So I would say, first of all, I do not have challenges doing them, but no, I'm kidding. So we do have challenges, and hopefully I'm going to highlight to you some of these challenges, and because that's an important way to avoid them is to be cognizant about them and to know how to deal with them. These are my disclosures for the purposes of this talk. So before we talk about challenges, I just want to paint the story. Why do we need these interventions? We need these interventions because we are approaching prevalence of excess adiposity or obesity that will be 60% in 2030. So right now, we have significant unmet needs because the vast majority of patients suffering from the disease of obesity are not getting an effective intervention. Penetrance of surgery is about 1% to 2%. Penetrance of medication is still at about 1% or so. Endoscopy offers value for patients. The value is organ sparing. It's safe and effective. There is no long-term consequences to health, so we're not dealing with reflux. We're not dealing with macro or micronutrient deficiency, and it's minimally disruptive to the patient's lifestyle. Compliance is improved because you do not have to remember to take your medication. So the landscape is being augmented. Medications are getting better, but also endoscopy is getting safer, and the combination now is going to be the best of both worlds with safety and efficacy. So this is the procedure that put us on the table to be a contender in managing the disease of obesity, and this is the endoscopic sleeve gastroplasty. So before we talk about challenges with this procedure, it's very important to highlight what is this procedure. This is a periolar procedure done as an outpatient in the endoscopy unit using a full-thickness suturing device, and this full-thickness suturing device allows you to place full-thickness sutures starting on the anterior gastric wall. Remember the anterior gastric wall, because my challenge is going to be with the anterior wall when I show you the video. Then you go in a U-shaped fashion, and you imbricate the greater curvature of the stomach along its long axis to make a tubularized and shorter stomach, tubularized and shorter stomach. I did not, going into GI, I never believed that we will see an era where we could do this through a patient's mouth, but we can do it now with the advent of endoscopic suturing. So this is the shape that you're targeting with this. You could see that this is functional MRI of the patient. This is a few months after the procedure. The greater curvature is imbricated. You could see these plication, this full-thickness plication, but why we don't get GERD? Because the stomach is functional. It's not denervated. It's still peristalting. And what you could see here is you could see a small fundus. Keep an eye on this fundus because it's also going to represent one of the challenges. But you could see a shorter tubularized stomach with a short fundus that changed the accommodation and the emptying of the stomach. But the atrial contractility is still preserved. That means you get delaying gastric emptying, but you don't get gastroparesis because eventually the meals end empty. And this publication highlights the physiology of the endoscopic sleeve gastroplasty that I would refer you to. So based on literally years of evidence and a pivotal trial published in The Lancet, the FDA did issue market clearance for the use of the endoscopic sleeve gastroplasty in management of patients with obesity and body mass index between 30 to 50. So what's the challenges? Sorry, I lost control here. So now here's one of the challenges here. We're starting at the level of the distal stomach. And love that procedure, clean procedure, we're tubularizing everything well. I start the second U-sequence and I take the first bite and I hit one of these vessels. I wish I could get a spurt or I did not start to build a submucosal hematoma. I recognize that submucosal hematoma starting, so I took a suture at that level and you could see the submucosal hematoma starting right up in this area. The reason I like a bleeding vessel than a submucosal hematoma because it almost immediately evacuates so it does not interfere with my procedure. I cinch it, it stops, I continue. Here if you do not manage the submucosal hematoma, you might need to terminate that procedure because it's going to dissect in the plane where you're going to do the suturing. So you're not going to be able to take a full thickness bite. So what I did is I took a suture, a bite from the hematoma and I immediately did this maneuver where I start cinching things together in order to stop the expansion of that hematoma. That's the first step. You recognize it's happening, you stitch on top of it and you cinch things together to prevent the expansion of the hematoma. Then here is what we did next. Here's the hematoma you could see on the anterior wall, it stopped expanding but now I still need to have a nice looking sleeve without interfering with my procedural efficiency. So I cinched that sequence and now I'm going to start the second U-sequence but I need to incorporate that hematoma in it because I don't want it to get in my way. So I took a bite above the hematoma, I took a second bite through the hematoma because now I control the expansion but I need to evacuate it and again having a full thickness endoscopic suturing device opens so many ways. Suturing transforms surgery as we know it and it will transform endoscopy and now here I incorporated the hematoma in the suturing and I keep cinching to keep evacuating. So it's squeezing that blood out of the hematoma as we're going through there. Then I go here to the posterior wall of the stomach and then go back to the greater curvature of the stomach and now cinch the entire sequence and we're back where we started. Hematoma is evacuated, bleeding is controlled and I have a nice glycation pathway to finish the procedure and give the patient optimal outcomes as shown here. You don't see an expansion of that hematoma along the anterior wall and that was a good thing for the patient. So now within the scopic sleeve gastroplasty this is 3D rendition before and this 3D rendition after you could see that the stomach is shortened so accommodation of the stomach and emptying of the stomach is affected but there's always a challenge of what to do with the fundus. That's a very common question. The design of the procedure has been that you leave a small pouch in the fundus to allow you to have food accommodate and convey vagal afferent signaling to the brainstem to terminate that meal. But small fundus means small fundus. It does not mean an orange sized fundus like you saw in this esophobogram and that's been a challenge with some people of how to manage the fundus. So here we're going to show how to manage the fundus. Here we're getting closer to the cardia of the stomach. You see a nice glycation line, all the stomach is coming together forming a banana shaped stomach and here I'm seeing the GE junction and I'm seeing that angle of the fundus. So rather than stopping here, we're not asking people to retroflex and go to the cap of the fundus and pull it, we're just, you could continue suturing by swirling your body to the left and start working in this orientation rather than in FOS to allow you to enter that cap and reduce that fundus a little bit. And again, you're still in a forward view, you do not need to do acrobats to do that but you need to be cognizant of what's going on. And here you could see now we're going to introduce the helix and we're going to reach into the fundus and pull it down a little bit to avoid having this grapefruit size fundus. Here is where we're putting that sequence and now we're introducing that helix and that helix allow us to pull the fundus down, take a suture out of that fundus and then finish the last suturing sequence at the level of the GE junction to have a nice tubular sleeve with a small fundus cap to allow us to maximize the physiological benefit of the procedure. And here you're seeing the last suture being administered at the level of the GE junction. We're cinching that sequence with a cinch and now we're going to take a look at the final product that shows the final anatomical manipulation of this. Now we're exchanging the scope to a forward viewing. I always do that here. You see you're starting with the pylorus, you have short antrum because now we're starting at that junction between the body and antrum and you have a tubularized small volume banana-shaped stomach all the way to the GE junction with a small cap in the fundus, not a big capacious fundus. So that's how you approach the fundus. Now changing gears in the last minute and talk about challenges in an intergastric balloon. Intergastric balloon is a technically safe procedure. That means an easy procedure because if you know how to push a nasogastric or an orogastric tube, you know how to push the intergastric balloon. And here you could see placement of the intergastric balloon. This is the single fluid filled intergastric balloon. You're advancing it to the stomach and you're filling it with about 600 cc's of saline or saline mixed with methylene blue and then you dissociate in the catheter and the catheter is left in there. And here's the balloon in its natural position. Natural position usually in the distal body of the stomach. So what's the challenges that could happen? The challenges is not with the technicality of the procedure but in after procedure care. That's why I picked that topic to talk in. Balloons definitely work by delaying the gastric emptying or at least a predominant mechanism of action is delaying gastric emptying. You see that in this randomized trial where placement of the balloon delays the gastric emptying compared to a control arm. And you could see this is the natural position of that balloon where there's the balloon sitting in the distal body and at the time of removal you always see some food. That's why we counsel the patient to be on clear liquid diet for a couple of days before balloon removal. So what happens with balloon is that not all patients are created equal. This is the gastric emptying of the first 100 patients that came for balloon and you could see its gastric retention varies at baseline. So if balloon works by delaying gastric emptying and now you start with a rapid normal gastric emptying you get a balloon. Now you are moderately delayed. You feel full with the balloon but you don't have much symptoms or you get transient symptoms then they go away. But if you started with a delayed normal gastric emptying and you get the balloon sometimes you get the risk of having too much delay in gastric emptying. The slides are not moving for some reason and you get this phenomenon here where the balloon is wedged in the distal body and you're getting dilation of the proximal stomach and you need to do something in this situation. You either need to decrease the volume of the balloon if you have adjustable balloon or you need to remove that balloon as shown here. So the other challenge is this hyperinflation where the balloon gets inflated with air and that could present a similar phenomenon abdominal pain or obstruction and you need to adjust that. In the unadjustable balloons most likely you're going to have to remove the device but with adjustable balloons that hopefully will will make it to market soon you could withdraw the the balloon inflation catheter and you could either evacuate the air that comes from hyperinflation or you could remove some of the volume of the balloon and adjust its position endoscopically to avoid early retrieval and manage this issue. But you cannot ignore this issue. With that I conclude these are my challenges and I thank you for your kind attention and thank you for the course organizer for inviting me to this forum. Thank you so much Dr. Abadaya. That was wonderful. Can you quickly just talk us through how you manage kind of an acute bleed in the setting of the endoscopic sleeve? You showed us very nice footage of these submucosal hematomas which can be more annoying than anything. How do you manage an acute bleed? Yeah that's why I said the acute bleed is actually better to me than the hematoma because the acute bleed all you need if you see a spurting vessel is just stop what you're doing find your best joke to tell your nurses because they're very anxious at that point and just pull on the suture. That's all you need within a second that bleed is stopped. You have the best hemostatic device in your hand which is a suture. So you either pull the suture and cinch or put another suture where the bleed is and cinch and that's the end of it. So that means an acute bleed is easier to manage than the submucosal hematoma that I demonstrated here. Yes, thank you. Agree entirely. So we're going to shift gears a little bit and Dr. Thompson is going to come up and talk to us a little bit about post-bariatric surgical complications.

endoscopic interventions

obesity

organ sparing

minimally disruptive

endoscopic sleeve gastroplasty