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Sa2014 Endoscopic Sleeve Gastroplasty: The Learning Curve
Abstracts
Sa2014 Endoscopic Sleeve Gastroplasty: The Learning Curve Christine Hill*2, Mohamad H. El Zein1, Abhishek Agnihotri3, Margo K. Dunlap1, Alison Agrawal1, Sindhu Barola1, Saowonee Ngamruengphong1, Yen-I. Chen1, Mouen A. Khashab1, Vivek Kumbhari1 1 Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD; 2Diversity Summer Internship Program, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; 3 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD Background: Endoscopic sleeve gastroplasty (ESG) is gaining traction as an alternative to the intragastric balloon for the minimally invasive treatment of obesity. Successful implementation of ESG has been reported in a small number of recent publications with promising outcomes. However, one of the main barriers, even amongst those who are proficient with endoscopic suturing for other indications, is a concern that the learning curve for performing ESG is slow. For the dissemination of any endoscopic therapy (including ESG), the procedure must be effective, safe, and able to be performed by a large number of providers. An analysis of the learning curve for ESG has yet to be performed. Aims: To define the learning curve for ESG by a single therapeutic endoscopist experienced in endoscopic suturing who underwent a one-day ESG training program. Methods: Consecutive patients who underwent ESG by a single endoscopist between February 2016 and November 2016 were included. After endoscopist achieved proficiency in endoscopic suturing for non-ESG procedures, they underwent ESG training which consisted of a half-day didactic session followed by one proctored ESG in a porcine explant stomach. The ESG program was then commenced at their institution. The outcome measurements were length of procedure (LOP) and number of plications per procedure. Nonlinear regression was used to determine the ESG learning plateau (theoretical best outcome a clinician could achieve with infinite practice) and calculate the learning rate (number of trials required to reach 90% of potential). Results: Twenty-one consecutive patients (8 males), with a mean age of 47.711.2 years, and a mean BMI of 41.88.5 kg/m2, underwent ESG. The median length of procedure (LOP) was 105 minutes (range 63-220), with a significant decrease in LOP over the course of consecutive procedures. The learning plateau was determined at 101.5 minutes, with a learning rate of 7 cases (pZ0.04) (Fig. 1). The number of plications performed per procedure also decreased significantly across consecutive procedures, with a plateau at 8 sutures and a learning rate of 9 cases (p<0.001) (Fig. 2). Of the 21 patients that underwent ESG, 4 were lost to follow-up. 30-day post-procedure followup data done on the remaining 17 patients showed a mean reduction in BMI of 3.41.3 kg/m2 (p<0.001) and a mean excess weight loss of 24.98.5 lbs (p<0.001). One adverse event of moderate severity was noted. This patient suffered peri-gastric fluid collection, which was responsive to antibiotics. Conclusions: Endoscopists with prior experience in endoscopic suturing are expected to achieve a reduction in both LOP and number of plications per procedure in successive cases, with progress reaching a plateau at 7 and 9 cases, respectively. The the learning curve is rapid which would facilitate it’s dissemination.
Figure 2: Number of plications per procedure significantly decreased over the course of consecutive endoscopic sleeve gastroplasty procedures, with a learning plateau at 8 sutures and a learning rate of 9 cases.
Sa2015 Analysis of Endoscopic Stent as Therapy for Leak After Gastric Bypass Josemberg M. Campos*1, Flávio C. Ferreira1, Helga C. Alhinho1, Lyz B. Silva1, Eduardo S. Godoy1, Delgis A. Martinez1, Cinthia B. Andrade1, Milton I. Tube1, Joana C. Silva1, Alvaro A. Ferraz1, Manoel Galvao Neto2 1 General Surgery Service, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; 2Gastro Obeso Center, São Paulo, São Paulo, Brazil Introduction: Gastric leak is one of the most serious complications after bariatric surgery, associated with high morbidity and mortality. It can be treated by support intervention, endoscopy, and/or surgery. Stent is one option of endoscopic treatment, with good results despite the fact that stent models are not developed to surgical anatomy. This study aims to evaluate therapeutic aspects of endoscopic stenting of leaks after Roux en Y gastric bypass, the association between time of healing and early use of stent, and to identify benefits of early use and removal of stents. Methods: Retrospective study of 103 patients with leaks after bariatric surgery. Eighteen of these patients received treatment for leak after Roux en Y gastric bypass through endoscopic stenting, between 2002 and 2015. Results: Twenty-two stents were used and remained on site for 31,714,7 days. Average age was 39,72 years (31-57) and Body Mass Index of 42,79 Kg/m2 (35,33-62,24). Time between fistula and stenting had a median of 22,927,0 days while the time of fistula diagnosis was 6,33,9 days after surgery. Stents used were self-expandable plastic stents (61,9%), fully covered self-expandable metallic stents (23,8%) and partially covered (14,3%), with 27,7% migration rate. Conclusions: Endoscopic treatment with stenting of fistulas after Roux en Y gastric bypass is feasible and safe, with global success of 94,4%. Shorter healing time was observed in patients that received early stents and had leaks under 10mm of diameter.
Sa2016 Intragastric Balloon Intolerance: A Retrospective Review of 100 Patients Treated With Two Different Devices Trace Curry*, Tracy Pitt JourneyLite of Cincinnati, Cincinnati, OH
Figure 1: Total procedure time significantly decreased over the course of consecutive endoscopic sleeve gastroplasty procedures, with a learning plateau at 101.5 minutes and a learning rate of 7 cases.
www.giejournal.org
Background: The ReShapeÒ and OrberaÒ intragastric balloons (IGBs) are safe and effective nonsurgical treatments for obesity introduced last year in the United States. Accommodative symptoms post-implantation may occur, reducing patient satisfaction and leading in some cases to early removal. We report on the tolerability of IGBs in 100 patients (the first 50 Orbera and the first 50 ReShape) from our bariatric practice. Methods: Standard preoperative screening and clinical assessments were followed by the outpatient endoscopic placement of the balloons. Routine pretreatment included famotidine (100%), hyoscyamine (98%), ondansetron (97%) and promethazine (91%). A progressive diet and monthly follow-up visits were scheduled, and the devices were retrieved endoscopically after 6 months. Data
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB277
Sa2014 Endoscopic Sleeve Gastroplasty: The Learning Curve Christine Hill*2, Mohamad H. El Zein1, Abhishek Agnihotri3, Margo K. Dunlap1, Alison Agrawal1, Sindhu Barola1, Saowonee Ngamruengphong1, Yen-I. Chen1, Mouen A. Khashab1, Vivek Kumbhari1 1 Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD; 2Diversity Summer Internship Program, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; 3 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD Background: Endoscopic sleeve gastroplasty (ESG) is gaining traction as an alternative to the intragastric balloon for the minimally invasive treatment of obesity. Successful implementation of ESG has been reported in a small number of recent publications with promising outcomes. However, one of the main barriers, even amongst those who are proficient with endoscopic suturing for other indications, is a concern that the learning curve for performing ESG is slow. For the dissemination of any endoscopic therapy (including ESG), the procedure must be effective, safe, and able to be performed by a large number of providers. An analysis of the learning curve for ESG has yet to be performed. Aims: To define the learning curve for ESG by a single therapeutic endoscopist experienced in endoscopic suturing who underwent a one-day ESG training program. Methods: Consecutive patients who underwent ESG by a single endoscopist between February 2016 and November 2016 were included. After endoscopist achieved proficiency in endoscopic suturing for non-ESG procedures, they underwent ESG training which consisted of a half-day didactic session followed by one proctored ESG in a porcine explant stomach. The ESG program was then commenced at their institution. The outcome measurements were length of procedure (LOP) and number of plications per procedure. Nonlinear regression was used to determine the ESG learning plateau (theoretical best outcome a clinician could achieve with infinite practice) and calculate the learning rate (number of trials required to reach 90% of potential). Results: Twenty-one consecutive patients (8 males), with a mean age of 47.711.2 years, and a mean BMI of 41.88.5 kg/m2, underwent ESG. The median length of procedure (LOP) was 105 minutes (range 63-220), with a significant decrease in LOP over the course of consecutive procedures. The learning plateau was determined at 101.5 minutes, with a learning rate of 7 cases (pZ0.04) (Fig. 1). The number of plications performed per procedure also decreased significantly across consecutive procedures, with a plateau at 8 sutures and a learning rate of 9 cases (p<0.001) (Fig. 2). Of the 21 patients that underwent ESG, 4 were lost to follow-up. 30-day post-procedure followup data done on the remaining 17 patients showed a mean reduction in BMI of 3.41.3 kg/m2 (p<0.001) and a mean excess weight loss of 24.98.5 lbs (p<0.001). One adverse event of moderate severity was noted. This patient suffered peri-gastric fluid collection, which was responsive to antibiotics. Conclusions: Endoscopists with prior experience in endoscopic suturing are expected to achieve a reduction in both LOP and number of plications per procedure in successive cases, with progress reaching a plateau at 7 and 9 cases, respectively. The the learning curve is rapid which would facilitate it’s dissemination.
Figure 2: Number of plications per procedure significantly decreased over the course of consecutive endoscopic sleeve gastroplasty procedures, with a learning plateau at 8 sutures and a learning rate of 9 cases.
Sa2015 Analysis of Endoscopic Stent as Therapy for Leak After Gastric Bypass Josemberg M. Campos*1, Flávio C. Ferreira1, Helga C. Alhinho1, Lyz B. Silva1, Eduardo S. Godoy1, Delgis A. Martinez1, Cinthia B. Andrade1, Milton I. Tube1, Joana C. Silva1, Alvaro A. Ferraz1, Manoel Galvao Neto2 1 General Surgery Service, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; 2Gastro Obeso Center, São Paulo, São Paulo, Brazil Introduction: Gastric leak is one of the most serious complications after bariatric surgery, associated with high morbidity and mortality. It can be treated by support intervention, endoscopy, and/or surgery. Stent is one option of endoscopic treatment, with good results despite the fact that stent models are not developed to surgical anatomy. This study aims to evaluate therapeutic aspects of endoscopic stenting of leaks after Roux en Y gastric bypass, the association between time of healing and early use of stent, and to identify benefits of early use and removal of stents. Methods: Retrospective study of 103 patients with leaks after bariatric surgery. Eighteen of these patients received treatment for leak after Roux en Y gastric bypass through endoscopic stenting, between 2002 and 2015. Results: Twenty-two stents were used and remained on site for 31,714,7 days. Average age was 39,72 years (31-57) and Body Mass Index of 42,79 Kg/m2 (35,33-62,24). Time between fistula and stenting had a median of 22,927,0 days while the time of fistula diagnosis was 6,33,9 days after surgery. Stents used were self-expandable plastic stents (61,9%), fully covered self-expandable metallic stents (23,8%) and partially covered (14,3%), with 27,7% migration rate. Conclusions: Endoscopic treatment with stenting of fistulas after Roux en Y gastric bypass is feasible and safe, with global success of 94,4%. Shorter healing time was observed in patients that received early stents and had leaks under 10mm of diameter.
Sa2016 Intragastric Balloon Intolerance: A Retrospective Review of 100 Patients Treated With Two Different Devices Trace Curry*, Tracy Pitt JourneyLite of Cincinnati, Cincinnati, OH
Figure 1: Total procedure time significantly decreased over the course of consecutive endoscopic sleeve gastroplasty procedures, with a learning plateau at 101.5 minutes and a learning rate of 7 cases.
www.giejournal.org
Background: The ReShapeÒ and OrberaÒ intragastric balloons (IGBs) are safe and effective nonsurgical treatments for obesity introduced last year in the United States. Accommodative symptoms post-implantation may occur, reducing patient satisfaction and leading in some cases to early removal. We report on the tolerability of IGBs in 100 patients (the first 50 Orbera and the first 50 ReShape) from our bariatric practice. Methods: Standard preoperative screening and clinical assessments were followed by the outpatient endoscopic placement of the balloons. Routine pretreatment included famotidine (100%), hyoscyamine (98%), ondansetron (97%) and promethazine (91%). A progressive diet and monthly follow-up visits were scheduled, and the devices were retrieved endoscopically after 6 months. Data
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB277