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Multiple intraabdominal abscesses after endoluminal bariatric surgery: Case report and literature review
Surgery for Obesity and Related Diseases 10 (2014) e1–e4
Online case report
Multiple intraabdominal abscesses after endoluminal bariatric surgery: Case report and literature review Omer M. Farhan-Alanie, M.B. Ch.B. (Hons)*, Hakim Benyounes, F.R.C.S., Nathan A Stephens, M.R.C.S. Department of General Surgery, Wishaw General Hospital, Wishaw, United Kingdom Received March 27, 2013; accepted May 22, 2013
Keywords:
Bariatric; Intraabdominal abscess; Endoluminal surgery
Current management options for obese patients include lifestyle changes, pharmacologic and behavioral therapies, and bariatric surgery. Although surgery is the only treatment that can provide a dramatic, lasting weight loss in these patients, it is associated with a significant morbidity. The obesity epidemic mostly concerns relatively less obese patients (i.e., body mass index [BMI] 30–35 kg/m2), with or without co-morbidity, who do not meet the current weight criteria for surgical therapy. Because of this, there has been a drive toward less invasive, endoscopic, potentially ambulatory procedures that mimic current mainstream bariatric procedures but with limited associated morbidity. Although there are now longer-term outcome data for many of these procedures, there are still emerging technologies for which there is limited safety and efficacy data. Furthermore, the drive toward “keyhole,” or minimally invasive surgery, has sometimes led to an expectation of “minimal” complications. This, in turn, has meant that invasive procedures have been offered to patients at the lower end of the obesity spectrum who may be better served with conservative measures. Primary obesity surgery endoluminal (POSE) is a restrictive weight loss procedure, which was pioneered in the United States and first carried out in 2009, and has become available throughout the world. It is carried out endoscopically and involves the insertion of 7 endoluminal sutures in the gastric fundus and 3 endoluminal sutures in the gastric *
Correspondence: Omer Farhan-Alanie, M.B., Ch.B. (Hons), Department of General Surgery, Wishaw General Hospital, 50 Netherton Street, Wishaw, ML2 0DP United Kingdom. E-mail: [email protected]
body. We present a case describing intraabdominal abscess after POSE, which highlights the potential for significant morbidity in an otherwise healthy individual. Such information may be useful in counseling this patient group before intervention. (Surg Obes Relat Dis 2014;10:1–4.) © 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. Case report A 51-year-old female underwent the POSE procedure using a tissue anchor delivery catheter, expandable tissue anchors, and a multilumen operating platform. Her BMI at the time of operation was 31 kg/m2, and she was otherwise fit and well. She had a past medical history of hypothyroidism for which she took levothyroxine 50 mg once daily. The procedure was uncomplicated, and she was discharged on the day of surgery. One week postoperatively, she developed dull left upper quadrant abdominal pain, intermittent fever, and rigors. This persisted for 4 weeks before she sought medical advice and was admitted to the department of general surgery at our hospital. Vital signs indicated a tachycardia, pyrexia of 391C, and a normal blood pressure. Abdominal examination showed mild tenderness in the left upper quadrant without any evidence of peritonism or a palpable mass. Routine blood tests found an elevated white cell count (WCC) of 14 109/L and C-reactive protein (CRP) of 214 mg/L. Liver function tests were also abnormal; aspartate aminotransferase (AST), 117 U/L; alanine aminotransferase (ALT), 101 U/L; alkaline phosphatase (ALP), 185 U/L; gamma-glutamyltransferase (GGT), 116 U/L; and bilirubin of 18 μmol/L. A left-sided
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.05.004
e2
O.M. Farhan-Alanie et al. / Surgery for Obesity and Related Diseases 10 (2014) e1–e4
pleural effusion was evident on chest x-ray, but an abdominal x-ray was normal. A diagnosis of intraabdominal sepsis was suspected, and intravenous antibiotics were commenced. A computed tomography (CT) scan of her abdomen and pelvis was performed the next day (Fig. 1). There was evidence of a perisplenic fluid collection (9.5 5 4 cm), multiple intrasplenic lesions, and a large multiloculated abscess in the right lobe of the liver (11 7.5 7.5 cm). Oral contrast showed no evidence of a gastric leak. She underwent a CT-guided insertion of 2 pigtail drains into the liver abscess and perisplenic collection, and the course of intravenous antibiotics was completed. She was discharged from hospital 1 month after admission. A repeat CT scan at discharge (Fig. 2) showed almost complete resolution of the abscesses. She remained clinically well at the follow-up outpatient assessment 4 weeks after discharge. Discussion POSE is a restrictive weight loss surgery procedure that is carried out endoscopically. It is one of a growing number of minimally invasive endoscopic techniques to appear over the past decade in the management of obesity. It is marketed as an ambulatory weight reduction procedure for individuals who do not meet the BMI criteria to qualify for conventional bariatric surgery. There is perhaps a perception among lay people that less “invasive” procedures are associated with better outcomes. The current case study
Fig. 1. Computed tomography of abdomen/pelvis performed on admission shows multiple hepatic and splenic abscesses post–primary obesity surgery endoluminal procedure.
Fig. 2. Computed tomography of abdomen posttreatment shows resolution of hepatic and splenic abscesses; drains visible in situ at time of scan.
highlights the potential for significant morbidity in an otherwise healthy cohort and should be useful in counseling patients before contemplating such surgery. Endoscopic techniques attempt to imitate the therapeutic features of conventional bariatric surgery. As such, the endoscopic weight loss procedures can be divided based on their modality of treatment into restrictive and malabsorptive procedures [1]. The former include intragastric balloon treatment, endoluminal vertical gastroplasty, transoral gastroplasty, and transoral endoscopic restrictive implant system, and the latter include duodenojejunal bypass sleeve. Gastroduodenojejunal bypass sleeve is a combination of both modalities. With the exception of the intragastric balloon, all other procedures are relatively new, with only limited clinical trials. These data tend to highlight a high success rate but with limited knowledge on safety and longterm efficacy. To the best of our knowledge, this represents the first case of multiple intraabdominal abscesses as a result of an endoscopic bariatric procedure. A PubMed search of the available trial data for transoral gastroplasty, of which POSE is one variant, revealed only 5 trials investigating the safety of this procedure (Table 1). These studies are limited by low to moderate patient numbers, variable endoscopic systems, and a lack of control patients, making the safety data challenging to interpret. There also are differences in the exact technique and stapling systems used to achieve gastroplasty, making meta-analysis nonfeasible. Furthermore, POSE uses a tissue anchor delivery catheter with expandable tissue anchors delivered through a multilumen operating platform, which is a stapling system that is different from those used in other studies. Although the POSE procedure has been in use since 2009, the only available data examining this procedure was published by Espinós et al. (2013). The study examines a small cohort of 45 patients, is an observational study with no control group, and provides only 6 months of follow-up data [7].
Complication of POSE Surgery / Surgery for Obesity and Related Diseases 10 (2014) e1–e4
e3
Table 1 Summary of current studies on endoluminal surgical techniques for obesity and reported complications [2–7] Title
Reference Stapling number system
Espinós et al., 45 Obes Surg 2013 Familiari et al., Gastrointest Endosc 2011 Deviere et al., Surg Endosc 2008 Brethauer et al., Surg Obes Relat Dis 2012 Moreno et al., Endoscopy 2008 De Jong et al., Gastrointest Endosc 2010
53
21
18
11
13
POSE
Trial type
Prospective, single-center, single-arm trial TOGA Prospective, multicenter, single-arm trial TOGA Prospective, multicenter, single-arm trial RESTORe Prospective, multicenter, single-arm trial TOGA Prospective, single-center, single-arm trial TERIS Prospective, single-center, single-arm trial
Patient demographic characteristics
Complication rate
34 females, mean age 43.4 (21–64) yr, BMI 36.7 (28.1–46.6) kg/m2 47 females, mean age 41.0 (23–59) yr, BMI 41.5 (35–52.7) kg/m2 17 females, mean age 43.7 (22–57) yr, BMI 43.3 (35– 53) kg/m2 17 females, mean age 40.4 (21–52) yr, BMI 38.6 (31.4–44.3) kg/m2 7 females, mean age 44.2 (26–59) yr, BMI 41.6 (37.2–52.6) kg/m2 10 females, mean age 37.2 ⫾ 7.9 yr, BMI 42.1 (35.5– 49.1) kg/m2
None
3.7% complication rate—respiratory insufficiency and asymptomatic pneumoperitoneum None
None
None
23% complication rate—1 patient developed gastric perforation after stapler malfunction; 2 patients developed asymptomatic pneumoperitoneum
BMI ¼ body mass index.
As these endoluminal procedures are marketed as a safer, effective alternative to conventional bariatric surgery, it is likely that they will attract a greater number of patients. Invariably, this number will include both patients who fall out with guidelines for conventional bariatric procedures and those with co-morbidities that make an endoscopic approach more appealing. However, safety and efficacy data are limited, and there is a pressing need for further studies examining the safety profile of these procedures before they can be adopted and used routinely in clinical practice. Furthermore, with the increasing awareness and need for informed patient consent, the current lack of safety data must be emphasized when these procedures are being considered. To determine whether this procedure is an effective alternative to conventional treatments, further information is required regarding the exact role and the efficacy of these procedures in inducing and maintaining weight loss. There are currently no randomized, controlled trials that compare endoluminal weight loss procedures with either conservative weight loss or conventional bariatric surgery management. Devière et al. (2008) performed a 6month follow-up endoscopy on patients who underwent a transoral gastroplasty using the TOGa system [3] and reported that 61.9% of patients had a gap in their staple line evident. Given that the maximum follow-up data available for these endoscopic procedures is 12 months, their role in long-term weight loss and maintenance remains to be seen. In the current case study, we hypothesize that one of 2 potential pathophysiologic mechanisms led to such a complication. The nature of this procedure requires multiple endoscopic staples to be inserted in an attempt to reduce the
volume of the cardia. This potentially produces a deadspace, which is isolated from the natural propulsive effect of the stomach and can allow bacterial overgrowth. Local ischemia occurs with secondary bacterial translocation, resulting in systemic sepsis. Alternatively, insertion of full-thickness gastric staples carries the risk of peritoneal exposure to gastric contents. Although the relationship between various well-established endoscopic procedures and bacteremia has been studied and antibiotic guidelines published [8], there is no literature surrounding the effects of the more invasive endoscopic bariatric procedures on bacteremia and the potential need for prophylactic antibiotics. This is an issue that needs further consideration. Conclusions This case represents the first published report of multiple intraabdominal abscesses secondary to an endoluminal bariatric procedure. The exact pathophysiologic mechanism of these abscesses is unknown, but we have speculated on the sequence of events. These procedures have limited trial and safety data, and caution should be exercised in using these on patients who do not qualify for conventional bariatric surgery and would normally be treated conservatively. Further large-scale trials are strongly recommended to determine the complication rates of such procedures before they can be safely and knowledgably advocated to patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
e4
O.M. Farhan-Alanie et al. / Surgery for Obesity and Related Diseases 10 (2014) e1–e4
References [1] Blackburn GL. Solutions in weight control: lessons from gastric surgery. Am J Clin Nutr 2005;82(Suppl):S248–52. [2] Familiari P, Costamagna G, Bléro D, et al. Transoral gastroplasty for morbid obesity: a multicenter trial with a 1-year outcome. Gastrointest Endosc 2011;74:1248–58. [3] Devière J, Ojeda Valdes G, Cuevas Herrera L, et al. Safety, feasibility, and weight loss after transoralgastroplasty: first human multicenter study. Surg Endosc 2008;22:589–98. [4] Brethauer SA, Chand B, Schauer PR, Thompson CC. Transoral gastric volume reduction as intervention for weight management: 12-month follow-up of TRIM trial. Surg Obes Relat Dis 2012;8: 296–303.
[5] Moreno C, Closset J, Dugardeyn S, et al. Transoralgastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study. Endoscopy 2008;40:406–13. [6] de Jong K, Mathus-Vliegen EM, Veldhuyzen EA, Eshuis JH, Fockens P. Short-term safety and efficacy of the Trans-oral Endoscopic Restrictive Implant System for the treatment of obesity. Gastrointest Endosc 2010;72:497–504. [7] Espinós JC, Turró R, Mata A, et al. Early Experience with the Incisionless Operating Platform™ (IOP) for the Treatment of Obesity: The Primary Obesity Surgery Endolumenal (POSE) Procedure. Obes Surg Epub 2013 Apr 17. [8] ASGE Standards of Practice Committee, Banerjee S, Shen B, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008;67: 791–8.
Online case report
Multiple intraabdominal abscesses after endoluminal bariatric surgery: Case report and literature review Omer M. Farhan-Alanie, M.B. Ch.B. (Hons)*, Hakim Benyounes, F.R.C.S., Nathan A Stephens, M.R.C.S. Department of General Surgery, Wishaw General Hospital, Wishaw, United Kingdom Received March 27, 2013; accepted May 22, 2013
Keywords:
Bariatric; Intraabdominal abscess; Endoluminal surgery
Current management options for obese patients include lifestyle changes, pharmacologic and behavioral therapies, and bariatric surgery. Although surgery is the only treatment that can provide a dramatic, lasting weight loss in these patients, it is associated with a significant morbidity. The obesity epidemic mostly concerns relatively less obese patients (i.e., body mass index [BMI] 30–35 kg/m2), with or without co-morbidity, who do not meet the current weight criteria for surgical therapy. Because of this, there has been a drive toward less invasive, endoscopic, potentially ambulatory procedures that mimic current mainstream bariatric procedures but with limited associated morbidity. Although there are now longer-term outcome data for many of these procedures, there are still emerging technologies for which there is limited safety and efficacy data. Furthermore, the drive toward “keyhole,” or minimally invasive surgery, has sometimes led to an expectation of “minimal” complications. This, in turn, has meant that invasive procedures have been offered to patients at the lower end of the obesity spectrum who may be better served with conservative measures. Primary obesity surgery endoluminal (POSE) is a restrictive weight loss procedure, which was pioneered in the United States and first carried out in 2009, and has become available throughout the world. It is carried out endoscopically and involves the insertion of 7 endoluminal sutures in the gastric fundus and 3 endoluminal sutures in the gastric *
Correspondence: Omer Farhan-Alanie, M.B., Ch.B. (Hons), Department of General Surgery, Wishaw General Hospital, 50 Netherton Street, Wishaw, ML2 0DP United Kingdom. E-mail: [email protected]
body. We present a case describing intraabdominal abscess after POSE, which highlights the potential for significant morbidity in an otherwise healthy individual. Such information may be useful in counseling this patient group before intervention. (Surg Obes Relat Dis 2014;10:1–4.) © 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved. Case report A 51-year-old female underwent the POSE procedure using a tissue anchor delivery catheter, expandable tissue anchors, and a multilumen operating platform. Her BMI at the time of operation was 31 kg/m2, and she was otherwise fit and well. She had a past medical history of hypothyroidism for which she took levothyroxine 50 mg once daily. The procedure was uncomplicated, and she was discharged on the day of surgery. One week postoperatively, she developed dull left upper quadrant abdominal pain, intermittent fever, and rigors. This persisted for 4 weeks before she sought medical advice and was admitted to the department of general surgery at our hospital. Vital signs indicated a tachycardia, pyrexia of 391C, and a normal blood pressure. Abdominal examination showed mild tenderness in the left upper quadrant without any evidence of peritonism or a palpable mass. Routine blood tests found an elevated white cell count (WCC) of 14 109/L and C-reactive protein (CRP) of 214 mg/L. Liver function tests were also abnormal; aspartate aminotransferase (AST), 117 U/L; alanine aminotransferase (ALT), 101 U/L; alkaline phosphatase (ALP), 185 U/L; gamma-glutamyltransferase (GGT), 116 U/L; and bilirubin of 18 μmol/L. A left-sided
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.05.004
e2
O.M. Farhan-Alanie et al. / Surgery for Obesity and Related Diseases 10 (2014) e1–e4
pleural effusion was evident on chest x-ray, but an abdominal x-ray was normal. A diagnosis of intraabdominal sepsis was suspected, and intravenous antibiotics were commenced. A computed tomography (CT) scan of her abdomen and pelvis was performed the next day (Fig. 1). There was evidence of a perisplenic fluid collection (9.5 5 4 cm), multiple intrasplenic lesions, and a large multiloculated abscess in the right lobe of the liver (11 7.5 7.5 cm). Oral contrast showed no evidence of a gastric leak. She underwent a CT-guided insertion of 2 pigtail drains into the liver abscess and perisplenic collection, and the course of intravenous antibiotics was completed. She was discharged from hospital 1 month after admission. A repeat CT scan at discharge (Fig. 2) showed almost complete resolution of the abscesses. She remained clinically well at the follow-up outpatient assessment 4 weeks after discharge. Discussion POSE is a restrictive weight loss surgery procedure that is carried out endoscopically. It is one of a growing number of minimally invasive endoscopic techniques to appear over the past decade in the management of obesity. It is marketed as an ambulatory weight reduction procedure for individuals who do not meet the BMI criteria to qualify for conventional bariatric surgery. There is perhaps a perception among lay people that less “invasive” procedures are associated with better outcomes. The current case study
Fig. 1. Computed tomography of abdomen/pelvis performed on admission shows multiple hepatic and splenic abscesses post–primary obesity surgery endoluminal procedure.
Fig. 2. Computed tomography of abdomen posttreatment shows resolution of hepatic and splenic abscesses; drains visible in situ at time of scan.
highlights the potential for significant morbidity in an otherwise healthy cohort and should be useful in counseling patients before contemplating such surgery. Endoscopic techniques attempt to imitate the therapeutic features of conventional bariatric surgery. As such, the endoscopic weight loss procedures can be divided based on their modality of treatment into restrictive and malabsorptive procedures [1]. The former include intragastric balloon treatment, endoluminal vertical gastroplasty, transoral gastroplasty, and transoral endoscopic restrictive implant system, and the latter include duodenojejunal bypass sleeve. Gastroduodenojejunal bypass sleeve is a combination of both modalities. With the exception of the intragastric balloon, all other procedures are relatively new, with only limited clinical trials. These data tend to highlight a high success rate but with limited knowledge on safety and longterm efficacy. To the best of our knowledge, this represents the first case of multiple intraabdominal abscesses as a result of an endoscopic bariatric procedure. A PubMed search of the available trial data for transoral gastroplasty, of which POSE is one variant, revealed only 5 trials investigating the safety of this procedure (Table 1). These studies are limited by low to moderate patient numbers, variable endoscopic systems, and a lack of control patients, making the safety data challenging to interpret. There also are differences in the exact technique and stapling systems used to achieve gastroplasty, making meta-analysis nonfeasible. Furthermore, POSE uses a tissue anchor delivery catheter with expandable tissue anchors delivered through a multilumen operating platform, which is a stapling system that is different from those used in other studies. Although the POSE procedure has been in use since 2009, the only available data examining this procedure was published by Espinós et al. (2013). The study examines a small cohort of 45 patients, is an observational study with no control group, and provides only 6 months of follow-up data [7].
Complication of POSE Surgery / Surgery for Obesity and Related Diseases 10 (2014) e1–e4
e3
Table 1 Summary of current studies on endoluminal surgical techniques for obesity and reported complications [2–7] Title
Reference Stapling number system
Espinós et al., 45 Obes Surg 2013 Familiari et al., Gastrointest Endosc 2011 Deviere et al., Surg Endosc 2008 Brethauer et al., Surg Obes Relat Dis 2012 Moreno et al., Endoscopy 2008 De Jong et al., Gastrointest Endosc 2010
53
21
18
11
13
POSE
Trial type
Prospective, single-center, single-arm trial TOGA Prospective, multicenter, single-arm trial TOGA Prospective, multicenter, single-arm trial RESTORe Prospective, multicenter, single-arm trial TOGA Prospective, single-center, single-arm trial TERIS Prospective, single-center, single-arm trial
Patient demographic characteristics
Complication rate
34 females, mean age 43.4 (21–64) yr, BMI 36.7 (28.1–46.6) kg/m2 47 females, mean age 41.0 (23–59) yr, BMI 41.5 (35–52.7) kg/m2 17 females, mean age 43.7 (22–57) yr, BMI 43.3 (35– 53) kg/m2 17 females, mean age 40.4 (21–52) yr, BMI 38.6 (31.4–44.3) kg/m2 7 females, mean age 44.2 (26–59) yr, BMI 41.6 (37.2–52.6) kg/m2 10 females, mean age 37.2 ⫾ 7.9 yr, BMI 42.1 (35.5– 49.1) kg/m2
None
3.7% complication rate—respiratory insufficiency and asymptomatic pneumoperitoneum None
None
None
23% complication rate—1 patient developed gastric perforation after stapler malfunction; 2 patients developed asymptomatic pneumoperitoneum
BMI ¼ body mass index.
As these endoluminal procedures are marketed as a safer, effective alternative to conventional bariatric surgery, it is likely that they will attract a greater number of patients. Invariably, this number will include both patients who fall out with guidelines for conventional bariatric procedures and those with co-morbidities that make an endoscopic approach more appealing. However, safety and efficacy data are limited, and there is a pressing need for further studies examining the safety profile of these procedures before they can be adopted and used routinely in clinical practice. Furthermore, with the increasing awareness and need for informed patient consent, the current lack of safety data must be emphasized when these procedures are being considered. To determine whether this procedure is an effective alternative to conventional treatments, further information is required regarding the exact role and the efficacy of these procedures in inducing and maintaining weight loss. There are currently no randomized, controlled trials that compare endoluminal weight loss procedures with either conservative weight loss or conventional bariatric surgery management. Devière et al. (2008) performed a 6month follow-up endoscopy on patients who underwent a transoral gastroplasty using the TOGa system [3] and reported that 61.9% of patients had a gap in their staple line evident. Given that the maximum follow-up data available for these endoscopic procedures is 12 months, their role in long-term weight loss and maintenance remains to be seen. In the current case study, we hypothesize that one of 2 potential pathophysiologic mechanisms led to such a complication. The nature of this procedure requires multiple endoscopic staples to be inserted in an attempt to reduce the
volume of the cardia. This potentially produces a deadspace, which is isolated from the natural propulsive effect of the stomach and can allow bacterial overgrowth. Local ischemia occurs with secondary bacterial translocation, resulting in systemic sepsis. Alternatively, insertion of full-thickness gastric staples carries the risk of peritoneal exposure to gastric contents. Although the relationship between various well-established endoscopic procedures and bacteremia has been studied and antibiotic guidelines published [8], there is no literature surrounding the effects of the more invasive endoscopic bariatric procedures on bacteremia and the potential need for prophylactic antibiotics. This is an issue that needs further consideration. Conclusions This case represents the first published report of multiple intraabdominal abscesses secondary to an endoluminal bariatric procedure. The exact pathophysiologic mechanism of these abscesses is unknown, but we have speculated on the sequence of events. These procedures have limited trial and safety data, and caution should be exercised in using these on patients who do not qualify for conventional bariatric surgery and would normally be treated conservatively. Further large-scale trials are strongly recommended to determine the complication rates of such procedures before they can be safely and knowledgably advocated to patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article.
e4
O.M. Farhan-Alanie et al. / Surgery for Obesity and Related Diseases 10 (2014) e1–e4
References [1] Blackburn GL. Solutions in weight control: lessons from gastric surgery. Am J Clin Nutr 2005;82(Suppl):S248–52. [2] Familiari P, Costamagna G, Bléro D, et al. Transoral gastroplasty for morbid obesity: a multicenter trial with a 1-year outcome. Gastrointest Endosc 2011;74:1248–58. [3] Devière J, Ojeda Valdes G, Cuevas Herrera L, et al. Safety, feasibility, and weight loss after transoralgastroplasty: first human multicenter study. Surg Endosc 2008;22:589–98. [4] Brethauer SA, Chand B, Schauer PR, Thompson CC. Transoral gastric volume reduction as intervention for weight management: 12-month follow-up of TRIM trial. Surg Obes Relat Dis 2012;8: 296–303.
[5] Moreno C, Closset J, Dugardeyn S, et al. Transoralgastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study. Endoscopy 2008;40:406–13. [6] de Jong K, Mathus-Vliegen EM, Veldhuyzen EA, Eshuis JH, Fockens P. Short-term safety and efficacy of the Trans-oral Endoscopic Restrictive Implant System for the treatment of obesity. Gastrointest Endosc 2010;72:497–504. [7] Espinós JC, Turró R, Mata A, et al. Early Experience with the Incisionless Operating Platform™ (IOP) for the Treatment of Obesity: The Primary Obesity Surgery Endolumenal (POSE) Procedure. Obes Surg Epub 2013 Apr 17. [8] ASGE Standards of Practice Committee, Banerjee S, Shen B, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2008;67: 791–8.