Peri-ESG Management

The technique uses endoscopic transmural suturing throughout the gastric wall to provide a gastric sleeve similar but not identical to sleeve gastrectomy in shape. To perform the gastroplasty, we deploy interrupted sutures from distal to proximal body. Each suture consists of six bites along the anterior/greater curvature/posterior gastric wall before it is cinched. Because this is not a continuous staple line, but, rather, an invagination of the greater curvature of the stomach, intraluminal gaps exist along the plication line. These gaps are of no clinical consequences as far as trapping food and are analogous to gaps seen with surgical plications of the greater curvature for weight loss. Reinforcing stitches are usually placed in the upper body of the stomach. The suture pattern has evolved from a very few cases addressing the fundus to the majority in which we leave the fundus open, so the patient can have a pouch and some accommodation ability.

The technique is performed under general anesthesia with the patient in the left lateral position and using endotracheal intubation. After procedure completion a second endoscopy is carried out to ensure the final tubular configuration, to examine any defects requiring supplemental closure, and to rule out potential bleeding [3] (Fig. 13.1).

Early Post-ESG

The immediate postoperative period includes inpatient surveillance for 24 hours. Medication during hospitalization includes omeprazole 20 mg/12 hours IV (optional: analgesia (metamizole IV) and antiemetic (ondansetron IV)). Lopez-Nava et al. [4] showed that the procedure does produce discomfort for patients in the immediate post-procedure period, with 50% experiencing moderate abdominal pain and 20% experiencing nausea, both of which can be controlled pharmacologically.

At 8 hours after the procedure, liquid tolerance is tested. Blood tests are performed at 6 and 24 hours after the procedure to rule out bleeding [3]. An oral contrast study is performed the day after the procedure (Fig. 13.2). Discharge is planned within 24 hours.

Activity restrictions are not specifically recommended after the procedure (lifting weights, return to work, travel, flight, etc.), beyond the feeling of weakness that the patient could have due to the low caloric intake.

Follow-Up of Patients

Post-procedure care with a nutritionist and a psychologist weekly or biweekly is maintained. Patient communication includes personal interviews (face-to-face), telephone interviews, e-mails, and text messages.

Nutritional intervention changes during the course of treatment. Initially, the focus is on a transitional diet post-intervention. A liquid diet is initiated on the day before the procedure and is continued for at least 2 weeks after. The patient then progresses from hypocaloric liquids to small semisolid meals over 4 weeks.

After patients are started on solid food, the focus is on following the prescribed hypocaloric diet and discussing healthy food choices and alternatives. Once the first phase is completed, nutritional support is shifted to providing patients with a workable diet program that they could follow over the long term, which is personalized to their individual needs. The psychologist coaches patients to follow the recommended lifestyle modification program necessary to maintain their weight loss over the long term. Furthermore, patients were coached on how to interact with food cues and obesogenic environmental stimuli. Finally, they are taught how to recognize emotional eating cues and deal with them. Gastric cavity restriction facilitates caloric limitation. Dietitians and psychologist are in continuous contact to resolve problems and to design the best strategy for treatment of each individual patient.

Exercise is recommended, taking into account each patient’s limitations and as prescribed by an exercise physiologist. An exercise plan that avoids increase in intra-abdominal pressure is recommended during the first month. Initially, walking is encouraged, with a progressive increase in the intensity of exercise as the diet progresses.

The team verifies weight loss results at different times post-procedure.

Results

Fogel in 2008 [6] and Brethauer in 2010 [7] showed the feasibility of endoscopic gastric volume reduction for management of obesity using a superficial endoscopic suturing device that mimicked vertical banded gastroplasty surgical anatomy. Subsequent to a pilot feasibility study in 2013 [1], that demonstrated the feasibility of the ESG

multiple groups have further demonstrated the technical feasibility, safety, and short-term efficacy in a variety of clinical settings [2–5, 8–10]. A recent study also demonstrated statistically significant physiologic changes associated with ESG including early satiety, delayed gastric emptying, and a trend toward increased insulin sensitivity [11]. Lopez-Nava et al. showed that at 1 year after the procedure, the number of nutritional and psychological interaction was predictive of success (Fig. 13.3). Sartoretto et al. [12] showed that male sex, greater baseline body weight, and lack of prior endoscopic bariatric therapy were predictors of greater weight loss at 6 months.

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