ESG and ESD TOR are performed using a single-channel suturing device. Endoscopic sleeve gastroplasty, or ESG, and transoral outlet reduction, or TOR, are two of the most common endoscopic bariatric and metabolic therapies. ESG is a primary weight loss procedure that uses an endoscopic suturing device to place full-thickness sutures in the stomach, reducing its size and altering its motility. TOR is a revisional procedure after Roux-en-Y gastric bypass and involves mucosal denudation around the gastrointestinal anastomosis before endoscopic suturing to reduce the size of the gastrointestinal anastomosis. The traditional endoscopic suturing device used to perform these procedures requires a double-channel endoscope, but a novel suturing device, pictured here, is compatible with standard single-channel endoscopes. Unique features of this suturing device include endoscopist-controlled tissue acquisition as well as enhanced endoscope retroflexion. We will demonstrate the use of this novel suturing device to perform two common endoscopic bariatric procedures with advanced suturing patterns. Next, we present the case of a 50-year-old woman with history notable for class II obesity who presented for a possible endoscopic bariatric procedure. Prior weight loss attempts, including lifestyle modifications and medications, were not successful. Her weight at the time of presentation was 228 pounds, corresponding to a BMI of 38. She elected to undergo ESG. Variable suture patterns have been described to perform ESG, with the U pattern being more recently used to decrease the width and length of the stomach. The endoscope is traditionally kept in the same orientation throughout the U. During the ascending portion of the U, the needle driver moves anterior to posterior while the suture moves posterior to anterior. This leads to looping of the suture, also known as alpha loop formation. We employ a novel suture pattern to avoid alpha loops. During the ascending portion of the U pattern, the endoscope is rotated 180 degrees, pointing the suturing device up along the greater curvature towards the anterior surface of the stomach, as depicted by the green arrows. This maneuver keeps the suture straight. Now back to our first case. Pre-procedure upper endoscopy revealed normal gastric mucosa. The procedure starts with a running suture at the level of the incisora. We descend along the greater curvature, staying opposite the incisora toward the lesser curvature. This creates a neopylorus and may contribute to delayed gastric emptying. Next, an interrupted suture is placed to reinforce the previous running suture. Next, we start our U suture. We start this as anteriorly as possible, just lateral to the anterior tissue fold created by our previous suture. The first leg of the U descends from the anterior surface of the greater curvature onto the posterior surface, staying as close as possible to the prior sutures. Now we are at the bottom of the U. We are going to rotate the device 180 degrees so that it is pointing up along the greater curvature towards the anterior surface. It helps direct your body towards the head of the bed and torque the endoscope clockwise. On the left, you can see a traditional approach. The device is not flipped upside down, and this leads to the formation of alpha loops, or looping of the suture, which we believe leads to increased suture tension, ischemia, and potentially earlier stitch loss. This is the appearance of the first U after cinching. The rest of the ESG is completed by performing an alternating U and interrupted suture pattern. This is the final appearance of the sleeve. The sleeve is relatively narrow, and the distance between the lower esophageal sphincter and incisora is shorter than prior to the procedure. On 3-month follow-up, the patient's weight was noted to decrease from 228 to 194 pounds, constituting a 15% total weight loss. In addition, her A1c decreased by 0.3%. A 64-year-old man with history of Class III obesity status post-rheumatoid gastric bypass complicated by dumping syndrome presented for possible endoscopic therapy. Prior treatments, including lifestyle modification and medications, were not successful. His weight was 256 pounds, corresponding to a BMI of 37. He elected to undergo TOR. While traditionally mucosal denudation around the gastrointestinal anastomosis is performed via argon plasma coagulation, this video demonstrates the use of a modified endoscopic submucosal dissection technique to expose the submucosal layer around the anastomosis prior to purse-string suturing. Pre-procedure endoscopy revealed a dilated gastrointestinal anastomosis, which is known to contribute to dumping syndrome. Modified ESD is performed circumferentially around the gastrointestinal anastomosis. This ensures that tissue apposition during suturing occurs at the submucosal and muscular layers rather than the mucosal layer. This is followed by APC to the inner and outer rims of the submucosal space. We see the gastrointestinal anastomosis after completion of ESD and APC. The endoscopic suturing device is then used to perform a purse-string suture around the gastrointestinal anastomosis. We start at the 5 o'clock position and work counterclockwise. We typically perform between 12 and 14 stitches. Prior to the last stitch, we intentionally cross the suture. The suture is cinched over a 7 to 8 millimeter balloon. This ensures that the gastrointestinal anastomosis is the correct size and helps avoid stenosis. Finally, an interrupted reinforcing stitch is placed in the pouch. This is the final appearance of the pouch and gastrointestinal anastomosis after completion of the ESD tour. On the 3-month follow-up, the patient's symptoms had improved and weight decreased by 20 pounds, constituting an 8% total weight loss. Utilizing this novel suturing device may lead to more widespread adoption of ESG and ESD tour as it obviates the need for double-channel endoscopes. In addition, these procedures may become more efficient as the physician can control tissue acquisition. Finally, the novel tissue helix may lead to less injury of extra-luminal structures and avoiding alpha loops may lead to decreased suture tension, ischemia, stitch loss, and post-procedural pain. In conclusion, ESG performed using an advanced non-alpha loop technique and ESD tour using a novel suturing device are technically feasible. Weight loss outcomes appear to be consistent with procedures performed using the traditional double-channel suturing device.

single-channel suturing device

endoscopic sleeve gastroplasty

transoral outlet reduction

weight loss

procedural efficiency