ESG is becoming popular as a safe and minimally invasive endoscopic bariatric therapy. ESG can be considered in patients with a BMI of more than 30 or patients with a BMI more than 40 who decline surgery or are not surgical candidates. ESG results in significant reduction in the volume of the stomach and can also alter gastric motility to assist in weight loss. ESG is performed using an endoscopic suturing device mounted on a double channel scope. ESG is performed under general anesthesia. Overtube can be used. Carbon dioxide is used for insufflation. EGD is performed distance of G-junction and pylorus are estimated. Presence of gastric lesion, neoplastic changes, large hiatal hernia and surgical changes can be a contraindication for ESG. Using argon plasma coagulation, anterior and posterior surfaces of the stomach are mapped. EGD scope is then withdrawn. Suturing device mounted on a double channel scope is then advanced. Full thickness bites are taken from the anterior surface starting at the incisora followed by greater curvature and the posterior wall. Suturing is repeated in the opposite direction from the posterior wall to greater curvature and the anterior wall in a U-pattern. Here is the first bite taken on the anterior surface close to the incisora. Helix device is used to bring the gastric tissue into the needle driver to allow full thickness bites. A total of 6 to 8 bites are taken per suture in the U-pattern. There is no standardized pattern and a variety of other suture pattern have been reported such as Z-pattern and triangular pattern. After completion of the suture pattern, anchor is released, tension is applied to the suture and is cinched tight using a cinching device. Pattern of suturing is repeated working proximally along the greater curvature towards the fundus. Layer of reinforcement sutures can also be placed. Number of total suture used are also highly variable but are usually reported between 5 to 10 in studies. Variability in the ESG technique exists between endoscopist. Evidence regarding the optimal number of sutures or the suture pattern is lacking. Full thickness suture bites are likely the most critical technical part of ESG. Failure in performance of full thickness sutures can result in early dehiscence of sutures and loss of stomach volume restriction. Suturing is only performed in the body along the greater curvature, no suturing is performed in the gastric antrum and fundus. Only a tubular or sleeve life configuration is formed in the gastric body. ESG can result in excellent short and midterm weight loss. Long term weight loss after ESG also looks promising. Recent study reported a mean total body weight loss of 16% at 5 years follow up. EGD findings in a patient with successful weight loss at 6 months follow up. EGD reveals mostly intact sutures, lumen remains restricted and has a sleeve like shape. Stomach is non-compliant and stomach restriction is maintained. Minority of patients may not have desired weight loss outcomes after ESG. Patient compliance with post-operative instructions and lifestyle modifications are crucial to achieving optimal weight loss outcomes. ESG procedure technique likely has an important role. Management of patients with weight loss failure or weight regain after ESG can be challenging and requires a multidisciplinary approach. ESG like other endoscopic procedures is repeatable. Redo ESG or re-suturing can be offered in selected patients. Redo ESG can also be offered as a step up approach in patients with weight loss plateau. Patients who report progressive increase in the size of meals, loss of early satiety and fullness after primary ESG can be considered for redo ESG. It should be noted that the proportion of patients who need and undergo redo ESG is low. EGD at 6 months post ESG in a patient with weight loss failure who reported the loss of early satiety and sensation of fullness. Partial and complete dehiscence of sutures is seen. The gastric lumen is not restricted and sleeve like configuration is lost. Stomach is more compliant and volume of stomach on insufflation also appears normal. Redo ESG was performed in this patient. Before performing redo ESG, we cut and removed partially or fully dehisced sutures using endoscopic seizures and biopsy forceps. We remove these sutures to avoid tangling and crossing of sutures as this may impair effective cinching. Technique for redo ESG is similar to primary ESG but modification may be required. We performed U pattern of suturing starting at the interior surface of the distal stomach followed by greater curvature and the posterior wall. Suturing is repeated in the opposite direction from the posterior wall to greater curvature and finished on the interior wall. We avoided including mucosal bridges and previous suture sites within suture placation. The helix was placed away from previous suture voids to avoid tangling and trapping of sutures and ineffective cinching. Stomach wall can be less elastic, remodeling fibrotic changes and additions from previous ESG can be seen. Slightly more bleeding can be seen during suturing. Bleeding during ESG is mostly self-limited or resolved with applying tension on suture or cinching. Cinching can also be slightly tricky and more resistance can be encountered. Gentle traction should be applied and excessive tension on suture should be avoided. Suturing is repeated working proximally. We placed a total of 8 sutures in this case. We performed APC ablation of the exposed surface of the gastric mucosa while avoiding the sutures. APC can potentially induce fibrosis and remodeling of gastric mucosa and help with better tissue opposition. However, data is needed. Patient tolerated the procedure well. There were no adverse events. At 3 months follow up after redo ESG, percentage total weight loss was 14%. In conclusion, ESG is a minimally invasive safe bariatric therapy with significant weight loss outcomes. ESG is repeatable and redo ESG can be a safe minimally invasive option for weight loss in selected patients.

Endoscopic sleeve gastroplasty

Minimally invasive bariatric therapy

Weight loss

Gastric motility alteration

Carbon dioxide insufflation