approach might contribute to more variable sleeve restriction. Can this have been a contributing factor to the described standard deviation of 26.6% for EWL in this cohort?
      Of course, the benefit of R-ESG is the reduction of operative adverse event risks. The authors reported no significant adverse events during the 12-month study follow-up. Unlike an LSG revision, RYGB, or duodenal switch, there are no anastomotic lines at risk of a leak with R-ESG. Comparatively, Maselli et al
      • Maselli D.B.
      • Alqahtani A.R.
      • Abu Dayyeh B.K.
      • et al.
      Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study.
      referenced adverse events of 10% to 15% in patients who underwent surgical revision.
      The effect of R-ESG on the development or treatment of GERD is also important to address. The size of the gastric sleeve is inversely proportional to luminal pressure. It is unclear from this study whether R-ESG will contribute to worsening or improvement of GERD symptoms. The authors stated that 26.7% of 15 patients had resolution of GERD symptoms within 12 months of endoscopic revision. Meanwhile, 9% of the 67 patients experienced GERD symptoms. Currently, the revisional surgery for patients with GERD after LSG is conversion to RBGY. Future studies need to elucidate whether E-RSG could be an option for patients with pre-existing GERD when revision is needed.
      Although weight loss is a strong factor for revision, improving metabolic comorbidities is just as important. It is well known that malabsorptive and restrictive procedures like RYGB improve the metabolic symptoms of obesity. The persistence of metabolic comorbidities after sleeve gastrectomy has been shown to improve after conversion to RYGB.
      • Iannelli A.
      • Debs T.
      • Martini F.
      • et al.
      Laparoscopic conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: indications and preliminary results.
      Unfortunately, these comorbidities such as diabetes and hypertension were not addressed in the study by Maselli et al.
      • Maselli D.B.
      • Alqahtani A.R.
      • Abu Dayyeh B.K.
      • et al.
      Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study.
      This will be a critical consideration for patients with recurrence or persistence of metabolic comorbidities before revision. The choice of revisional surgery should take into consideration these patients’ metabolic symptoms.
      Overall, R-ESG is a novel approach to revision after LSG. This study indicates a strong potential for this procedure to benefit patients needing revision after weight recidivism. It shows to be a good alternative for patients who are high risk for surgical adverse events. However, more studies, with more diverse patient populations, are needed to clarify the risks and benefits of R-ESG when it comes to revision after a previous sleeve for both weight loss as well as GERD. Long-term durability of this procedure needs to be better elucidated as well. As more bariatric endoscopists develop and improve their skills to perform endoscopic sleeve gastroplasty, more studies on its application to revision after LSG are expected.

      Disclosure

      Dr Marks is a consultant for Olympus and Boston Scientific. The other author disclosed no financial relationships.

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      Linked Article

      • Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study
        Gastrointestinal EndoscopyVol. 93Issue 1
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          Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort.
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