Bienvenidos a nuestra nueva serie de seminarios web llamada ASGE Global Spotlight. Estos seminarios web contarán con expertos mundiales en su campo, y estoy muy emocionado por la presentación de hoy en español. Tenemos asistentes de toda América Latina que aseguran a nosotros, y la Sociedad Estadounidense de Endoscopía Gastrointestinal, o ASGE, agradece su participación. El evento de esta noche se titula Manejo Multidisciplinario de la Obesidad y el Síndrome Metabólico. Más que un concepto. Mi nombre es Hernando González, presidente del Grupo de Interés Especial Latinoamericano del ASGE. Soy el director de Endoscopía Intervencionista del Centro Médico Hennepin Healthcare y profesor asistente en la Universidad de Minnesota. Seré el moderador de esta presentación. Antes de comenzar, solo algunos detalles importantes. Habrá una sesión de preguntas y respuestas al final de la presentación. Las preguntas se pueden enviar en línea en cualquier momento utilizando el cuadro de pregunta o question en el panel de GoToWebinar en el lado derecho de la pantalla. Si no ve el panel de GoToWebinar, haga clic en la flecha blanca en el cuadro naranja ubicado en el lado derecho de la pantalla. Tenga en cuenta que esta presentación se está grabando y se publicará dentro de dos días hábiles en GILIP, la plataforma de aprendizaje en línea del ASGE. Tendrá acceso continuo a la grabación en GILIP como parte de su registro. Ahora, es un placer para mí presentarles a nuestros expositores de hoy, la doctora Victoria Gómez de Mayo Clinic, Jacksonville, Florida, y el doctor Juan Carlos Caramés del Centro de Endoscopía Terapéutica Avanzada de Reynosa, México. Nuestra primera presentadora es la doctora Victoria Gómez. Ella es fellow de la Sociedad Estadounidense de Endoscopía Gastrointestinal, o ASGE, profesora asociada y gastroenteróloga académica en la Clínica Mayo en Jacksonville, Florida, con especialización y experiencia en endoscopía intervencionista. Tiene experiencia clínica y de investigación especializada en el campo de la gastroenterología, que incluye imágenes avanzadas, terapias endoscópicas bariátricas, y estudios relacionados con las enfermedades pancreatovirales. La doctora Gómez es diplomado de la Junta Estadounidense de Medicina de la Obesidad y ayudó a iniciar el Programa de Endoscopía Bariátrica en Mayo Clinic en Florida. La doctora Gómez es la directora asociada del Programa de Residencia en Medicina Interna en Mayo Clinic. Su enfoque principal es la supervisión de la investigación y las actividades académicas para los residentes en capacitación. También se mantiene muy activa a nivel local, nacional e internacional, participando en comités educativos centrados en el servicio a través de la Sociedad Estadounidense de Endoscopía y Gastrointestinal y la Organización Mundial de Endoscopía, WIO. Ahora le pasaré la presentación a la doctora Gómez. Victoria. Muchas gracias, Dr. González, y buenas noches a todos mis colegas. Gracias por esta oportunidad de participar en este webinar sobre la endoscopía bariátrica. En esta charla voy a hablar sobre la reducción transoral del vaciamiento gástrico, lo que llamamos en inglés el TOR. Estos son mis conflictos de interés. Los objetivos de esta presentación son, en primer lugar, conocer las indicaciones del TOR para así poder seleccionar el candidato ideal, entender que la realización de un TOR conlleva un abordaje multidisciplinar donde varios especialistas trabajaremos en equipo hacia un mismo objetivo para el paciente, comentarles brevemente los resultados de esta técnica en los Estados Unidos, y mostrarles, por último, los resultados de esta práctica en la Mayo Clinic Florida. En la actualidad, estamos enfrentándonos a una pandemia, y no estoy hablando de la coronavirus. Hay día de hoy más de 700 millones de adultos sufren de obesidad. En los Estados Unidos, dos tercios de los adultos tienen sobrepeso y un tercio tienen obesidad. Sabemos que el peso excesivo es un factor de riesgo para enfermedades cardiovasculares, diabetes, enfermedades de hígado grasa, y además está identificado como factor de riesgo oncogénico. En este contexto, cada año aumenta el número de procedimientos de cirugía bariátrica. Simultáneamente, estamos viendo aumentar las revisiones de estas cirugías por diversos factores, entre los que se encuentra la ganancia de peso. La ganancia de peso, con las consecuentes comorbididades después de un bypass en Wideroo, son problemas que estamos viendo con más frecuencia. Por regla general, todos los pacientes suben de peso después de una cirugía bariátrica. Sin embargo, algunos de estos pacientes pueden situarse en los extremos de sufrir una ganancia excesiva de peso, o por el contrario, un síndrome de mala absorción o dumping. Sabemos que las causas que llevan a una nueva ganancia de peso son multifactoriales, incluyendo la dieta o el estilo de vida. Sin embargo, existen también factores anatómicos que pueden estar jugando un papel importante en este aumento ponderal. Concretamente, sabemos que el diámetro de la anastomosis gastroyayunal se correlaciona linealmente con el riesgo de ganancia de peso después de un bypass gástrico. Una boca anastomótica amplila conlleva un paso más rápido del alimento hacia el ayuno, con lo que el paciente pierde la sensación de saciedad precoz y se siente hambriento más frecuentemente. Este incremento del aporte calórico conlleva lógicamente un incremento proporcional del peso. Aquellos pacientes que experimentan una reganancia de peso deben ser sometidos a una evaluación minuciosa. Por un lado, se debe excluir la presencia de una físula gastrogástrica mediante estudios radiológicos. Además, es necesario realizar una gastroscopía diagnóstica para comprobar la anatomía del bypass, específicamente la integridad y diámetro de la anastomosis gastroyayunal. En pacientes en los que se confirma un paso de salida dilatado y esto encaja con la sospecha clínica, debe abordarse este problema ya sea quirúrgica o endoscópicamente. La revisión quirúrgica es invasiva, puede ser técnicamente compleja debido a la presencia de adherencias, suele conllevar una estancia hospitalaria y sus consecuentes costes asociados, y además, algunos pacientes pueden no disponer de una cobertura del seguro adecuada. Afortunadamente, en la actualidad disponemos un abordaje endoscópico gracias al sistema de sutura disponible en el mercado. Lo cierto es que esto puede hacerse mediante la aplicación de argón en solitario o combinando esta técnica con la sutura transmural. Hoy en día, la combinación del argón y la sutura transmural suele ser el método de elección. En este video, les demuestro el procedimiento TOR. Todos nuestros procedimientos se realizan bajo intubación orotraqueal para confort del paciente y protección de la vía área. Empezamos realizando una gastroscopía para evaluar la anatomía posquirúrgica y medir la boca. A continuación, empleamos el argón para quemar los bordes, dibujando un halo grueso en el área mencionado. Una vez realizado el primer paso, empleamos el sistema endoscópico de sutura para disminuir de forma significativa el diámetro de la salida del remanente gástrico. Para ello, empleamos material de sutura no asorbible y o bien un gastrosco hipoterapéutico de doble canal o un estándar de adulto. Se han descrito varios patrones de sutura, siendo lo más común es una figura de ocho o sutura corrida simple. Una vez que se completa el patrón de sutura, se aplica tensión en la misma para reducir el orificio de salida del diámetro deseado y, por último, se corta el hilo de sutura con el cinch incluido en el sistema. En mi caso, realizo a continuación una gastroscopía con el gastroscopio pediátrico para inspeccionar visualmente el resultado tanto en la cara gástrica como yayunal, así como para comprobar ausencia de complicaciones con el sangrado. La imagen a la derecha es cómo se suele ver tras la sutura endoscópica. Reducimos el diámetro hasta 6 a 8 milímetros y el paciente recibe el lata al mismo día. Cuando no se dispone del sistema de sutura endoscópica o este no es técnicamente posible de llevar a cabo, se puede emplear argón como tratamiento único de forma secuencial para así ir reduciendo el diámetro. Aquí vemos cómo se realiza un halo grueso con argón en la vertiente gástrica, lo que ocasiona inflamación y tejido cicatricial que, en último lugar, genera una reducción del diámetro. Estas son imágenes de un paciente que traté a lo largo de cuatro meses por el síndrome de dumping. Pueden observar cómo el diámetro de salida se va reduciendo progresivamente con cada sesión de TOR. Si bien es cierto que aún no disponemos de muchos estudios, ambos métodos de TOR parecen ser igualmente efectivos para conseguir una pérdida de peso. En este meta-análisis, ambas modalidades fueron comparadas con semejantes resultados en cuanto a la pérdida de peso, siendo esta en torno al 5-10% del peso corporal total. Por otro lado, ambas técnicas tienen un perfil de seguridad superponible. Sin embargo, si el TOR se realiza únicamente con argón, esto va a conllevar varias sesiones endoscópicas y, por tanto, es necesario tener esto en cuenta a la hora de plantear si la cobertura del seguro del paciente va a cubrirlo. Además, obviamente, cada sesión de endoscopía conlleva sus riesgos inherentes asociados. En estos resultados, el grupo de Chris Thompson del Hospital Brigham and Women's se siguieron durante cinco años 331 pacientes a los que se les había realizado un TOR. La mayoría del cohorte estaba formada por mujeres. El índice de masa corporal medio en el momento del TOR era 40, con un tiempo de medio de nueve años desde el bypass gástrico. Lo más interesante de este estudio es que se dispone de la información de 276, 211 y 102 pacientes a los uno, tres y cinco años de seguimiento respectivamente. Se observó que los pacientes perdieron peso. Concretamente, a los cinco años del TOR habían conseguido perder casi 9% de la pérdida de peso total. El 62% del cohorte experimentó al menos una pérdida de peso corporal total de 5%. A continuación, me gustaría mostrarles nuestro protocolo en la Mayo Clinic Florida que incluye cómo seleccionamos, evaluamos y seguimos a aquellos pacientes a los que les practicamos un TOR. La selección del paciente es fundamental y el primer paso del proceso. Generalmente, ofrecemos el TOR a pacientes con índice de masa corporal entre 30 y 40, aunque sí que hemos hecho alguna excepción en pacientes con el IMC menor de 30 que ya han optimizado los cambios en el estilo de vida sin resultados, así como a pacientes con IMC mayor de 40 que necesitan un pequeño empujón para iniciar la pérdida de peso y que ya han demostrado haber realizado cambios tanto en el estilo de vida como conductuales. Estos pacientes suelen llevar más de dos años desde la cirugía del bypass gástrico y han experimentado una pérdida ponderada significativa como consecuencia de ello. Cada centro suele tener su propio criterio, pero solemos considerar una pérdida de peso de al menos 25% del peso corporal total después de dos años, un criterio que referencia basado en los datos del Grupo del Estudio de la Obesidad Sueco. La mayoría de estos pacientes habrán perdido la sensación de saciedad precoz, mientras un pequeño subgrupo de pacientes, pero igualmente importante, padecerán el síndrome de dumping. Realizamos una gastroscopía diagnóstica en todos estos pacientes para medir el remanente gástrico, así como el diámetro de la boca, anastomótica graso-genunal. Asimismo, se indica un estudio radiológico con Mario para excluir la presencia de fístulas gastrogástricas. Estos son algunos de los criterios de exclusión. Desde un punto de vista técnico, aquellos pacientes con un bypass gástrico portadores de una banda grástrica no pueden someterse a una sutura endoscópica por el riesgo de que el porta de la aguja se pueda enganchar en la banda. Un factor importante que intentamos siempre indagar es el abuso de sustancias así como el consumo activo o reciente de tabaco. Si existe la sospecha de tabaquismo reciente, solicito un test de metabolitos de nicotina en la orina. El TOR puede exacerbar de forma significativa la clínica de enfermedad de reflujo gastroesofágico, con lo que la presencia de un reflujo ácido grave es un criterio de exclusión. Un abordaje multidisciplinar es de suma importancia al evaluar estos pacientes. Todos nuestros pacientes se comprometen a un mínimo de 12 meses en nuestro programa de pérdida de peso. Las clínicas e instituciones requieren un equipo conformado por endoscopistas, nutricionistas, internistas y psicólogos quienes se especializan en el manejo de la obesidad. Es muy importante descartar potenciales trastornos de la alimentación en los pacientes, indagar sobre su motivación para cambiar el estilo de vida y valorar también deficiencias nutricionales. Un aspecto diferente con respecto a la cirugía bariátrica es la importancia de comentar con el paciente sus expectativas y metas fijadas con el tratamiento endoscópico. La pérdida de peso alcanzada con TOR es mínima comparada con la pérdida alcanzada con la cirugía bariátrica. Desde el inicio, le explicamos al paciente que los cambios neurohormonales y fisiológicos que ocurren después de la cirugía no se pueden reproducir con TOR. Esto ayuda a fijar un esquema de tratamiento con el paciente. Y lo que le digo a mis pacientes es que este tratamiento les ayuda a iniciar el proceso de pérdida de peso. Una vez este proceso se ha iniciado, es su responsabilidad continuar con la pérdida de peso. En nuestras consultas nos gusta citar la información del estudio sueco de obesidad. Si los pacientes son capaces de mantener el 25% de su pérdida total de peso en cualquier momento después de dos años de la cirugía, entonces lo consideramos un éxito. La discriminación y el sesgo, que como sociedad tenemos sobre la obesidad, hace como médicos veamos la ganancia de peso como un fallo de tratamiento, aun cuando esto es incorrecto. Antes del procedimiento, los pacientes deben de mantenerse con dieta líquida. Para el manejo de las náuseas, les tratamos con un parche de escopolamina detrás de la oreja administrado la noche antes del procedimiento. El día del procedimiento se premedican con una grama de acetaminofén tres horas antes de la intervención. En conjunto con nuestros anestesiólogos, utilizamos el mismo protocolo de anestesia usada en cirugía bariátrica. Este se basa en no utilizar agentes volátiles y así minimizamos las náuseas y el vómito post-procedimiento. Toda inducción se hace con Propofol. También les damos dexametasona y un antiemético como leundancetron y les hidratamos generosamente con el ánimo de reducir todas náuseas post-procedimientos. Tras el procedimiento, los pacientes son alzados a su domicilio. Se les indica que retiren el parche de escopolamina al día siguiente de la intervención. Lo que nos ha ayudado significativamente a reducir las náuseas es usar leundancetron cada ocho horas durante las primeras 48 horas, incluso aunque no presenten la sintomatología. Esto ha sido fundamental para suprimir las náuseas. Y ha funcionado y funciona maravillosamente. Durante un mes mantienen el omeprazole en frecuencia de dos al día. Personalmente les indico que abren las cápsulas y disuelven con su contenido con líquidos en vez de tragarlas enteras. Esto es debido a que, por culpa de la anatomía del bypass, cabe la posibilidad de que la cápsula no tenga tiempo de disolverse y la medicación se absorba en el intestino delgado distal o colon. Todos los pacientes sufrirán estreñimiento especialmente durante la primera semana tras el procedimiento debido a la disminución de la ingesta oral y el cambio drástico de la dieta. Por ello, usa un laxante diario a todos ellos. Se mantienen los suplementos multivitamínicos. Normalmente recomendamos aquellos masticables. La dieta post reducción gástrica consiste básicamente en líquidos durante un mes antes de progresar algún tipo de comida sólida. Los pacientes se citan con nuestros nutricionistas de la clínica bariátrica antes del procedimiento para revisar menús de ejemplo y explicar los objetivos proteicos y calóricos. Mantenemos un seguimiento durante al menos un año con visitas a varios de los miembros del equipo multidisciplinar en diversos momentos de la evolución, así como realizamos seguimientos analíticos para detectar insuficiencias o déficits nutricionales. Ahora les voy a comentar sobre nuestra experiencia en la Mayo Clinic en Florida. Estos son datos recogidos durante el año pasado y solo incluye a aquellos pacientes con un seguimiento de al menos 12 meses. La mayoría de nuestros pacientes que sometieron a un TOR son mujeres con un índice de masa corporal mayor o igual a 35 y el motivo principal fue la reganancia de peso. De media, estos sujetos mantuvieron una pérdida del peso corporal total de entre 5 a 6 por ciento. Empleamos el peso inmediatamente anterior al TOR como referencia, lo cual es importante ya que algunos estudios han recogido en su lugar el peso previo a las estrategias para la pérdida ponderal que se llevan a cabo antes del TOR. En conclusión, el manejo de la reganancia de peso tras un bypass gástrico en wider root es complejo y multifactorial. Aquellos pacientes interesados en un intervencionismo para tratar esta ganancia de peso requieren una evaluación en profundidad para identificar problemas conductuales del estilo de vida así como factores puramente anatómicos. Una anastomosis gastrointestinal dilatada puede asociarse a una reganancia de peso y sabemos que el TOR ofrece un abordaje no quirúrgico seguro y efectivo para reducir el vaciamiento gástrico. Determinar unas expectativas razonables y factibles con la pérdida de peso con el TOR es crucial para su éxito a largo plazo. Muchas gracias por su atención y estoy disponible para preguntas. Victoria, muchas gracias por esa excelente presentación. Gracias. Creo que vamos a proseguir porque están entrando algunas preguntas, pero me gustaría seguir con la siguiente presentación de Juan Carlos Caramés para después hacer la sesión de preguntas y respuestas. Nuestro próximo oponente es el doctor Juan Carlos Caramés Aranda. Él es fellow también de la Sociedad Estadounidense de Endoscopía Gastrointestinal egresado del Hospital Juárez de México, director del Centro de Endoscopía Terapéutica Avanzada de Reynosa, jefe de la Unidad de Endoscopía del Hospital Santander Reynosa, él es experto y profesor internacional de las técnicas de endoscopía del tercer espacio y uno de los pioneros de la manga gáfrica endoscópica en México. Juan Carlos, te damos el pase, por favor. ¿Qué tal? Un saludo a todos mis amigos de Latinoamérica y quisiera agradecer al doctor Hernando González por esta atenta invitación y a todos los organizadores de la ASGEP para este webinar. En esta ocasión voy a hablar acerca de la manga gástrica endoscópica y la experiencia inicial en México. Los objetivos de esta charla serán revisar las indicaciones de la manga gástrica endoscópica, analizar los resultados a nivel mundial y report the initial experience of our results in our country here in Mexico. As Victoria mentioned, in the United States it occupies the first place in obesity in the world, and this is increasing every year. Surprisingly, Mexico occupies the first place in child obesity in the world, and it is the second place after the United States in obesity in adults, with the comorbidities already mentioned, such as diabetes, arterial hypertension, chemical, coronary diseases, cerebral vascular events, hepatic sciatosis, among others. The treatment as described, there are different methods, the first intention is to invite the patient or to request changes in their eating habits, to increase their physical activity, and sometimes medical treatments are used to reduce the weight. When this has not been sufficient, then the gold standard so far has been the surgical treatment with the gastric gland via the laparoscopic, but in recent years, endoscopic treatment or gastric gland by endoscopy is becoming increasingly important among these patients. According to the body mass index, the proposed treatments are as follows. In patients with obesity between 26 and 29, they are indicated exercise patients, changes in physical activity, medications, and the intragastric balloon can be used. In patients, as Victoria said, between 30 and 40 of the body mass index, the endoscopic gastric gland is acquiring more and more importance or greater relevance. In patients above 40 of the body mass index, laparoscopic surgery, or in those patients with super obesity, the gastric bypass is also indicated. The indications then for the endoscopic gastric gland are patients with a body mass index between 30 and 40 who have had failure to attempt changes in their eating habits and changes in their lifestyle. Frequently, we have had patients who have a body mass index greater than 40 who do not want to carry out the gastric gland procedure through laparoscopic surgery or who, due to some alteration of their arterial hypertension or comorbidities, cannot be taken to surgery. Another indication of the endoscopic gastric gland is that it serves as a bridge that prepares our patients to achieve an accelerated weight loss and subsequently lead them to a heart transplant, hip replacement, or bariatric surgery due to super obesity. In this study, reported by Dr. López de Nava and Dr. Michel Kalé, who has been my tutor in this endoscopic gastric gland technique in recent years, reported 248 patients with an average age of 44.5 plus or minus 10 years. The majority were also female patients and with a follow-up at 24 months. The total weight loss was 15% at 6 months and at 24 months up to about 19%. In this study carried out in India, where for the first time 1,000 patients were brought together for endoscopic gastric gland surgery or those who were given the endoscopic gastric gland procedure, it is the largest experience so far in a single center with the first 1,000 patients who were subjected to this procedure. The average age was 34.4 in a range between 18 and 60 years of age and about 90% were also female. They used an average of 4.2 plus or minus 0.5 sutures per patient with a range between 4 and 6 stitches per patient and the basal body mass index was 33.3 plus or minus 4.5 kilograms per square meter. And we see that the body mass index was modified and went down to 5 points and the total weight loss was also 14.8 plus or minus 8.5 kilos. How is endoscopic gastric gland surgery compared to endoscopic gastric gland surgery? This picture is very evident. We see here that with the endoscopic gastric gland, what we are doing through the suture using the Apollo system is that we apply the stitches only in the major curvature of the gastric body, leaving the gastric background intact due to the physiological and also hormonal consequences that this entails and also leaving the gastric gland intact. So what we achieve is a reduction of the transversal diameter of the stomach, although also longitudinally we achieve a slightly smaller reduction, thus reducing the size of the stomach, although, I repeat, the gastric background is left intact and this allows the patient not to lose the feeling of appetite and satiety by ingesting a small amount of food that is going to be filled in the gastric background. The difference with the gastric gland surgery is that it dries up, it is altering both the anatomy and the physiology of the stomach, losing all the gastric background along with all the major curvature of the stomach with the consequent physiological and hormonal alterations that this can entail. Now, adverse events compared to the endoscopic gastric gland occur in a very low proportion compared to the endoscopic one. In this study, we have only a 5.2% compared to a 16.9% in the endoscopic surgery and the periods of new reflux presentation, here is 1.6% compared to 14.5% in patients subjected to endoscopic surgery. We see that the difference is interesting and important. In this study published in the Journal of Gastrointestinal Surgery, the results of 278 patients were commented, where the laparoscopic gland was compared, the surgical gland by laparoscopy, the gastric gland by endoscopic and the bypass, with very similar body mass indexes among these groups of patients and what we observe is that the weight loss was obviously greater with the gastric gland, but we see here, interestingly, that the endoscopic method, the gastric gland by endoscopic, when we study the result of the total weight loss, plays an important role and is giving comparatively significant results with the rest of the procedures. When we study adverse events of the endoscopic gastric gland, if we can see here in the line on the right, they are all below 1%, including or adding up to 1.1%, but we have adverse events such as an intra-abdominal collection, remember that the structure must be transluminal, it must occupy the total thickness of the stomach so that it is effective and this can sometimes give small leaks outside the stomach and make a collection, but it occurs at 0.4%. The hemorrhage that requires an intervention, a transfusion or an endoscopic intervention is less than 0.5%. The refractory symptoms that required the removal or removal of the gastric gland are only 0.2%. Pneumopeltonia and pneumothorax are 0.1%, which is an extremely low percentage. Pulmonary embolism is also 0.1%, as well as perforation or death caused by this is absolutely zero. So we see here that the adverse events of the endoscopic gastric gland are minimal. In this study, where Dr. Abudaye also participated and reported the results of 1,772 patients, we saw here that the results or the symptoms reported in the patients were also less than 1% and the most important was pain or nausea that required hospitalization only at 1.08%. Approximate digestive hemorrhage at 0.5%. Perigastric leak or collection at 0.4% and pulmonary embolism and pneumoperitoneum at 0.06%. So the adverse effects of the endoscopic gastric gland are minimal and also no patient died because of the procedure. So how is the surgery compared to the adverse events? We see that the gastric gland, in terms of adverse events, plays a very important role and has a lower percentage of complications or adverse events compared to the endoscopic gastric gland surgery or the bypass. So this is the importance of using or carrying out this procedure. Now I am going to comment on the results of the endoscopic gastric gland in our country. We have had the opportunity and the privilege of working together with Dr. Michel Kalle, who is my friend and tutor in this procedure. It is a procedure that is carried out through the oral pathway. It does not require incisions in the skin. It is really minimally invasive. It is carried out, as we have already mentioned, in patients who are not candidates for surgery. It is a completely reversible procedure. When, for some reason, the patient should no longer have the sutures, we can go back through the endoscopic pathway, remove the sutures, and the stomach is 100% integral. We are not altering or mutilating the stomach. This endoscopic gastric gland procedure does not contraindicate a subsequent surgery. It is an ambulatory procedure. So far, we have kept the patient in the hospital for the first 24 hours to monitor their side effects and give them a better hydration. And, obviously, the APOL suture system is used. As Dr. Victoria mentioned, this procedure cannot be carried out if it is not carried out through a multidisciplinary team, which involves nutritionists, internal medicine doctors, and very often the psychologist or the psychiatrist who will help us with the management of the patients. And, obviously, our entire team, both medical and nursing, is properly trained to be able to carry out this procedure. In our case, all cases have required or we have had supervision, either in person before this pandemic and virtually in the rest of the cases so far by Dr. Michel, who, I repeat, has been my friend and to whom I take the opportunity to publicly thank for his help and his teaching. In all cases, we use a double-channel endoscopy and the APOLO system, in our case, and with the opinion of experts around the world, it is preferable to use the double-channel endoscopy and the APOLO system to carry out this endoscopic procedure of the gastric sleeve. Not so in other, for example, small perforations, where the monochannel can be used, but for the endoscopic gastric sleeve it is preferable and it is indicative to use the double-channel endoscopy. And the APOLO system consists of the endoscopic suture system itself, the suture port that goes through the major duct of the double-channel endoscopy, the helix, which has a function, it is actually an accessory in the form of a corkscrew, and it has the function of taking the stomach wall, retracting it and allowing us in this way to make a complete thickness point of the stomach wall, because it is necessary to have or give a complete thickness point so that the suture remains in position and gives the complete decrease effect of the stomach size. It is important to point out here that three turns must be given in the direction of the clock hands to be able to have enough tissue, pull it and give a complete thickness point. If we give less turns of the three, we can only have the mucous and finally that point will be released, or if we give more than three turns, we can completely perforate the stomach and then have the complications that we have mentioned. Obviously, we also have the low knot, as Victoria mentioned, we cut it down and adjust the suture and finally cut the suture that is not absorbable. It also requires the use of other equipment such as the CO2 inflator. Personally, practically all the procedures, even the diagnoses, are carried out with CO2, but this particular procedure, the endoscopic gastric sleeve, cannot be carried out without using the CO2 inflator. And also the Herve Bio 300D for the argon plasma application at the time of marking the sites or lines where we are going to place the sutures. All our patients carried out the procedures with general anesthesia and there are two ways to place the stitches, in Z or U shape. At the beginning, we were using the Z shape or the stitches in Z, but the vast majority of patients are already using the stitches in U with excellent results. There is no technical difference or difference that it is better to give one stitch or another, we have simply chosen the U-shaped stitches. We are using an average of six stitches per patient, with a range between six to eight stitches, and thus we achieve the reduction of the size of the stomach body, as I mentioned a moment ago, up to 70%, which will cause us to have a reduced gastric background, or a gastric background, sorry, respected. But the patient, when he eats, soon feels the satiety of the stomach, it takes longer to empty this small amount of food because the transverse diameter of the stomach is reduced, and once he reaches the anus and continues to the thin intestine, all functions are respected and the absorption mechanism of nutrients is carried out normally. The average time of the procedure is 1.5 hours. These are our results, so far we have had the opportunity to carry out 29 cases in Reynosa, 17 have been women, and 12 patients have been of male sex. The average age is a young man of 15 years, sorry, and the oldest has been 51 years old, with an average age of 33.7. This boy, worth mentioning, 15 years old, already had problems in his knees due to overweight, and obviously had diabetes with hemoglobin over the normal. Three patients of this group of 29 had the habit of smoking, and four patients had diabetes mellitus, arterial hypertension, and four patients also with reflux disease. The rest of the patients were only asymptomatic and only came for overweight. This slide shows the changes in body mass index and weight in our patients, and these that are highlighted in red are patients who were above 40% of body mass index, and unfortunately not all patients have continued until 12 months, but in the group of patients that we have had the opportunity to follow up to 12 months, we see that in this patient, for example, the body mass index at the beginning was 49.8, and at 12 months we had a decrease of up to 34.2. In this other patient, with an initial index of 42.8, and at 12 months we saw a decrease of up to 27.9%. This other patient, with an initial body mass index of 47.6, and at the end, 36.3. And so, the last patient, last week, in just one week, the body mass index went down from 36.3 to 34.3 of body mass index. So, the average weight at the beginning was, in general, 137.24 kilos, with a body mass index average of 36.2, and at three months we achieved a weight reduction on average of 96.03 kilos, and a reduction of the body mass index also of 32.9. In the seven patients that we have managed to follow up to 12 months, we have had a reduction of up to 88.1 kilograms on average, with a reduction of the body mass index up to 31.4. As a follow-up comment, we see here that the consequences, both metabolic and arterial hypertension, are also evident. The average at the beginning, before the endoscopic gastric sleeve procedure, the average arterial pressure was 131 over 77.8, and after three months, this arterial pressure had a significant drop on average of 117 over 70. Also, from a metabolic point of view, we had a reduction in hemoglobin, which at the beginning was an average of 6.96. After three months, we also have a reduction of 5.2. This is at normal levels, as far as the decrease in caloric intake is supporting or helping the patient to reduce the levels of glucose. We have had zero morbidity. This means that no patient has required re-intervention or hospitalization due to any complication. There have been no perforations, no bleeding, no leaks, and thank God, we have not had any mortality either. Here in this video, I am going to show you how we carry this out. Here in this image, we have the points that we initially placed on the back wall and the front wall of the major curvature, using argon plasma to place these points, which will allow us to serve as a guide to place the sutures, and this will achieve the reduction of the transverse diameter. Here we are using the Apollo system. We are transferring the suture. Precisely, we are now using the helix, and see how we are applying three turns in the direction of the clock. We retract the tissue until it is properly attached to our endoscope, and then we give the suture, and we do it over and over again on the back face, on the major curvature itself, and on the front face, making sure that the points are completely transmural. And see here, we already have the first suture line, and here are two options. One is that we go back, in this sense, as I am pointing out here in the video, with points in U, or we start again on the back wall, on the major curvature and the front wall, to give a point in Z. I repeat, there are no benefits indicated that are greater for one type of suture or for the other. In all cases, the suture is not absorbable. And finally, this is the result, the decrease up to 70-80% of the light of the stomach, and here we already have the gastroenteritis. This is the result, sorry, that we see in the esophageal-astrodenal series that we ask the patient a week later. This study is carried out with a hydrosoluble material, and we can see here the permanence of the gastric background, an important decrease in the diameter throughout the gastric body, and again the diameter is opened in the anus, and the passage of the contrast medium to the intestine is continued without any obstruction. These are just two of the results of patients that we have had. This is the boy that I presented to you in the first place. He had a body mass index of about 60. In eight months, we achieved this significant decrease to a body mass index of about 34. And this young man, in four months, we achieved this reduction, he also had a body mass index above 40, 40.5, and we managed to reduce it to about 30% in just four months. And finally, I want to show you here how we are working with a whole team that is fully trained, and I want to publicly thank Dr. Michel, who has been my tutor and supervisor in all 29 cases of our experience in Mexico, and I want to thank all of you for your attention. Again, I thank you for the invitation, and I am open to questions and answers. Well, thank you very much, Juan Carlos, for that excellent presentation. We wanted to remind you that if you have any questions, you can at any time use the question box in the GoToWebinar panel on the right side of your screen. If you don't see the GoToWebinar, click on the white arrow in the orange box located on the right side of the screen, and so we can ask the questions. There are several interesting questions here that I would like us to start reviewing, and perhaps the first question I will ask Victoria. Victoria, as you said, Chris Thompson's group from Boston has also done a lot of research, and also colleagues from Brazil, Dr. Thompson and Dr. Diego de Morúa, did a review on the use of argon plasma during the reduction of TOR-E, but they did endoscopic resection of the submucosa with the argument that doing a deeper dissection could improve the sutures, but we know that they are sutures of the entire thickness or thickness of the stomach. So, do you think there will be any benefit instead of doing argon, doing submucosa resection? Submucosa resection is much more difficult to do in our Latin American countries. It would be perhaps a little more complicated to do it. What do you think? No, thank you for the question, Dr. González. So, yes, this study was published last year in the magazine Gastrointestinal Endoscopy by Chris Thompson's group and Pichamol Girapinho, and they studied 19 patients who performed the TOR with the endoscopic submucosa resection technique. What they thought was that doing endoscopic submucosa resection helps expose the submucous layer and the muscle layer itself to increase the position of the tissue with the sutures. So, you know, they showed that the weight loss was more than with the traditional TOR with the suture machine. The problem is that this was a very small study of 19 patients. The ESD requires more technique and is not generalizable by everyone, by the entire endoscopic community. Also, the ESD carries more risk of complications, such as perforation, which is one of the most worrying, and also bleeding, and it takes longer, too. So, until we have more multicentric prospective studies, it is very difficult to say at this time that it is superior to the traditional method with the suture and the Argon. But maybe in the future we will see more studies published, but it is too early to say that at this time. Perfect. Juan Carlos, we know that in the laparoscopic sleeve there is a very high percentage of gastroesophageal reflux with these patients, and also recently a prevalence of barbary esophageal in 11% of these patients was described. Do you think there is an advantage with respect to the endoscopic gastric sleeve compared to the endoscopic gastric sleeve? Thank you, Hernando. It is an excellent question. Yes, there is a difference. Remember that the endoscopic gastric sleeve, the gastric background remains intact. We respect that. And that allows us to have enough space. Unlike the gastric sleeve, the endoscopic gastric sleeve is completely sectioned up to 70% of the stomach. So we have a space, a gastric reservoir in the background that is important not only to retain food and avoid reflux, but the most important thing to point out in this procedure is that the physiological and hormonal functions of the gastric background that we all know are respected, they are intact. That is why they not only reduce the possibility of having reflux, but also the chances of gaining weight in the long term are lower with the endoscopic gastric sleeve because we have respected the hormones that are secreted in the gastric background. And interestingly, as I was saying, we have the gastric background, the patient ingests a smaller amount of food and feels satisfied. He will never lose that feeling of satisfaction. And that small amount of food takes longer to empty into the gastric background and continue into the thin intestine. And that also gives us a longer time of satiety of the patient. And when he gets hungry again, he eats a small portion again and this is repeated over and over again. So it not only has an advantage in having less percentage of reflux, as we saw in the slides, but also a lower percentage of weight gain in the long term. Excellent answer. And there really is a very important phenomenon, mechanical and hormonal, right? Because you don't lose so much of the HIIS angle in this type of surgery. The sleeve gastrectomy is like a straight line where you already lose, let's say, that gastric background. So I think it's very valuable for us to take into account that difference, right? Exactly. Also, Juan Carlos, I wanted to ask you another question because recently, after the gastric sleeve, the paroscopic, endoscopic revisions, because the stomach expands, it shrinks, it makes a bigger cavity, and it has been described that you can do endoscopic revisions with some good results. What can you say about that? Yes, what Dr. Michel has commented, who is one of the most experienced, and Dr. Manuel Galvao in Brazil as well, is that they are also doing a redo, what they call redoing the gastric sleeve that was initially done by the paroscopic, again achieving to give the shape of the sleeve to the stomach. Let's remember that the stomach is a smooth muscle that after the gastric sleeve is done, when the patient begins to eat larger portions, that muscle of the stomach begins to dilate more and more, and we can enter and see again an almost normal stomach, as if we had not had any previous surgery. And we have every possibility, because entering through the endoscopic, we will not find the adherence that could be found if it were done through the paroscopic, so we are practically finding, we could say, a virgin stomach, because nothing has been done inside, and also the gastric chamber has dilated again, so we can redo the endoscopic gastric sleeve and cause the patient to lose weight again. And it is described, it has been done, and it has excellent results. Perfect, excellent. Now a question for Victoria. Victoria, we know that these patients who get RUENY and gain weight again, many times they are also patients, as you said, who do dumping. Do patients who have dumping problems also have overweight problems or not? And if you reduce the TOR for dumping, do they lose weight? Yes and yes, this is a simple explanation. Most patients have gained weight, or let me say that all patients more than two years after the gastric bypass are going to gain weight. But the patients that I have seen with dumping syndrome, their problem is not the gain of weight, it is not the reason they see me in the clinic. It is because of diarrhea, palpitations, low sugar levels. But yes, when we do the TOR, we do the TOR, they do lose a little weight. But interestingly, these patients are not worried about gaining weight. They have a dumping syndrome that they can't leave the house, they can't work. And by reducing the exit, the gastrointestinal anastomosis, I mean, it can change their life. So that's what they focus on. Excellent. Well, we could stay here talking longer. There are very good questions, but we are running out of time. Here's a question. I think I could ask Victoria, what is the ideal diameter to leave that anastomosis? Again, will it be 10 centimeters? Or what is the ideal diameter? We try to reduce it to less than 10 millimeters, or less than a centimeter. I reduce it to between 6 and 8 millimeters. I mean, of course, you don't want to close it completely, because then the patient can't tolerate liquids. But you have to take into account that at the beginning, when the procedure is finished, everything is going to look very swollen, with a lot of congestion and edema. So the exit is going to look very, very small, but over time, when the edema is resolved, it's going to open up a little more. But many of my patients, before we do the anesthesia induction, they ask me not to forget to do it very tight. And I tell them, look, I have to be careful, because I don't want them to go to the emergency room, because they can't tolerate liquids. But less than a centimeter. Okay, perfect. Usually, those patients have diameters of 25 centimeters, initially 30 centimeters. So it's really a significant reduction in diameter, right? Yes, but what you have to keep in mind is that just because a patient has a very dilated exit, it's not always associated, it's not always the factor or the reason why they've gained weight. For example, I could repeat the procedure, repeat the endoscopy a few months after doing the TOR on a patient who keeps losing weight, and the exit can be dilated again. But I'm not going to do anything, because if they're following their lifestyle, changing their lifestyle, diet, exercise, there's nothing to do. But sometimes there are patients who have a dilated exit of no more than 15 millimeters. And I'm going to reduce it anyway, because I know that's going to help them. Perfect. Juan Carlos, a question, maybe one of the colleagues from Mexico, who asks what is the approximate cost of the endoscopic sleeve in Mexico? It's an interesting question. Right now, as the fact of using the Apollo suture system makes the procedure more expensive. But we hope that as this gets done more and more routinely, and we can do it in more hospital centers, and we can get more patients to do the endoscopic sleeve, we're going to reduce the budget, the cost of the patients. But just the suture is what takes up the largest proportion of the costs for the patient. Perfect. And the other question they ask is, in terms of training, how long does it take to gain experience? How many procedures can be done to gain experience? And maybe Victoria can also comment on that with the TOR. Yes. It's worth mentioning, and it's a super, super interesting question. As Victoria mentioned, to be able to carry out these procedures, exhaustive training is required. To be participating not only in a single workshop or in a single course that we could attend. You will remember, Hernando and Victoria, when we first met in the first course of endoscopic dissection of mucosa and techniques of the third space in Chicago, you and I had been attending courses over and over again. And specifically with the gastric sleeve, I was with Dr. Michel in the Well Cornell at the time, participating for hours and hours, practicing with the endoscopic gastric sleeve. Apollo, the company, has a trailer, a truck that moves from one place to another. And I had the grace that he was here for a while in my city, in McAllen, where I live. So we took advantage of it. And since we had the whole unit for us, we were also doing the procedure over and over again. And we have been doing courses in different places. And another important detail, and this is where the importance is, exhaustive training is required. A single course is not enough to give you the capacity to be able to carry out these procedures, but it requires several courses and practicing in pigs, practicing in live tissue. But also, and as I mentioned, in our case, we have had the opportunity that in all cases, Dr. Michel has been with us, initially in person, and now through Zoom, we are connected. And he is practically just watching and giving some opinion, because we have been acquiring the experience more and more. But we have always had, and it is advisable, as the Japanese also comment, for the endoscopic dissection of your mucosa, to have a number of courses first, initially, until you acquire more and more practice. And the first cases, always have the professor there on one side, the expert on one side, to be able to carry out these procedures safely. It is not described and it is not published how many cases of endoscopic gastric sleeve you need to do to have enough experience and be able to carry it out. But at least in the first five or six procedures, the tutor or the expert should be on one side with you. Perfect. Victoria? Yes, I think the same. I think that in addition to what Juan Carlos said, for me, what is most important is to know how to handle complications. Because we can all attend these courses and practice putting transmural sutures in the stomachs of pigs, you know, ex vivo. But when you have a patient, the stomach is going to bleed and you have to know how to handle those complications or perforations, amnioperitoneal, etc. So, you know, for many of the endoscopists or fellows, for example, who want to do endoscopic suturing, they try to learn it during the fellowship. And then, of course, attend the courses. But for me, our experience in the Mayo Clinic, for the first five cases, my tutor was Dr. Abudaya from the Mayo Clinic in Rochester. And he came to our center and served as my tutor for those first five cases. But what I have noticed is that every ten cases that I complete, I can reduce the time it takes me to do the procedure. So, the learning curve, you know, goes like this. Every ten procedures becomes easier. For the TOR, the TOR is simpler. Simpler, you know, because there are always complications as well. But it takes about 15, 20 minutes to do the sutures. But, you know, you always have to, I think, do these procedures with a humble character because you never know when you're going to have complications. If you'll allow me, Hernando. Perfect. Let's go. If you'll allow me, Hernando, I want to add something. And it's precisely, Victoria, you're absolutely right. I remember we had a case of a patient who, when placing the helix, we did it very close to the previous suture that we had already applied. So, the helix got stuck with the suture that we had applied. And it was really a concern because, what can we do in this case, right? And I go back to the same thing. Dr. Mitchell was already connected. It was already during the pandemic. He was connected and we had to use the argon plasma to cut the tissue that was already taken with the helix. And we managed to cut it. And finally, the helix came loose and we were able to continue with the procedure. In this patient, we didn't wait until a week later to do the series. The next day, we did a series with the soluble material. And fortunately, everything was fine. There was no leak. The patient had a completely normal evolution. But it is interesting what you say, Victoria, to be able to solve the complications or the situations that can occur with each patient. Well, perfect. Thank you again, Victoria and Juan Carlos, for being here with us tonight. I'm afraid it's all the time we have available, but I think it's been excellent. And I think you two have enjoyed it a lot, right? Before closing, I want to tell you that we are going to launch a quick survey to verify the quality of this presentation. Your experience with these learning events is important to us. So I would like you to please connect us, to answer all of these questions right now. What did you think of the general classification? Do you find it very informative? Do you find that it provides several useful information points? There you see the answer. I would appreciate it if you answered these questions. Let's give it a few more seconds to see if you can answer us. Okay, perfect. And also, the LASGEE staff will be sending you a very short survey about this session so that you can complete it. It lasts less than a minute, so we would appreciate it very much. And as a final reminder, we want to tell you that there are other activities that we are doing for the LASGEE Latin American Interest Group. We are doing podcasts for the magazine Caso Intestinal Endoscopy in Spanish. There you see, we have already generated two. We have a specific website on the GIE website for podcasts in Spanish, so we would like you to review them there. We have two published, and a third is already in publication, which will be uploaded to the website soon. And we also wanted to talk about another free event that we are doing at the GIE, which will be presented now on March 5 and 6, and is entitled New Borders in CPRA and Endoscopic Ultrasound. This event will take place on the new virtual platform of the LASGEE, where you will have the opportunity to interact with colleagues, leaders of your field, and representatives of the industry. And to finish, again, I would like to thank Victoria and Juan Carlos for those excellent presentations, and thank our assistants for making this session interactive. And we hope that this information has been useful to you and will help you manage your patients. Thank you all very much. Many greetings. Thank you very much, Hernando. Thank you. Thank you very much, Hernando, and congratulations on this wonderful course. Thank you very much to all of you, to all the participants. Thank you. It was a pleasure to see you. Goodbye. Bye. Ciao.

Multidisciplinary Management

Obesity

Metabolic Syndrome

ASGE Global Spotlight

Endoscopic Sleeve Gastroplasty

ESG

TOR

Transoral Outlet Reduction

Gastric Bypass Surgery

Weight Loss