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:
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 )
24-months 18.6% (95% CI )
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%
Variable
1-month
3-months
6-months
12-months
BMI loss (kg/m2)
2.8 +/- 0.8
4.9 +/- 1.6
6.9 +/- 2.9
7.3 +/- 4.2
Total Weight loss
7.9 +/- 2.7
14.1 +/- 5.5
19.6 +/- 9.1
21.1 +/- 12.6
% TBWL
7.4 +/- 2.3
12.9 +/- 4.3
17.8 +/- 7.5
18.7 +/- 10.7
% EBWL
24.0 +/- 11.8
40.5 +/- 16.5
53.9 +/- 24.8
54.6 +/- 31.9
Lopez-Nava et al. End Int 2016

6. Endoscopic Sleeve Gastroplasty Improvement in Metabolic Syndrome
Pre-ESG, mean (SD)
12-month post ESG, mean (SD)
P-value
HbA1C, %
6.6 (1.2)
5.6 (0.5)
0.002
Waist Circ, cm
119.7 (14.1)
92.8 (5.9)
<0.001
SBP, mmHg
129 (13)
122 (13)
0.02
LDL, mmol/L
3.1 (1.0)
3.2 (0.4)
0.79
TG, mmol/L
1.5 (0.9)
1.0 (0.4)
0.017
ALT, iU
32 (16)
20 (11)

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

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 Aug 24  

15. Results: ESG vs LSG 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)
V Kumbhari et al. Gastrointest. Endosc Aug 24

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