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Background

Background. Bariatric interventions offer a more efficacious and durable weight loss than non-surgical approaches Surgical weight loss procedures are limited by appeal, availability, cost and short and long term risks

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Background

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  1. Background • Bariatric interventions offer a more efficacious and durable weight loss than non-surgical approaches • Surgical weight loss procedures are limited by appeal, availability, cost and short and long term risks • Endoscopic Sleeve Gastroplasty is an incisionless, minimally invasive technique Treatment Target • Clinically significant improvements in obesity related co-morbidities are higher when %TBWL exceeds 10%. (lifestyle intervention typically results in 3-5% TBWL)

  2. Procedure • ESG reduces the volume of the stomach (~80%) using a series of endoscopic sutures (5- 9x) • The final shape of the stomach resembles a traditional sleeve without the need to amputate the greater curvature, thus less invasive

  3. Patient Selection and Exclusion Recommendations • Age: 18-65+ • BMI: 30-45kg/m2 (BMI is not limited to 45. The IFSO/OSSANZ bariatric guidelines are followed) • Compliant with prescribed diet, aftercare instructions Exclusion Recommendation Family history of Stomach Cancer Hiatus hernia >5cm Previous gastric surgery Gastric ulceration Cirrhosis Pregnancy or plans of pregnancy in the next 12 months Coagulation disorders or chronic use of anticoagulants*** Any active medical condition that would preclude a safe endoscopic suturing repair ***at the discretion of the treating physician

  4. ESG for Obesity: a Multicenter Study of 248 patients with 24-months Follow-Up • Mean age 44y, 73% female. • Baseline BMI 37.8 (+/- 5.6 Kg/m2) Results Weight Loss (%TBWL) 6-months 15.2% (95% CI 14.2- 16.3) 24-months 18.6% (95% CI 15.7- 21.5) Lopez-Nava et al. Obes Surg Apr 2017

  5. Endoscopic Sleeve Gastroplasty; 1-year Follow-Up Results Changes in weight loss post ESG Adverse Events • No major events or bleeding complications • Post discharge pain 50%, and nausea 20% Lopez-Nava et al. End Int 2016

  6. Endoscopic Sleeve Gastroplasty Improvement in Metabolic Syndrome

  7. Endoscopic Sleeve Gastroplasty; 1-year Follow-Up Endoscopic view, 1-year post ESG Barium study, 1-year post ESG. Arrows show suture plications Lopez-Nava End Int 2016

  8. Short term Outcomes of ESG in 1000 consecutive patients A. Alqahtani et al (Suadi) GASTROINTESTINAL ENDOSCOPY in-press, 2019

  9. ESG: Outcome Percentage excess weight loss after ESG N=1000. Mean BMI 33.3 +/- 4.5Kg/m2. Age 34.4 +/-9.5 yr. 89.7% female Operating time 82 +/- 20min (procedure 61 +/- 16min) Mean 4.2 +/- 0.5 sutures

  10. ESG: Metabolic Outcomes N=4 N=14 N=28 N=13 N=18

  11. ESG complications Abdominal pain and nausea 92.4% N=2 required blood t/f

  12. Comparison with Surgical procedures.

  13. Background: ESG vs LSG Laparoscopic sleeve gastrectomy is the most common bariatric procedure; 58.1% of the 216,000 bariatric procedures performed in US 2016 Complication rate 13%, and a 9% re-operation rate Leak rate 1.21%, PE 0.25% Development of GER 21% (conversion surgery in 2.9%).

  14. Results: ESG vs LSG • Subgroup Analysis: (BMI >40Kg/m2 vs BMI<40kg/m2) • BMI >40kg/m2: %TBWL in ESG group remains significantly lower than LSG (coefficient -8.25; p<0.001) • BMI <40Kg/m2: %TBWL in ESG group borderline significantly lower than LSG (coefficient -2.98, p=0.05) V Kumbhari et al. Gastrointest. Endosc. 2018 Aug 24

  15. Results: ESG vs LSG V Kumbhari et al. Gastrointest. Endosc. 2018 Aug 24 Adverse Events ESG significantly lower rate of adverse events than LSG (5.2% vs 16.9%, p<0.05). All ESG patients were discharged on the same day. Re-admission: GI bleeding (2), Perigastric fluid collection (1). All conservative management LSG patients: hypotension (1), transfusion (2), dehydration (1), abdominal pain (2), intractable N&V (3), GI bleed (1), acute pancreatitis (2) New Onset GERD: ESG 1.9%, vs LSG 14.5%, (p<0.05)

  16. Endoscopic Sleeve Gastroplasty • ESG is an effective and durable treatment for weight loss • Weight loss at 2 years ~16-20% TBWL • Lower morbidity than surgical treatments

  17. Conclusions A multidisciplinary and population based approach is required. - Diet, exercise and behavioural management - ?Pharmacologic treatments - Intragastric Balloon: ?long term efficacy - Endoscopic treatment: Endoscopic sleeve gastroplasty vs Surgical treatment

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