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

2. Disclosures
Occasional consultant for ETHICON ENDOSURGERY

3. 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

4. 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

5. 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)

6. 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 mm diameter

7. 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

8. Endoscopic options when bariatric surgery fails (3)

9. The Montpellier Protocol
Multicenter study in France
74 patients,
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

10. 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

11. 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

12. 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

13. Endoplication: Apollo System13

14. Endoplication: USGI System

15. The metabolic asset, Sleeve Endobarrier

16. Additional bets? ASPIRE System

17. Surgical options when bariatric endoscopy fails

18. Surgical options when bariatric endoscopy fails

19. 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

20. 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

21. Plication

22. Laparoscopic Gastric Vertical Plication (Talebpour)

23. 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.

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