a novel approach to endoluminal gastroplasty using a modified gastrostomy tube and laparoscopic stapler. These are our disclosures. The field of bariatric endoscopy continues to grow with the introduction of new technology and refinement of endoscopic techniques. Recently, the gastric antrum has gained interest as a potential novel therapeutic target. The gastric antrum represents the motor function of the stomach and as such, alteration to the antrum could result in changes that impact motor function and result in enhanced satiety and satiation. However, antrum reduction through per-oral suturing has limitations with long-term durability. Therefore, we investigated the use of a novel modified gastrostomy tube and non-cutting stapling device to reduce the gastric antrum. In this video, we demonstrate the use of both devices to perform a novel approach to endoluminal gastroplasty. The procedure was performed safely and effectively in two porcine models. To start the procedure, an intragastric trocar is placed using a technique analogous to that of the pull-through placement of a percutaneous endoscopic gastrostomy tube. A site contralateral tube and facing towards the gastric antrum is chosen in order to optimize endoscopic visualization and positioning of the stapling device in the direction of the gastric antrum. An introducer needle is then inserted into the stomach under endoscopic vision. A wire is passed through the needle, grasped by the endoscope using a snare, and removed trans-orally in a similar fashion to when placing a percutaneous gastrostomy tube. Externally, a small cutaneous incision is made in the abdominal wall to facilitate pull-through of the modified gastrostomy tube, also known as a percutaneous intragastric trocar. Once through the abdominal wall, the trocar is secured with an internal and external bumper. The distal tip of the trocar is then cut and replaced with a 12-millimeter gastric port attachment to complete the device assembly. The fully assembled device creates a functional gastric port capable of accommodating large diameter instruments, such as a laparoscopic non-cutting stapler. With the device assembled, a non-cutting stapler can then be passed through the port and into the stomach. One operator is charged with accessing the gastric port and controlling the stapler, while a second operator controls a gastroscope situated within the stomach lumen. The goal of this procedure is to tubularize and reduce the gastric antrum in order to promote weight loss. To accomplish this, surgical staples are deployed in a sequential fashion along the anterior wall and posterior wall, creating full thickness bites that imbricate and eventually reduce and tubularize the gastric antrum. A helical endoscopic tissue grasper is used to secure and retract full thickness tissue from the gastric antrum. The stapler is maneuvered around the retracted tissue until a full thickness bite can be achieved. The tissue is pulled through the jaws of the stapler, and once in good position, the stapler is fired to complete the first bite and create the staple line. The procedure is then repeated multiple times along the anterior wall, greater curvature, and posterior wall to extend the tubularization effect until the antrum has been effectively reduced. From the first operator's perspective, the stapler must be maneuvered until the tissue is well situated between the jaws of the stapler. The stapler handle is then depressed to deploy the staples in a line along the retracted tissue. Once complete, the stapler can be released and removed, and the port site ultimately closed with a separate suture or over-the-scope clip. During necropsy, full thickness staples are seen running across the gastric antrum with successful apposition and imbrication of gastric tissue. Further dissection of the staple site reveals a durable staple line opposing a length of gastric antrum. The percutaneous intragastric trocar site was also examined and demonstrated an intact percutaneous gastrostomy with the trocar well seated across the abdominal and gastric walls. No perforations or other adverse events were noted during necropsy. In conclusion, we demonstrated a novel approach to endoluminal gastroplasty using a modified gastrostomy tube and non-cutting stapler. The use of a modified gastrostomy tube, also called a percutaneous intragastric gastroplasty, allowed us to achieve a more robust endoscopic approach. Further studies are needed to refine this technique and explore antrum reduction in the treatment of obesity.

endoluminal gastroplasty

modified gastrostomy tube

laparoscopic stapler

gastric antrum

weight loss