Jerome DARGENT, Lyon (France) Endoscopic bariatric techniques as a re-do Bariatric surgery as a re-do after endoscopic techniques Jerome DARGENT, Lyon (France)

Disclosures Occasional consultant for ETHICON ENDOSURGERY

Background (1) Endoscopic techniques may solve problems after bariatric surgery, with new possibilities On the other hand, new endoscopic bariatric options come up… but may fail in the short or mid-term. Bariatric re-do surgery after bariatric endoscopy is a new strategy that needs to be addressed

Background (2): A focus on new bariatric technologies New technologies are most often criticized owing to insufficient long-term weight loss… although they may be repeated upon demand Should we redefine patient access to a bariatric techniques according to different weight loss patterns? Caution is recommended in both directions

Endoscopic options when bariatric surgery fails (1) Early and late post-operative complications: stenosis, ulcers, leaks… Stents, Pigtail drainage, clips (Ovesco) Particular use of stitching material for chronic leak/fistula (e.g. gastro-gastric after bypass)

Endoscopic options when bariatric surgery fails (2) Late revision for weight-regain Overstitch/POSE: pouch reduction/ anastomosis restriction Literature: good results, +/- 30% EWL Discussion: size of the anastomosis matters more than pouch size, the goal beeing a 10-12 mm diameter

Endoscopic options when bariatric surgery fails (3): literature Incisionless revision of post-RYBGP stomal and pouch dilatation: multicenter registry results, Horgan, SOARD 2010 Endocinch restore Trial, Thompson 2013 Double-blind, 50 pts Vs 27 sham, WL 15.9 vs 7.7 kg Meta-analysis, Am J Gastroenter 2015 APC: Argon Plasma Coagulation

Endoscopic options when bariatric surgery fails (3)

The Montpellier Protocol Multicenter study in France 74 patients, 2014-2017 7 centers; goal: 25%EWL at 2 years (15% at 1 year) Randomized Control Trial/ crossover at 1 year for sham pts 2 perforations of GJ anastomosis in on center

Other bariatric interventions? Laser and injections at the level of GI anatomosis/sclerotherapies failed Other plicating/stapling devices… on hold! Gastric tubes? Injections at the GE level? Alternative surgical options: pouch reduction +/- banding/ bilio-pancreatic diversion or lengthening of the alimentary limb

Bariatric surgical options when bariatric endoscopy fails (1) Balloons/different types (gastric size may be important) Primary OVERSTITCH and POSE In the future: any kind of endo-plicating/stapling device EndoBARRIER Endo-Aspire, i.e. gastrostomy

New balloons: THE ELIPSE™ is swallowed and naturally excreted Same proven mechanism of action as endoscopically-administered IGBs Made entirely from thin, flexible materials intended to avoid GI tract obstruction (<10% compressed volume of BIB) Provided to patients in a capsule for easy swallowing Swallowed and filled during a 20 minute, in-office procedure without anesthesia or sedation Release valve opens at 3-months allowing immediate device drainage and natural passage at home; lost to follow up not a concern 12

Endoplication: Apollo System 13

Endoplication: USGI System

The metabolic asset, Sleeve Endobarrier

Additional bets? ASPIRE System

Surgical options when bariatric endoscopy fails

Surgical options when bariatric endoscopy fails

Bariatric surgical options when bariatric endoscopy fails (2) Caution: pre-operative endoscopic assessment/removal of endoscopic material (e.g. stitches) Time interval>2 years Sleeve and bypass Similar issue: greater curve plication

A particular issue: Laparoscopic plication Vs Endoscopic plication Similar issue Tissue thickness, risk of leak/bleeding Same precautions for a re-do Does endoscopic plication match lap-plication

Plication

Laparoscopic Gastric Vertical Plication (Talebpour)

A compromise for a reasonable WL profile A compromise for a reasonable WL profile? American Society for Gastrointestinal Endoscopy Endoscopic bariatric therapies offer a viable, safe alternative for patients who have been unsuccessful at weight loss with diet and exercise. They may also be appropriate for patients who are not suitable for, or are unwilling to undergo a more invasive surgical procedure. Preservation and Incorporation of Valuable endoscopic Innovations (PIVI): Excess weight Loss (EWL) of more than 25%, Total Body Weight Loss (TBWL) >5%, with a difference of more than 15% than the control group, less than 5% Severe Adverse Events (SAE); significant impact on at least one obesity related comorbidity.

Lyon (France) April 21-22, 2017: 3rd joint symposium (VIth International symposium on non invasive bariatric techniques) 24 24