Training in Bariatric Endoscopy

Training in Bariatric Endoscopy

Diogo Turiani Hourneaux de Moura, Pichamol Jirapinyo, and Christopher C. Thompson

Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

Bariatric endoscopy is an emerging subspecialty for gastroenterologists and surgeons encompassing a broad array of procedures including treatment of post‐bariatric surgery complications, primary endoscopy bariatric and metabolic therapies (EBMTs), and revisional procedures for weight regain.

Endoscopic therapy provides minimally invasive treatment of common postsurgical complications such as fistulas, leaks, stenoses, marginal ulcers, and erosion of foreign material. Revisional weight loss procedures focus on reduction of the dilated gastrojejunal anastomosis (GJA) and/or the dilated gastric pouch, which are considered potential mechanical etiologies of weight regain. Primary endoscopic weight loss procedures seek to create a “first‐option” transoral bariatric procedure with current strategies focusing on gastric volume alteration and luminal prosthetics that target metabolic mechanisms.

This chapter addresses the process of incorporating bariatric training for gastroenterologists and surgeons. It is important to note that this chapter is based largely on expert opinion and is intended to start a discussion regarding the introduction of bariatric endoscopy into gastroenterology and surgical training programs as well as to serve as a general guide for trainees and training programs moving forward.

Bariatric endoscopy procedures

Bariatric endoscopy encompasses three main categories (Table 23.1):

  1. Management of post‐bariatric surgical complications
  2. Revisional procedures for weight regain
  3. Primary bariatric and metabolic procedures

Training goals

Bariatric endoscopy training may be divided into two levels. Level 1 represents basic training, including postsurgical anatomy understanding. Level 2 represents advanced training for endoscopists who are interested in specializing in obesity medicine and bariatric endoscopy.

Bariatric endoscopy programs should provide all trainees with general understanding of the following topics:

  1. Establish a comprehensive understanding of obesity pathophysiology and management

    Trainees should understand current theories and hypotheses regarding how obesity occurs, including but not limited to genetic and epigenetic factors, metabolic abnormalities, hormonal imbalance and changes in the microbiome, motility, and bile acid composition. Throughout training, trainees should learn to evaluate patients with obesity and its related comorbidities and post‐bariatric surgical patients in a clinical setting.

  2. Establish an understanding of important elements of an interdisciplinary obesity management team

    Trainees should understand available treatment options for obesity, which include the various diet plans, physical activity, medical therapy, endoscopic therapy, and surgery. Additionally, an emphasis on an interdisciplinary team strategy is essential. Rotation through different services above, or through an interdisciplinary bariatric center of excellence, and multidisciplinary meetings is necessary to better understand the importance of integrative care.

  3. Establish an understanding of post‐bariatric surgical anatomy

    Trainees should understand the anatomy of different types of bariatric surgery. Additionally, when the type of surgery is unknown, trainees should learn to identify the specific type based on endoscopic findings. Understanding possible complications of each bariatric surgery and how to medically and endoscopically manage those complications is also essential.

  4. Establish technical proficiency in endoscopic bariatric and metabolic therapies

    Trainees should know the currently available endoscopic bariatric devices and procedures, the patient population that the device is approved for, and possible adverse events. In general, trainees should start by learning less complex procedures prior to advancing to more complex techniques.

    Table 23.1 Summary of bariatric endoscopy—categories, specific procedures, and skill sets.

    Categories Specific procedures/devices Optimal skill sets

    • 1. Management of postsurgical complications

    • Fistula/leak closure
    • Stenosis treatment
    • Foreign body removal
    • Hemostasis of marginal ulcers

    • Stent placement
    • Glue delivery
    • Endoscopic suturing
    • Balloon dilation
    • Foreign body removal
    • Endoscopic hemostasis
    • Tissue dissection
    • Fluoroscopic interpretation

    • 2. Revisional procedure for weight regain

    • Sclerotherapy
    • APC
    • OverStitch*
    • IOP*

    • Endoscopic injection
    • Endoscopic ablation
    • Endoscopic suturing
    • Endoscopic plication

    • 3. Primary EBMT

    • Intragastric balloons
    • OverStitch*
    • IOP*
    • Duodenal‐jejunal bypass sleeve*
    • Duodenal mucosal resurfacing*
    • TransPyloric Shuttle*
    • AspireAssist*
    • Botulinum toxin injection

    • Endoscopic suturing
    • Endoscopic plication
    • Implant placement
    • Endoscopic ablation
    • Implant removal
    • Injection
    • Submucosal endoscopy
    • PEG placement

    * Manufacturer information in text.

Infrastructure and personnel


Most bariatric procedures should be performed in a hospital setting. However, some endoscopic bariatric procedures, such as intragastric balloon (IGB) placement and removal, may be performed in an ambulatory setting. The facility should be equipped to accommodate bariatric patients in a sensitive manner, including having larger armless chairs, stretchers with appropriate width, obesity scales, and larger blood pressure cuffs. Additionally, the facility should be part of a bariatric center of excellence, where patients can receive care from the medical bariatrician, bariatric surgeon, nutritionist, psychologist, and lifestyle coach.


Educators should have expertise in both medical bariatrics and endoscopic bariatrics, including knowledge on post‐bariatric surgical anatomy, expertise in advanced intraluminal techniques, and experience in endoscopic suturing and other endoscopic weight loss modalities. If the hospital does not have a bariatric center, a multidivisional team of faculty should be formed to provide adequate training. These specialties should include nutrition, exercise physiology, lifestyle coaching, obesity medicine, endocrinology, psychology, and bariatric surgery. For institutions where this multidisciplinary group is not available, didactic and hands‐on courses hosted by different universities and professional societies may provide an alternative solution.

Simulators and hands‐on for training

Simulator training for bariatric endoscopy is an emerging field. Traditionally, trainees may start by learning the device and simple steps using ex vivo animal models. These models are usually available at most hands‐on courses and conferences. While in vivo animal models are generally more realistic than ex vivo models, this type of simulator is currently not widely available for bariatric endoscopic training. Alternatively, training with a mechanical simulator may be considered. For example, an endoscopic suturing simulator developed by our group (Figure 23.1) allows trainees to familiarize themselves with the endoscopic suturing device and to learn stitch placement to perform purse‐string transoral outlet reduction (TORe) for endoscopic management of weight regain. Furthermore, company‐ and device‐specific models (Figure 23.2) are becoming increasingly available, and trainees are encouraged to seek these training opportunities.


Currently, the level of endoscopic experience required prior to undergoing training in bariatric endoscopy is unclear. Trainees should at least be comfortable with standard upper endoscopy and basic therapeutic techniques, such as hemostasis. Prior experience in interventional endoscopy, such as endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, or tissue dissection, is not mandatory. Bariatric endoscopy training may be pursued during the standard surgical or gastroenterological fellowship or as an additional year following general surgery or gastroenterology training. Due to an increasing number of available bariatric endoscopic procedures and the importance of an interdisciplinary training approach, an additional year dedicated to training in bariatric endoscopy is suggested.

Photo depicts mechanical simulator for purse-string endoscopic suturing training.

Figure 23.1 Mechanical simulator for purse‐string endoscopic suturing training.

Photo depicts mechanical simulator for duodenal-jejunal bypass liner (EndoBarrier) placement and removal training.

Figure 23.2 Mechanical simulator for duodenal‐jejunal bypass liner (EndoBarrier) placement and removal training.


Training in bariatric endoscopy is best pursued at a certified Bariatric Center of Excellence. Such centers are multidisciplinary and provide a well‐rounded experience, including nutritional, metabolic, psychosocial, and other medical elements that are critical to proper bariatric care. They also have experienced surgeons to provide further mentorship and procedural backup. Such centers also have adequate procedure volumes to permit proper training. Other special considerations, such as a dedicated advanced bariatric nursing team, may be considered.

Pre‐procedural assessment

A comprehensive understanding of pre‐procedural assessment is crucial. Specifically, focused medical and surgical history, current medications, history of prior weight loss attempts, and smoking history should be obtained. Consultation with a cardiology or neurologist should be pursued for patients who are on an anticoagulation or an antiplatelet to determine if the medication can be held safely peri‐procedurally. If not, the procedures should be postponed until the antiplatelet or anticoagulation can be safely held. Additionally, patients should also undergo psychological and nutritional evaluation. After meeting clinical criteria necessary for EBMTs, upper endoscopy is performed to evaluate the anatomy and to assess any pathology that may preclude endoscopic procedure.

Prior to the procedure, trainees should have an understanding of preoperative instructions for each procedure. These instructions may include the requirement of proton pump inhibitor (PPI) or antiemetic administration prior to the procedure. Some medications, especially antiemetics used in patients undergoing chemotherapy, may require prior authorization from the hospital or from the insurance company, which should be arranged in advance. In addition, for some procedures, such as argon plasma coagulation (APC) and TORe, an arrangement for a liquid or crushable form of the patient’s medications should be done prior to the procedure in collaboration with the providers who prescribe the medications and the pharmacist. Prior to the procedure, trainees should understand the components of each device and how they work. Detailed procedural steps should be reviewed with the mentor, especially during the initial phase of training, and with assisting nurse or technician.


Procedures for endoluminal bariatrics require an array of different devices and equipment. In addition to forward‐viewing endoscopes, these procedures often utilize carbon dioxide (CO2) insufflation with or without instillation of simethicone. Different equipment will be required depending on which procedure is employed. Typical equipment needs are listed in Table 23.2.

Procedural considerations and techniques

Similar to other standard endoscopic training, training in bariatric endoscopy should gradually progress from less complex to more complex procedures. Trainees should start by learning to assist prior to performing the procedure to understand the steps and how to manage the devices. Subsequently, they may take on simpler steps with less risk involved prior to progressing to more technically challenging and invasive steps prior to becoming independent. The learning curve and learning style for each trainee may vary. Therefore, specific feedback from the mentor during and after each procedure especially during the initial phase of training is essential.

Table 23.2 Typical equipment used in bariatric endoscopy.

Post‐bariatric surgery complication management Endoscopic revisional procedures Primary EBMT Others custom devices

  • Forward endoscope
  • Balloon dilators
  • Endoscopic scissors
  • Endoscopic clips
  • Rat tooth forceps
  • Nitinol wires—biliary
  • Mechanical lithotripter
  • Range of covered self‐expandable metal stents
  • Mucosal ablative therapies including APC
  • Endoscopic sealants such as fibrin glue
  • Steroids and/or saline for injection
  • Needle‐knife cautery
  • Methylene blue/contrast

  • APC
  • Suturing or tissue anchoring device (OverStitch*, IOP*)
  • Sodium morrhuate
  • Measuring devices
  • Endoscopic scissors
  • Overtube/bougie system
  • Small caliber scope (4 mm) in addition to a standard forward‐viewing endoscope
  • Double‐channel endoscope
  • Standard hemostasis equipment (epinephrine, injection needle, clips)
  • Extra suture material and associated knot tying device/materials

  • Small caliber scope (4 mm) in addition to a standard forward‐viewing endoscope
  • Double‐channel endoscope
  • Standard hemostasis equipment (epinephrine, injection needle, clips)
  • Extra suture material and associated knot tying device/materials
  • Suture cutting scissors
  • Measuring devices
  • Overtube/bougie system

  • Balloon systems
  • Suturing/plication device
  • Balloon catheter device for duodenal ablation (duodenal mucosal resurfacing*)
  • Custom barrier device and anchoring systems (EndoBarrier*)
  • Extra suturing material and associated knot tying device/materials

* See text for manufacturer information.

Bariatric endoscopy procedures

Bariatric endoscopic procedures may be divided into (1) management of post‐bariatric surgical complications, (2) revisional procedures for weight regain, and (3) primary weight loss and metabolic procedures. Endoscopic treatments of postsurgical complications typically require advanced skills with subtle modification of standard methods. Revisional procedures typically require advanced skill sets in combination of learning novel equipment and methods. Primary EBMTs are similar to revisional procedures in terms of skill set required. General skill sets and specific patient population knowledge must be provided by medical societies and fellowship training programs. Evolving device‐specific elements are best addressed by ongoing corporate training programs. It is important to teach not only on how devices work and how to perform procedures but also on how to troubleshoot when unforeseen events occur. This portion of the chapter focuses on some unique elements of this training that are less likely to be covered in a standard industry‐sponsored training program.

Endoscopic management of post‐bariatric surgery complications

Despite satisfactory results of bariatric surgery, a number of complications following bariatric surgeries may occur (Table 23.3) [1]. Several postsurgical complications may be addressed endoscopically. These include leaks or fistulas, stenosis, obstruction, ulcers, and erosion of bands and foreign material. Currently, the standard approach to many of these complications is surgical revision; however, with increasing skills and tools, an endoscopic approach may be preferable. Incidences of the major complications are:

  • Postsurgical leaks in 0.4–5.6% of cases [14]
  • Stenosis in 1.6–31% [5, 6]
  • Ulcers reported as high as 16–20% [7, 8]
  • Band erosion/ring slippage in 0.3–11% [9, 10]

The skills required for procedures that address these complications range from moderate to high (which may be more readily accomplished by operators trained in advanced intraluminal therapeutics).

Table 23.3 Complications after bariatric surgery.

Roux‐en‐Y gastric bypass (RYGB) Sleeve gastrectomy (SG) Laparoscopic adjustable gastric band (LAGB) Vertical banded gastroplasty (VBG)

  • Surgical leaks
  • Marginal ulceration
  • Gastrojejunal anastomotic stenosis
  • Gastrogastric fistula
  • Intestinal obstruction
  • Choledocholithiasis
  • Weight regain

  • Sleeve leaks
  • Sleeve stenosis
  • Reflux and its complications
  • Weight regain

  • Reflux esophagitis
  • Esophageal dilatation
  • Band erosion
  • Band slippage

  • Anastomotic stenosis
  • Band erosion
  • Staple line dehiscence


Leaks are the most common serious adverse event associated with bariatric surgery, with rates varying from 0.4 to 5.6% after Roux‐en‐Y gastric bypass (RYGB) and 1.9–5.3% after laparoscopic sleeve gastrectomy (LSG), with increasing rates after revision surgeries [14]. Leaks are often located at the suture and anastomosis line and are defined as a communication between intra‐ and extraluminal compartments due to a defect in the gastrointestinal (GI) wall. Fistulas usually occur due to an untreated long‐term leak and can be divided into either internal (between an abdominal organ and another organ) or external (extending from an abdominal organ to the skin surface). Chronic fistulas involve an epithelialized tract that is typically surrounded by unhealthy tissue making this one of the most challenging adverse events to treat endoscopically [1, 3].

An upper endoscopy is performed, and suspected sites of leak or fistula are carefully evaluated. Precise diagnosis of the fistula site is essential prior to any therapy. Leak sites are confirmed with methylene blue injection through an existing drain and/or by fluoroscopy using water‐soluble contrast. Understanding the surgical anatomy, post‐procedural complications, and endoscopic techniques for optimal management is essential. In addition to treating the leak or fistula, it is essential to also treat any distal obstruction, either with balloon dilators or luminal stents, and to remove foreign bodies (FBs) from the leak site such as staples, sutures, and external drains that may be close to the defect [1] in order to optimize outcomes.

Leaks after RYGB may appear in several locations such as the gastric pouch, the GJA, and the excluded stomach and occasionally in the blind portion of the Roux limb and the GJA. Leaks after LSG occur along the superior staple line just below the gastroesophageal junction (GEJ). Timing of the leak, as classified in the international consensus, is essential in choosing the appropriate treatment [11]. If the leak is acute (<7 days) or early (<45 days), CSEMS are recommended. CSEMS work by covering the orifice of the leak and also shaping the stomach and treat distal obstruction/stenosis [12]. The overall success rate of CSEMS was 72.8% for LSG leaks and 76.1% for RYGB leaks, with a migration rate of about 30% [13]. Therefore, proximal stent fixation, either with endoscopic suturing or cap‐mounted clips or with the nasal bridle technique, should be considered [1315]. More distal leaks are not good candidates for stent placement and have worse outcomes. In the literature, some case series describe several options for endoscopic treatment of these leaks, including TTSCs, cap‐mounted clips, suturing devices, and tissue sealants [16, 17]. In case of extraluminal collections in early leaks, drainage is needed (surgical, radiological, or endoscopic). During endoscopic internal drainage (EID), it is possible to introduce the endoscope into the cavity to wash the contents, followed by placement of double pigtail stents or endoscopic vacuum therapy (EVT) [12, 18, 19].

In chronic bariatric leaks and leaks with a well‐defined extraluminal cavity, stents are not effective, and therefore EID is indicated, either with pigtails, EVT, or septotomy [18, 20, 21]. Septotomy should only be performed if there is a well‐defined septum between the perigastric cavity and the gastric lumen to allow communication between them [12, 19]. Additionally, the use of a cardiac septal occluder (CSO) showed satisfactory results in the management of chronic fistulas after bariatric surgery [3, 22]. Gastrogastric fistulas can be managed with closure devices, such as endoscopic suturing. However, long‐term outcomes remain suboptimal, especially for fistulas larger than 1 cm [14, 23]. An alternative approach to treat a large gastrogastric fistula in RYGB patients who present with weight regain is to perform endoscopic sleeve gastroplasty (ESG) of the remaining stomach through the fistula [24].

It is important to note that there is not enough data to establish a precise algorithm for post‐bariatric leaks and fistulas. Local expertise should be considered when choosing the best approach. Figure 23.3 shows several endoscopic devices and techniques for the treatment of leaks and fistulas after bariatric surgery.


GJA stenosis following bariatric surgery has been reported to be as high as 31% [5, 6]. Patients usually present with obstructive symptoms especially when the GJA diameter is <10 mm [25]. Endoscopically this can be managed by balloon dilation, injection therapy, or incisional therapy. Therapy should not be performed in the setting of active ulceration. Balloon dilation is the standard approach and is successful in over 95% of cases, often requiring 2–3 sessions [5, 6, 25]. Caution should be made to not overdilate the GJA to greater than 15 m as patients may experience weight gain. Outlets refractory to balloon dilation should be carefully examined for suture material in the adjacent area, as this may prevent balloons from achieving their maximal radial force. If suture material is present, endoscopic shears and forceps may be used for removal. If no extrinsic barriers are present, inflammatory, fibrotic, and postsurgical tissue changes should be considered and potentially addressed using injection therapy with saline or steroids. This potentially breaks up scar tissue and may aid with subsequent dilations. A more invasive approach for stenosis refractory to dilation involves incisional therapy using an electrocautery needle‐knife. This is an advanced technique and is performed by creating short perpendicular linear incisions around the outlet with subsequent dilation [26, 27]. Additionally, lumen‐apposing metal stent has been used in the management of benign strictures, with satisfactory results [28]. Key concepts for the management of outlet stenosis include avoidance of overdilation as this carries an increased risk of perforation and weight regain and careful inspection of the surrounding mucosa for suture material.

Sleeve stenosis is the second most common adverse event following sleeve leaks, with an incidence rate between 0.7 and 4%. Two different entities can cause the obstruction: mechanical stenosis, often in the body of the sleeve, and axial deviation, occurring at the level of the incisura angularis [2, 29, 30]. Clinically, these patients present with obstructive symptoms such as nausea, vomiting, retrosternal burning, epigastric pain, early satiety, and rapid weight loss. To confirm the diagnosis of sleeve stenosis, radiologic imaging and upper endoscopy are essential [29, 30]. Endoscopic management with achalasia balloon dilation (ABD), stent placement, or both can be used, with success rates up to 86.6%. Additionally, a recent technique to treat stenosis after LSG was described by de Moura et al. [2], named endoscopic tunneling stricturotomy. This technique involves advanced endoscopic techniques, including submucosal tunneling, stricturotomy, and suturing.

Image described by caption.

Figure 23.3 1. Closure of esophageal defect using TTSCs. 2. A. Esophageal fistula (arrow), B. closure perforation site with cap‐mounted clip, and C. fluoroscopy demonstrating no leakage after closure. 3. Endoloop technique: A. wall defect, B. TTSC placed with an endoloop at the margin of the defect, C. closing the endoloop approximating the edges of the defect, and D. final aspect of the defect closure. 4. Suturing a defect with endoscopic suture device. 5. CSO sealing a chronic fistula after a LSG. 6. Tissue sealants: cyanoacrylate to closure fistula tract after endoscopic fistula closure. 7. CSEMS covering a LSG fistula. 8. “Septum” between defect and lumen after a LSG. 9. Achalasia balloon dilation after septotomy. 10. EID with double pigtail stents. 11. EVT. 12. A. Granulation tissue in the fistula tract during EVT and B. esophageal scar (arrow) at site of prior fistula, after successful closure with EVT.

Foreign body reaction/pain syndromes

Some RYGB patients present with abdominal pain despite normal upper endoscopy and radiographic studies. In this situation, FB at the GJA should be assessed and removed if present [31]. These procedures are generally performed under light sedation in order to intraoperatively affirm reproducibility of pain symptoms by pulling tension on the FB [32]. FB removal can then be achieved using rat‐tooth forceps and endoscopic scissors through a double‐channel endoscope. Loop cutters may be used for prolene suture removal; however, they should not be used for silk suture as this may become lodged in the loop cutter, making removal difficult. Key to success is elimination of other possible etiologies of abdominal pain prior to endoscopic intervention. Multiple sessions may be required to achieve complete FB removal.

Band erosion/ring slippage

Gastric band erosion is reported in up to 11% of patients with gastric band and may occur at any time after initial surgery [31, 33

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Jul 31, 2022 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Training in Bariatric Endoscopy
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