Hello, and welcome to our presentation on long-term endoscopy follow-up of endoscopic sleeve gastroplasty and technical aspects of redo ESG. The goal of ESG is to approximate the anterior and posterior gastric walls to achieve tubular reconfiguration, thus decreasing gastric volume. Currently, data is lacking to demonstrate long-term ESG durability as well as long-term weight loss outcomes. Additionally, it is unclear if weight loss in ESG is due to gastric restriction alone or in combination with other factors. We discuss three cases of ESG where a revision was performed either for weight regain or for desired additional weight loss. We present imaging from the initial ESG procedure as well as contrast imaging for evaluation of the sleeve stomach post-endoscopy and at follow-up. We conclude each case with video of the redo ESG procedure as well as contrast x-ray imaging of the completed revision. Our first patient is a 39-year-old female with a weight of 111 kg, BMI of 46, and HbA1c of 11.5%. Her comorbidities included hypertension, type 2 diabetes, and obesity. She did not prefer surgery for weight loss and elected for endoscopic treatment. We first demonstrate images from the initial ESG procedure as well as contrast x-ray one day after the procedure, demonstrating the completed initial sleeve. On one month follow-up, the patient had lost 20 pounds, but on follow-up at 6 and 12 months, the patient had regained almost all of his weight and elected to have revisional ESG. Contrast x-ray at 6 month follow-up revealed approximately 75% opening of the sleeve stomach. Endoscopy directly preceding the revision procedure shows detachment and partial reopening of sutures placed during the initial sleeve, as well as formation of mucosal bridges from the approximated anterior and posterior gastric walls. Partially disrupted sutures are removed with rat-tooth forceps, while partially reopened sutures are left in place as they continue to provide some traction. The endoscopic suturing system is loaded with polypropylene suture. We begin at the anterior wall with sub-segment bites taken from the greater curve and posterior wall with the same suture. We take further bites in the opposite direction, from the posterior wall to the anterior wall, along the greater curve to create a U-shaped pattern with full thickness suturing. We ensure full thickness bites by rotating the tissue clamp a minimum of 3-4 times and by visualizing pink-out, red-out, or rotation of mucosal tissue. The running suture is then tightened to approximate the anterior and posterior gastric walls. Here we demonstrate endoscopic footage of the completed revision. The patient initially presented for ESG revision weighing 242 lbs, nearly his original pre-sleeve weight. On one month follow-up after revision, he had lost 22 lbs and now weighed 220 lbs. Contrast x-ray confirms the integrity of the revision as well as demonstrates the intact fundus left in redo ESGs. Our second patient is a 57-year-old female with a weight of 141 kg, BMI of 60, and HbA1c of 7.6%. Her comorbidities included obesity, obstructive sleep apnea, asthma, type 2 diabetes, and endometrial hyperplasia. She did not prefer surgery for weight loss and elected for endoscopic treatment. Here we show a contrast x-ray taken after completion of the initial sleeve, again demonstrating tubularization of the stomach with intact fundus and antrum. On one month follow-up, the patient had lost 26 lbs, and on 6 and 12 month follow-up, the patient had lost another 39 and 19 lbs for a total of 84 lbs lost since initial sleeve. However, the patient requested revision in order to qualify for hysterectomy due to cancer. Contrast x-ray at 11 month follow-up revealed approximately 25-50% opening of the sleeve stomach. We again visualize complete detachment of the sutures and absence of intact sleeve. We conduct the revision in a similar fashion, where we take bites starting at the insusura and perform continuous suturing in a U-shaped pattern ascending to the fundus. We make sure to avoid overlap with previous partially exposed sutures when placing the new sutures. Endoscopic footage from the conclusion of the revision demonstrates reduced overall gastric volume as well as length along the greater curve, with all sutures securely in place. At 1 month follow-up after the revision, the patient had lost an additional 20 lbs and her BMI had dropped from 47 to 43, and she was now considered an adequate candidate and had a successful hysterectomy. Contrast x-ray confirms the tubularization of the stomach. Our final patient is a 50-year-old female with a weight of 87 kg, BMI of 34, and HbA1c of 4.4%. Her comorbidities included obesity, fatty liver, hypothyroidism, and hemochromatosis. She did not prefer surgery for weight loss and elected for endoscopic treatment. Here we see the stomach prior to any intervention. In this image, we demonstrate placing markings using argon plasma coagulation along both anterior and posterior walls of the stomach, which will guide the development of the sleeve stomach. Finally, we demonstrate images from during and after the initial sleeve gastroplasty. Contrast x-ray at 7 day follow-up reveals tubularization of the stomach with intact antrum and fundus. On 12 month follow-up after the initial sleeve, the patient had lost 35 pounds. Her BMI decreased from 34 to 28. However, she still preferred additional weight loss for cosmesis. Contrast x-ray at 5 month follow-up revealed approximately 50% opening of the sleeve stomach. We again demonstrate complete detachment of the sutures on follow-up endoscopy. We complete the revision with similar U-shaped continuous suturing in an ascending pattern along the greater curve before tightening the sutures to approximate the anterior and posterior gastric walls to create the revised sleeve. Endoscopic footage from the conclusion of the procedure demonstrates the gastric walls securely brought together along the greater curve. The patient presented for ESG revision, weighing 158 pounds after already losing 34 pounds from her baseline weight pre-ESG. On 1 month follow-up after revision, she had lost another 7 pounds and BMI decreased from 28 to 26. We present 3 cases of patients who underwent ESG revision 14 to 22 months after their initial ESG with indications of weight regain, additional weight loss required as a bridge to hysterectomy, and cosmesis. On endoscopic follow-up, all 3 patients had loss of sleeve integrity with visible sutures and mucosal bridges. Sutures were still present but no longer reducing the size of gastric body. Despite lack of durability of the sleeve, 2 of the 3 patients maintained significant weight loss with revision done to achieve additional weight loss. Total body weight loss after revision of ESG from baseline weight respectively for our 3 patients was 9.84% at 17 months after initial sleeve, 30.97% at 22 months after initial sleeve, and 21.35% at 15 months after initial sleeve. Gastric restriction is important in weight loss after ESG in the short term, but long term weight loss maintenance is likely due to other factors. Despite loss of suture integrity, patients are still able to maintain weight loss. Thank you for watching our presentation on long term endoscopy follow-up of endoscopic sleeve gastroplasty and technical aspects of redo ESG.

endoscopic sleeve gastroplasty

long-term follow-up

redo ESG

weight loss outcomes

revision procedure