We are first going to answer a question. There was one question related to jealousy, and this can be a combination of Dr. Thompson and Dr. Shariah answering this question. Can jealousy be used in patients after ESG? And if so, how long after the initial ESG? And while we're doing that, I'm going to have our ASGE tech people pull up the slide or hand over to Dr. Girapino, who's going to do a case presentation after we answer this question. So I guess that's a great question. It was one of the exclusions from this study, sort of anyone who's had any sort of GI surgery, which would certainly include ESG. I think the main thing that I can say from this and just studying our patients that have had it and have had it since is that to just use it with caution. Again, you can try out two to three capsules for a couple of days and see the majority of times it will pass through, but maybe it will take a little bit longer. So maybe the GI side effects will be a little bit more in terms of the abdominal distension or the diarrhea. Yeah, I've not tried that as of yet. I think that you definitely want to wait several weeks, like six weeks, so you don't put the procedure in any jeopardy. But it's also nice to see how much weight they're going to lose with the original procedure. So I tend to not make too many modifications for the first three months. Great. All right, Dr. Girapino, can you pull up your case? Wonderful. So just to get started, we have a few cases for our speakers here. So case one, we have a 45-year-old woman. She had class one obesity, BMI 33.4, with hypertension and GERD. She underwent Nissen fundoplication about five years ago, who came to your office for an endoscopic weight loss option. So she previously tried Atkins diet, Weight Watchers, and Phentylmine, which caused her palpitations. So she had to discontinue the medication. Right now, her only medications are Losartan and PPI 20 BID. So I'm just wondering what would you recommend for her from an endoscopic weight loss standpoint? So if I could start just on the balloon side, I would not put a balloon in this patient because she has had a Nissen fundoplication. So I would consider this a complete contraindication for this patient. And the other thing that I really want to bring up in this case that you've presented, and I think all of us on this panel can kind of chime in about this, is that when we talk about the patients that are coming in for endoscopic bariatric therapy, by and large, they have had multiple attempts at commercial weight loss programs. In many cases, they've had medical weight loss as well. And I know over 50% of the patients that I see have also been on medications, and either medications aren't working for them, or they've had some kind of side effect and then are looking for another therapy. But in this case, balloons, definitely out. I would agree with that. You know, what's interesting is, I don't know how long ago her Nissen was, but she would have been a good candidate to be talking about surgery. Because if you come in and have significant reflux and obesity, I think that's a great place to be thinking about doing a Roux-en-Y bypass, for example, which would be anti-reflux and anti-obesity. That's a great thought. I think that Roux-en-Y gastric bypass is a phenomenal treatment for reflux, and we forget about that sometimes. A little on the lighter side would be MI33, but I think they've had good success even with lower BMIs in some situations. But in our center, we would generally see this person together, probably with the surgeons, just because we're co-located, and we'd probably have that discussion. I think they'd be a great candidate for ESG or gastric plication procedure as well. We've recently been doing, I think actually, Reem, you've done some work with this as well, combining endoscopic anti-reflux procedure with primary bariatric procedure. We've been specifically doing that with plication, so she'd probably be a good candidate for that. Yeah, I would agree. She fits the category 30 to 40 BMI. You would exclude the balloon because of prior surgical procedures, and so you're left with really that or aspiration. I mean, those would be the two options we would give her. Shelby, have you had experience post-NISN placing a tube for aspiration? One. And it's, I mean, you can pull the PEG tube through it. Or anything that you could pull a PEG tube, remember, you're probably going to be able to pull the A tube through it because the internal bumper is about the same. And I would say that in this patient, I have placed A tubes. I have one patient who had a BMI below 35 who did get an A tube. She had comorbidities, so she had hypertension, prediabetes, and hypercholesterolemia, and lost 20% total body weight loss and is off of all medications. Wonderful. So yeah, so thank you, everyone. So I think the key teaching point for this one is that NISN phenoplication is a contraindication for intragastric balloon. We can consider endoscopic sleeve, aspiration therapy off-label, or consider bariatric surgery kind of off-label as well. All right. So let's move on to the second case. So here we have a 38-year-old man, history of class 3 obesity now. So BMI 43, prediabetes, and OSA. And he's seeking an endoscopic weight loss option. Right now, he's pretty adamant about not undergoing bariatric surgery. He tried intermittent fasting, NutriSystem, and also succenda. So he's on succenda, maximal dose, 3 milligrams daily, metformin, 500 milligrams daily. And now he's seeking, he would like to lose more weight despite some weight loss with succenda and metformin. Which one do you think might be a good option for him? So if I may, I would still start similar to what Dr. Thompson was saying, that it's important that they actually see a bariatric surgeon and see someone at your institution, which we all have sort of centers of excellence. And I think that's because a lot of patients come with the preconceived idea that they don't want surgery because they've heard about surgery complications, but it's important to be educated in the fact that surgery will actually cure their diabetes, they'll probably be off CPAP, and it's more durable than any of the endoscopic options out there. Having said that, the other options, again, similar to the prior discussion, would probably be aspiration therapy or either plication or an endoscopic sleeve, but definitely would have them see a surgeon. Yeah, any other thoughts? A couple other thoughts, too, is that in this particular case, so I agree that I usually try to have patients see bariatric surgery. Sometimes patients will completely refuse, but I try to tell them that, look, I want you to be happy with the therapy that you get, and I want you to understand the weight loss that I can provide for you and the weight loss that surgery can provide for you. And obviously, there's differences in adverse events, but I want you to really understand what the difference is, even if you don't end up proceeding with, I mean, you don't have to go through with bariatric surgery, I just want you to be fully informed. But the other thing that I would point out is that I usually do a shared decision-making with patients. So we go through, like, what are the benefits and limitations of the different therapies that we have? And I will tell you that I still have patients that are in this kind of BMI category range that say, you know, I've done the bariatric surgery seminar, I don't want to do bariatric surgery, I don't want to have any changes to my GI tract, I don't want to have any risk of scarring, I don't want to have any alterations. Well, that's going to knock out a number of therapies, and then we're really talking about balloons. And so it's really important, if you're going to be talking about balloons with those patients, that you, you know, really have them understand how much weight loss you expect to get. And then, you know, even considering they're already on medication, but, you know, even adding other potential medications to maximize their weight loss. The last thing that I'll just bring up is, you know, we've been talking about these small bowel effects of our therapies, and the kind of effects, what we think of like weight loss independent effects of gastric bypass. But there was a recent paper by Dr. Klein's group at Washington University in the Center for Human Nutrition, that was published in New England Journal that looked at a specific level of weight loss. So they got lifestyle therapy patients and gastric bypass patients to about 18% total body weight loss. So their weight stabilized for three weeks, and then they studied these patients. And essentially, what it really shows is that at some point, total weight loss is going to overcome kind of anything else. And total weight loss may trump everything else in terms of what these individual small bowel effects or other, you know, potential independent effects, weight loss independent effects of these therapies. And so, you know, when we think about saying that gastric bypass is going to resolve your diabetes, that is absolutely true. It's possible that it may be because of the total weight loss that they get. So, you know, using our therapies, plus adding on weight loss medications and things like that to try to maximize the weight loss, you know, we may see some, you know, additional benefits in that metabolic range as well. Yeah, very nice study by Dr. Sam Klein. Since we have everyone here, just maybe like your experience on adding medications with primary bariatric endoscopic therapies, like when do you consider it, at what time is a good time, and which patient population would you add after your therapy? I tend to like doing it around a three-month visit. You know, we'll see them at the day after the procedure, generally two weeks, and then three months, six months, et cetera, and we have the nutritionist and others seeing them as well. But when they come back to see me at three months, I think that's a good time to think about it. If they're really not losing the weight, they're adherent to their diet plan, and you talk to the dietician and whatnot, and they seem to just not be losing enough, I think that's when I tend to consider it. And I think we need a lot more data about looking at instituting multiple therapies in sequence. You know, when would you add pharmacotherapy? What is the right timing? It needs to be really studied. There's clinical practice, but do we have good data that that will help to advance it? And we don't even have really good data on adding that to surgery, you know, when is optimum tracking, weight regain, and making intervention. This is such a fruitful area for people to be working in. We need some other interventions too, like culinary competency and understanding whether you could get people to be different on their trajectory after our endoscopic treatments because they're now doing something differently. That's a great point. And also, you know, which medicines are better after which procedures, you know? GLP-1 agonists, are they hitting a different mechanism or synergizing with one? There was interesting work, I think was done with the endo barrier where they found that it was surprising, in fact, when they added GLP-1 agonists, you know, to get more weight loss than they would have anticipated because you thought it was maybe working on similar mechanisms, but a lot of work there.

jealousy

endoscopic sleeve gastroplasty

gastrointestinal side effects

Nissen fundoplication

intragastric balloon