Recent Advances in Minimal Access Surgery Subhash Khanna
Page numbers followed by ‘f ’ and ‘t’ indicate figures and tables respectively.
incision 198
middle upper 47
closure 236, 246
compartment syndrome 179
laparoscopic techniques 166
wall 41, 46
injury to 41
transillumination of 47
Abdominoperineal resection 199
Access-related pain 49
Accidental eventuality 210
Adhesion formation, risk of 193
Adipocyte cytokines 123
Adipokines 127
Adipose tissue 127
Alkaline phosphatase 152
American Edwards Laboratories California 3
American Society for Metabolic and Bariatric Surgery 14
American Society of Colon and Rectal Surgeons 190
American Society of Gastrointestinal Endoscopy 1
Amino acid protein 127
Anaglyph filter glasses 58
mechanism of 59f
Anastomosis gastric bypass 146, 148
Anastomotic leakage 193
Anesthesia, extension of 218
Antidiabetic medications 122
Anti-incretin effect 127
Antireflux procedure 37, 105, 112
Antisecretory pharmacologic therapy 92
Anvil into esophagus, insertion of 116
Apollo OverStitch Device 9f, 10f
Appendectomies 54
Arantius ligament 170
ASMBS guidelines on hernia in obese 72
Aspire Assist aspiration device 8f
Assessment, main role of 35
Auditory information 33
Australasian Laparoscopic Colon Cancer Study 189
Autosomal dominant polycystic kidney disease 95
Avascular lateral attachments 191
retrorectal plane 193
Band leakage 137
Bariatric procedures, modalities of 126
Bariatric surgery 1, 37, 70, 123, 148f
effect of 124
in diabetes 122
modalities of 125, 130, 131
prior to hernia repair 71
advantages 70t
disadvantages of 70t
procedures, commonly performed 128
revisions 138
types of 137
esophagus 88
metaplasia 111
Belsey's fundoplication 88
Beta cell function 122
Bile duct stone 152
following lap cholecystectomy 157
fogarty balloon 155, 157
pancreatitis 152
reconstruction 174
sludge and stone 157
sphincterotomy 154
tract malignancy 178, 182
Biliopancreatic diversion 125, 129f, 130, 130, 131
limb 138
Billroth II gastrectomy 158
Binocular cues 58, 58f
Bioenteric intragastric balloon 4
percutaneous 182
under guidance 183
Bipolar devices 21
Blood pressure, elevated 124
hemostat under vision 44f
inline retraction 107
trocar 44f
Body mass index 10, 42, 123, 124, 137
basis of 67
Bolam's test 211
Boston Scientific Corporation 9
Botulinum toxin 110
adherent 41
in a normal location, injury to 41
injuries 40
resection 236
resection and ileal pouch creation 246
Bypass liners 2, 10
malabsorption 130
restriction 126
Calot's triangle 168
Capnothorax 107
Carcinoma breast, mastectomy in 213
Cavitron ultrasonic surgical aspirator 165
Cefoperazone 232
Center for Devices and Radiological Health 48
Cesarean section 213
Chemoradiotherapy 202
Cholangitis 11
incidence of 11
Cholecystectomy 22f, 29
on porcine liver 30
Choledochoscope 21, 156
Chronic kidney disease 81
Chronic obstructive pulmonary disease 81
Clinical Practice Guidelines Committee 190
Clinical risk score system 182
Closed technique See Veress needle technique
Closed-entry technique 48
ability 25
function, combination of 17
skills 29
technical and nontechnical skills 38
training constitutes 17
Colic vessels, right 191f
Collagen production 81
College of American Pathologists 249
Collis gastroplasty 110
Colon cancer
ascending 198
laparoscopic 89
Colon mobilization start-up, right 241f
Colonic neoplasia 228
Colorectal cancer 182, 196
conventional vs laparoscopic-assisted surgery 189
malignancy 178
mobilization 229
resection 193
specimen 229
surgery 37
Common bile duct
exploration 37
stones 219
transcystic exploration of 156
Competency assessment tool 29, 36
Competency-based surgical education 23
Complete mesocolic excision 187, 197, 228
Computer-based simulators 21
Concomitant abdominoplasty 70
Concomitant bariatric surgery 69
Concomitant hernia repair
advantages 70t
disadvantages of 70t
Confidence interval 202
Congress of the German Surgical Society 17
Consumer Protection Act 211
Continuing medical education 18
Controlled radial expansion 155
Conventional 2D laparoscopy 61
mechanism of 57f
parallel edges 55
Coronary ligament 169
Corridor 215
Couinaud's segments 167
Cremaster and hernial sac 80
Criminal medical negligence, complaints of 211
Criminal negligence amounts 210
Critical resource, management of 29
Customer relationship management 200
Cytoreductive surgery 180
Deliberate practice 33
Denonvillier's fascia 243
Dense adhesions 148f
Depth perception, principles of 56
induced mortality 123
remission: bariatric surgery 124
Didactic endoscopic retrograde cholangiopancreatography 20
Didactic module 20
Dietary assessment 138, 147
Difficult bile duct stones, management of 158
gastric pouch 14
gastrojejunal stoma 12
Dilemmas 208
Dingfelder technique, direct trocar insertion 41
Dipeptidyl peptidase 4 122
Direct trocar insertion technique 45
Direct vision entry trocar 51
Discharge/death summary 221
Discount application 225
Disease-free survival 197, 200201
results of local recurrence 198
Distal gastrectomies conventional 119
Distal gastrectomies vagal preservation in 119
Distal gut 131
Distal transverse mesocolon mobilization 239f
Doctors and hospitals 220
Doctrine of consent 215
Dormia basket 157
Dreyfus model of skill acquisition 25
Dumbbell-shaped device 7
Dumping syndrome 14, 150
bulb 11
exclusion 131
mucosal resurfacing 12
switch 129f, 130
ulcer 37
bypass liner 11
nutrients 11
Early gastric cancer, detection of 119
Echogenic serosal layer 106
Educational and training program 33
Elective preoperative ERCP, role for 154
Electrical stimulation 2
Electrosurgery, fundamentals of 21
Elipse balloon 7
Emergency surgery 231
Endobarrier gastrointestinal liner 10
Endocatch bag 116
Endogastric solutions 94f
Endohernia Society 75
classification 82t
recommendations of 83
Endoloop placement 19
bariatric surgery 1
emerging trends and techniques 1
indications 1
procedures 3f
surgery 1
suturing 92
Endoscopic bariatric
devices 2, 21
evaluation 138
gastrostomy, percutaneous 19
jejunostomy, percutaneous 20
retrograde cholangiopancreatography 152
RFe delivery 89
sleeve gastroplasty 8, 9
stone extraction 154
surgery, fundamentals of 20
suturing 14
techniques, number of 138
therapies 21
therapy 14
ultrasound 177
Endoscopist maneuvers 93
Endo-trainers 214
Energy-based devices in pediatric surgery 21
Enhanced recovery after surgery 119, 231
Enoxaparin 232
Entails creating 229
Enteral access 20
Enteroendocrine hormones 122, 130
Enzyme dipeptidyl peptidase IV 126
Epidemic proportions 67
Epigastric vessels 41
Ergonomic restrictions 28
Esogastric junction creating a neostomach 9
cancer 182
dilatation 138
division, level of 116
injuries 107
malignancy 178
perforation 96
wall 105
Esophagectomy 111
Esophagitis 88
Esophagogastrectomy 111
fundoplication 93
junction malignancy 178
Esophagogastroduodenoscopy 20
Esophagojejunal anastomosis 117, 118
Esophyx device 93, 94f
EsophyX2 device 93
European Association for Endoscopic Surgery guidelines 83
Excess weight loss 1, 136, 144, 149
Extracorporeal suturing 19
Extracorporeal tourniquet 161, 162f
Extraparenchymal division 169
Falciform ligament 169, 170
Familial adenomatous polyposis 229, 230, 231f
colonoscopic view of 231
Family counseling sheet 214
attachments 229
degeneration 81
Fasting plasma glucose 124
elevated 124
Fatty tissue surrounding 169
appropriate 34
extrinsic 33
formative 34
frequency of 34
performance 33
summative 34
Female gender 81
Fibroblast proliferation 81
Fine needle aspiration for cytology 177
FLS trainer system 18f
Fluid-filled balloon 4
Fluorodeoxyglucose-positron emission tomography 178
Fluoroscopically guided 157
Foregut hypothesis proposes 127
Foreign body removal 21
Frequency of incisional hernia 161
Function preserving gastrectomies, concept of 119
Fundal wrap, assessment of 105
Fundic wall 9
Gallstones with concomitant bile duct stones 152154
Garren-Edwards gastric bubble 3
Gas embolism 41
artery, left 116f
balloon implantation 71
bypass 139
component 127
Roux-en-Y 128f
cancer 181
risk of developing 113
cardia 113
contents, aspiration of 8
emptying 127
fundal injury 108
lumen 105
malignancies 177, 178
mucosal involvement 177
outlet obstruction 138
stenosis 140
Gastrocolic attachments 191
Gastroduodenojejunal bypass liner sleeve 11
Gastroepiploic vessels 115
Gastroesophageal junction 89, 117f
level of 9
Gastroesophageal reflux disease 104
causes of mortality 108
complications and failures 104
endoscopic versus surgical procedures for 88
endotherapy for failed fundoplication 109
evaluation 105
dynamic contrast imaging 106
endoscopic ultrasound 105
endoscopy 105
impedance 106
magnetic resonance imaging 106
of surgery for 104
description of 108
gastroparesis 109
intraoperative complications 107
esophageal injuries 107
other injuries 108
management options for complications 104
postoperative complications 108
severe 137
surgery for failed fundoplication 110
Gastrogastric fistulae 138
fundoplication 93
Gastrograffin swallow 147
Gastrointestinal barium studies 137
Gastrointestinal endoscopy
lower 20
upper 20
Gastrojejunostomy 146
Gastropancreatic masses 46
Gentle retraction 117
Gerota fascia 192
Ghrelin concentration 127
Global assessment forms, using of 30
Global Assessment of Gastrointestinal Endoscopic Skills 36
Global assessment of skills 36
Global Operative Assessment of Laparoscopic Skills 35
Global rating skills 35
Glucagon-like peptide 1 122
Glucose-dependent insulinotropic polypeptide 126
Glycemic control 11
postbariatric surgery 125
postbariatric surgery, mechanism of 126
Glycemic status 12
Granulation tissue production 81
Greater curvature, mobilization of 115
Greater omental attachment 193
Groin hernia, diagnosis of 68
Gynecological malignancy 178, 182
Hand-assisted approach 171
google patients 220
instruments 17
Haptic feedback 33
Hasson technique 179
advantages 44
complications 44
limitations 44
overview of 43
Healthcare, safety of 38
Health-related quality of life 91
Hemi-hepatectomy 160
Hemostasis 20
branch of vagus 108
flexure retrocolic mobilization 241f
lobectomy, left 172
metastasis, detecting of 181
pedicle 168, 170
Hepatobiliary surgery 37, 160
Hepatocellular carcinoma 164
Hepatorenal ligament 169
connective tissue disorders 81
nonpolyposis cancer 230
after ileostomy reversal 198
in obesity
epidemiology of 68
pathogenesis of 67
recent guidelines 67
what to treat first 70
repair in obese complications of 69
repair options 69
bariatric surgery with 69
laparoscopic approach 69
open repair 69
size of 79
surgery in obese, algorithm for 71
Herniasurge group, levels of risk factors 81
HHL (Berlin), mechanism of display 61f
Hiatal dissection 116
Hiatal hernia 96
repair of 88
High density lipoprotein 124
High intraperitoneal pressure entry 50
High vascular capture 230
High-resolution manometry 105
Hilar plate 170
Hindgut hypothesis assumes 127
Homemade single-port device 172f
Hospital violence 221
Human vision 55
Hybrid Nissen 110
Hydrophilic guidewire 155
Hypercapnia 179
Hyperglycemia 123
Hyperglycemic status 124
Hyperinsulinemia 123
Hyperthermic intraperitoneal chemotherapy 179, 180f
Hypogastric plexus, superior 244
Hypoproteinemia 81
Hysterectomies 55
Hysterectomy 213
anal pouch anastomosis, completed 248f
anal stapled anastomosis 248f
J-pouch creation 247f
pouch creation 236
pedicle 190, 191
vasculature, high-transection of 241f
vessels 191f
Ileostomy 246
Iliac port
left 235
right 235
Incisional hernia 193, 200
after colorectal cancer surgery 203t
in laparoscopy vs open colorectal cancer surgery 197
primary, recurrent 67
repair 37, 68
Incisionless operating platform 9
hormone function 127
secreting cells 127
Infection 79
Inflammatory bowel disease 229
Infradiaphragmatic wrap 109
eventration 82
hernia repair 37
Inpatient department 212
Intact specimen, safe extraction of 230
Intensified depth perception 55
Intensive care unit 178, 215
Intercostal space CO2 insufflation, ninth or tenth 47
Internal herniation 130
International Diabetes Federation 123, 124t
International Federation for the Surgery of Obesity 138
International Index of Erectile Function 199
International Prostate Symptom Score 199
Intestinal mucosa, cellular level 128
Intestines, division of 192
abscess 150, 193
aspect 41
pressure 67
anastomosis 246
suturing 19
Intragastric balloon, option of 4f
hemorrhage 41
laparoscopic access techniques 40
Investigational devices and modalities 11
Jaundice 81
obstructive 152
Jejunal limb 118
Jejunojejunostomy 146
Jejunum limb 130
Judgment, error of 210
Kugel meshes 84
rendezvous procedure 158
single site 171
alternative access sites 46
choice of technique 48
injuries types of 41t
primary 41
radially expanding access system 45
sites of entry 45
techniques for 41
adjustable gastric banding 135, 146
appendectomy 64, 213
approach 219
biopsy 182
bowel grasper and purse-string suture 118f
cart 233
cholecystectomy 54, 64, 155156, 213
colon resection 185
cancer surgery 228
resection long-term, results of 196
surgery short-term, advantages of 196
common bile duct exploration 156
ductal exploration 157
current perspectives of 40
in high-risk patients 49
sites of 46
technique 51
fundoplication 104
gastrectomies 113
gynecologic surgeon 213
hysterectomy 64
in oncological sciences
contraindications 179
diagnostic accuracy of the procedure 181
indications 178
recent advances role of 177
technique 178
incisional 70
inguinal hernia repair 83
inappropriate fixation 79
incomplete dissection 79
recurrence after 79
left colectomy, technique of 192
left hepatectomy 171f
left lateral hepatectomy 162f
liver resection 173
liver surgery 160
major hepatectomy 174
Nissen fundoplication 64
ovarian cystectomy 64
ports and liver retractor placement 115f
primary access procedures 40
procedures 18, 19, 40, 50
proctocolectomy 229
aim 230
anesthesia 233
contraindications 231
triple-track technique for
indications 230
operative theater setup 232
patient position 233
patient preparation 231
port strategy 235
position of the surgical team 234
rationale for 228
stages of the operation 236
technical summary 229
repair of recurrent inguinal hernia 83
resection in rectal cancer 199
resection of colorectal cancer 196
right hepatectomy 168f, 170f, 190
Roux-en-Y gastric bypass 139
segment 1 hepatectomy, port positioning 167f
simulators 20
skills gradation of 23
sleeve gastrectomy 64, 135
splenectomy 64
surgery for
colon cancer 202t
colorectal cancer 196, 200
data analysis 197
methodology 196
review 196
fundamentals of 1820
safe performance of 51
3-D visualization technology for 54
surgical techniques, development of 185
total proctocolectomy 250
totally extraperitoneal 64
toupet fundoplication 107
training, basic 33
transabdominal preperitoneal 64
triple-track technique 250
ultrasonography 177, 179
uro-surgeon 213
vagal sparing total gastrectomy 113
operative technique 113114
patient selection 113
postoperative course 119
ventral hernioplasty 64
vs open colorectal surgery, trials on 188t
vs open surgery, comparison of 197
vs robot-assisted 199
Large hiatal hernia 88
Latif's point 47
Law collagen 81
Lax capsules, tightening of 89
Leaving against medical advice cases 222
Lee-Huang point 47, 49, 50
Legal and ethical issues 208
Legal defense
good 212
poor 212
Life, cost and quality of 186
Ligasure and clip application 192
LINX device 96, 97f, 98f
LINX reflux, management system 96
augments 99
current evidence 97
procedure 96
recommendation 98
Lipoma 80, 85
disease 113
malignancy 178
metastases, superficial 182
parenchyma, bridge of 162
Lower anterior resection syndrome 199, 202
Low-molecular-weight heparin 232
Lymph node
intermediate 230
metastases 181
Lymphoma 178, 182
Magnetic resonance imaging 21
Magnetic sphincter augmentation using linx device 89
Major blood vessels, injury to 41
Malabsorptive procedure 137
primary 138
Malabsorptive segment, correction of 138
Mallory-Weiss tear 3
Malnutrition 81
Mass practice for skills acquisition 34
Matrix metalloproteinase 81
McGill inanimate system 18, 35
Medial recurrent hernia 80
Medical Council of India 213
Medical litigations 211
Medical negligence 209
Medical practice 213
continuity of care in 211
Medical records 211
good 212
poor 212
cases 211
problems 208
Medigus Ultrasonic Surgical Endostapler 93
Mesenchymal metabolic defects 81
Mesenteric artery
inferior 192, 229, 238f
superior 229
Mesenteric vein, inferior 193, 229
Mesh 80
Mesh fixation in laparoscopic approach 85, 86f
Mesh infection, risk of 69
disorders 138
syndrome 124
disease 177
low risk of developing 119
Methylene blue dye 149
Metronidazole 232
Microwave energy systems 21
Midclavicular lines 114
Minilaparotomy 236
and specimen extraction 246
Minimal access
advantages of 186
colorectal surgery, complications of 193
hepatectomy, technique of 160
proctocolectomy 228
surgery 28
basic and advanced to specialty procedures 28
benefits to patients 55
benefits to surgeons 55
monocular aspects 55
program grades 2932, 36, 37
prospective randomized controlled study 54
subjects and methods 54
surgeons medicolegal dilemmas for 208
3D vision vs 2D vision in 54
training and assessment path in 28
surgical skills 17
optimal training technique 17
surgical training 25
Minimally invasive
colorectal surgery 185
early short-term 186
conventional open surgery oncological 186
hernia repair to prevent recurrence, important points for 85
liver surgery benefits 161
surgery 187
surgical trainer 22
vs conventional open surgery, advantages of 185
Missed hernias 80
Mobile omentum 228
Monitor display systems 54
cues 58
vision 56f
Monofilament suture, absorbable 119
Monopolar devices 21
Motion parallex, size constancy 59f
Motivation 33
Mucosal inspection 21
Mucosal lacerations 92
Multifocal intramucosal cancer 113
Multimodality venous thromboembolism 232
Multiple small tumor nodules, confluence of 179
Multirecurrent hernias 82
Multisegmental colorectal resections 228
Myocardial infarction 70
Myopectineal orifice 76
anterior view 78f
posterior view 78f
Nathanson liver retractor 114
National Accreditation Board for Hospitals and Healthcare 212
National Commission 219
National Consumer Disputes Redressal Commission 210
Natural Orifice Transluminal Endoscopic Surgery 1
Neomycin, consisting of 232
Nephrectomy 213
Neuronal signaling 122
Newer minimally invasive techniques 187
Nichols-Condon bowel preparation 232
Nissen fundoplication 55, 93, 88, 105
Nodal resection 115
Noncommunicable disease, chronic 135
Nonsite specific studies, results of 201t
Nonsteroidal anti-inflammatory drugs 130
Nontechnical skills training 37
Nontraumatic forceps 157
Nonverbal communication supplemented 214
Nutritional deficiency, severe 137
Nyhus classification 82, 82t
Nylon tape encircling 117
Obalon gastric balloon 6
Obesity 1, 67, 135
conducted to manage 122
dependent diabetes 122
related comorbidities 123
surgery endoluminal, primary 8
Observational Clinical Human Reliability Analysis 36
Oncological resection 229
Online consultations 219
Online e-learning portal, using 29
Open technique See Hasson technique
Operating room 240f
related factors 79
stages of 236
diagnostic laparoscopy 236
left-track stage 236
pelvic-track stage 240
right-trac stage 237
Operative room 244f
Orbera intragastric balloon 5f
OTSC clips for revision bariatric surgery 13f
Outpatient department records 212
Ovarian cystectomies 55
Palmer's point 46, 4950
Pancreatic and periampullary carcinoma 181
malignancy 178
Paracolic lymph nodes 230
Parastomal hernia 37
probability of 68
Parenchymal transection 170
Parietal hematoma 41
Partial resection of posterosuperior segments 160
Patient communication 214
chart 215, 223
Patient controlled analgesia 119
Pelvic dissection
anterior 245
posterior 244
Pelvic fascia 243
Penrose drain wrap 107
Peptide YY 127
Peristomal granulation 8
cancer index 179, 180f
carcinomatosis management of 180
cavity 44f
metastasis 182
Pfannenstiel laparotomy incision 163
Pigtail plastic stent 155
Plausible solutions 111
Pneumoperitoneum 40, 161, 179
creation of 114
facilitates 169
Polarization of light, mechanism of 62f
Polarizing filters 58
Polymer pill 7
Polyposis syndromes 229
Porcine liver 29
Port placement for left hemicolectomy 190f, 192f
Port positioning 164f
segmentectomy 166f
Port strategy 235f
Pose device 10f
procedure 9
Positron emission tomography 113, 177
Postfundoplication gastroparesis 109
Postlaparoscopic adjustable gastric banding 139, 144
Postsleeve gastrectomy 140
Postvertical gastric banding 140
Potential life-threatening complications 152
Pouch dilatation 137
distribution 34
variability 35
Practicing physicians 25
Preperitoneal space, dissection of 86
Pringle maneuver 161, 162
Procedure-based assessment 24
Proctectomy prograde 229
indemnity insurance 211
jurisdiction 213
Proficiency-based curricula 35
Prolene hernia system 84
Prostate ablation benign prostate hyperplasia 89
Proton pump inhibitor 88
advent of 104
Prototype from philips, mechanism of 62f
Proximal enteric vasculature 229
Psychological evaluation 138
Psychomotor skills 17
automating 17
programmed 17
assessment 29
Pulmonary complication 108
Pure laparoscopic
anterior liver segments resection 163
approach 161
left lateral sectionectomy 161
major hepatectomy 167
posterior-superior liver segments resection 165
segmentectomy I 166
Pyloric antrum 9
Quadrant, left upper 46
ablation 12
energy with endoscopy 89
for soft tissue ablation 21
Radiological assessment 138
Recirculating hot water balloons 12
Rectal cancer 199
compression of result 200f
Rectum proximally 229
Recurrence after hernia repair, etiology of 79
Recurrence in laparoscopic inguinal hernia repair, causes of 80t
Recurrence of large hernias, incidence of 79
Recurrence-free survival 197
hernia 68
classified 82
incidence of 81
management of 83
inguinal hernia
anterior surgical approach 76f
for laparoscopic repair 84
minimal access surgery in 75
myopectineal orifice 77f
posterior surgical approach 77f
problems with laparoscopic repair 84
recurrence statistics 75
surgical anatomy 76
Redo surgery 110
principles of 110
role of resectional procedures 111
role of surgery for failed 111
Referral summary 222
Reflux symptoms 88
Reinhold criteria for predicting 136
cell carcinoma 182
malignancy 178
Reoperative bariatric surgery 144
complications 150
indications 144
morbidity rate of 145
preoperative evaluation 147
dietary assessment 147
documentation 147
imaging studies 147
technical intraoperative factors 147
types of 145, 146t
Resected specimen, examination of 248
Resection, lower anterior 197, 202
Reshape duo: fluid-filled dual balloon 5
procedures 8
vs malabsorptive procedures 147
Retinal disparity 58
Retrocolic mesenteric defect 119
Retroflexion technique 105
hemorrhage 41
space, injury to 41
structure 229
tumors 179
Revision bariatric surgery 141
Revisional surgery, principles of 138
Revita device for mucosal resurfacing 12f
Robot-assisted laparoscopic
liver resection 174
major hepatectomy 173f
approaches 250
liver resection 173
surgery 37
Roticulator stapler 169
Roux limb 128, 130
Roux-en-Y gastric bypass 69, 110, 125, 128, 135, 146
primary versus revision 139
jejunal loop, construction of 117
Roux-en-Y procedure 111
Roux-en-Y rescue procedure 135, 139
indications for reoperation 135
patient evaluation 137
Sacral promontory 244
Safe access techniques 40
Safeguarding quality 38
Safety tests 42
SAGES university master's program 25
Scissural vein 163
Sclerotherapy for Roux-en-Y stoma 13f
Screen-detected diabetes 122
Sectionectomy 160
Sedation and analgesia 20
Seereal technologies 61
Segmentectomy 160
Serosafuse fasteners 93
Serum glutamic
oxaloacetic transaminase 152
pyruvic transaminase 152
Sexual and urinary complications 204
Sham procedure 91
Shielded trocars 50
Shutter glasses 60
advantage 60
disadvantage 61
cancer 199
colectomy 229
mesocolon 192, 237f
resection 192
Signet-ring cell gastric carcinoma 177
Sine-wave energy 89
Single session procedures 154
Single-port laparoscopic surgery 187
acquisition, leading to enhanced 35
laboratory 33
Sleep apnea, obstructive 140
Sleeve gastrectomy 9, 55, 125, 129f, 130, 144, 146
mechanism of action of 130
with duodenojejunal bypass 146
Sleeve stenosis, case of 148f
Sliding hernia, presence of 81
Slippage 138
Slipped stomach 109
Small bowel diverting therapies 10
Small gastric pouch restricts 130
Smoking and chronic cough 81
Society for American Gastrointestinal and Endoscopic Surgeons 92, 250-251
Solid visceval space-occupying lesion 183
Space-occupying devices 2
Spatz adjustable balloon 6
Spatz balloon 6f
Specimen extraction 236
Spectrum of issues 208
Sphincter function, results of 202t
Splenectomy 37, 55
Splenic flexure, mobilization of 193
Standalone procedure 14
Standard operating procedures 210
Staple line disruption 137
State commission dismissed 219
Stereopsis 55, 56
Stereoscopic in 3D 55
Stereoscopic view in 3D vision, mechanism of 57f
Stimulate angiogenesis 81
and division of duodenum 115
specimen retrieval of 118f
marginal ulceration 130
ulcer 138
Stretta 89
device 89
procedure 90, 91f
to laparoscopic fundoplication 91
Stylet-fastener assembly 93
port, left 235
colectomy 228
Subxiphisternal port, right 235
Subxiphoid 172
Sugarbaker technique 180
Supracolic compartment 117
Supradiaphragmatic herniation 109
Supradiaphragmatic slip of stomach 109
Suprapubic port 235
Supreme Court of India 210
energy program, fundamental use of 21
energy, fundamental use of 21
knots 17
rehearsal 22
site infection 81
site infections, increased risk for 67
skills, acquisition of 17
skills, nontechnical 29
technical skills 29
technique for
left hepatectomy 169
right hepatectomy 168
Suture material 79
Symptomatic cholelithiasis 152
Synchronous cancers 230
Task complexity, increasing level of 35
Task difficulty 35
Teaching methods, variety of 25
Technical skills
acquisition of 34
feedback 33
Tension 79
Terminal ileum 247f
Thigh-length antiembolic stockings 232
Thoracic surgery 37
Thoracoscopic surgery 54
camera final view of object 63
mechanism of 63f
view with two cameras 63f
work 61
high definition system 64
laparoscopic surgery 187
Time taken: various procedures 64t
Tissue removal 20
Total laparoscopic hysterectomy 213
Total mesorectal excision 202
concept of 187
Total proctocolectomy
specimen 249t
triple track-technique for 250f
Totally extraperitoneal vs transabdominal preperitoneal 84
Training proficiency-based 34
Training sessions 34
Trans cul-de-sac CO2 insufflation 47
individualized levator transection 199
preperitoneal 54
Transanal minimally invasive surgery 187
Transcystic exploration 154
Transductal exploration 154
endoscopy 21
procedures 1
Transient lower esophageal sphincter 88
Transillumination of anterior abdominal wall 48f
Transoral incisionless fundoplication 89, 92
esophyx device 93
procedure 95f
Transpyloric shuttle 7, 7f
Transumbilical 45
incision 198
Transuterine insufflation 47
Transverse colon cancer 197
Trendelenburg position 114, 114f, 234
Triglycerides, elevated 124
Tubular fluoropolymer sleeve device 11
dimension 231
invading surrounding structures 231
rupture of 230
Turnbull “no-touch” technique 230
Twin session therapy 154
Ulcerative colitis 229
Ultrasonic energy devices 21
hernia surgery 70
tube 44f
wound 119
Umbilicus 45
Union for International Cancer Control 196
United States Food and Drug Administration 89
Unresectable disease 181
and sexual complications 199
bladder 41, 232
tract infection 108
Urological malignancy 182
US Preventive Services Task Force 49
Vagal nerve injury 109
Vagal preservation
advantages of 120
important role in 120
Vagal trunk 120
anterior 116
posterior 115
Vascular injury 41
VBLAST system 24f
Vena cava, inferior 162
Ventral hernia 67, 68
Ventral hernioplasties 55
Veress intraperitoneal pressure 42
Veress needle technique 4142, 48, 179
angle of insertion 42
complications 43
high-pressure entry 42
modifications 43
number of veress needle insertions attempts 43
overview of 42
safety tests 42
Vergence 56
banded gastroplasty 137
gastric banding 135
Very-low-calorie diets 71
Vessels of the abdominal wall, injury to 41
Video recording
communication of 218
factum of 218
procedures of 218
Virtual simulators 21
fat 68
injury 41
Vitamin deficiencies 81
Weight loss 139
inadequate 136, 144
options prior to hernia surgery 70
procedures 135, 136t
Weight regain 136, 139, 145
revisional therapies 12
Wide stoma 137
Will of God 215
Will-power of the patient 215
Wolff-Parkinson-White syndrome 89
cellularity 81
infection 108, 193
Z-line based 90
Chapter Notes

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Endoluminal Bariatric Surgery: Emerging Trends and TechniquesCHAPTER 1

Subhash Khanna
Bariatric surgery is the most effective treatment for obesity, but it is cost-prohibitive on both national and individual scale. Access to this surgery is thus limited as only few centers and surgeons are doing this surgery on a regular basis, and less than 1% of the eligible population receives bariatric surgery as the rest cannot afford the expensive treatment and also do not come forward as they fear an irreversible procedure. In the last decade, endoscopic therapies for obesity have emerged as an alternative to bariatric surgery particularly after the advent of natural orifice transluminal endoscopic surgery (NOTES). Some of these new treatment modalities have also received the Food and Drug Administration (FDA) approval. Endoluminal surgery by definition is a surgery that requires placement or removal of some device in the stomach and bowel with the help of a flexible endoscope for the management of weight loss or treatment of glucose intolerance. There are issues in operating an obese patient and that include a high incidence of morbidity and up to 2% mortality which is not acceptable. Patient may want nonsurgical and reversible therapy and that in bariatric surgery is not possible. Surgeons at many a times are at a crossroad in a very high-risk patient as he is not able to answer whether it is worth taking so much risk and many times he ends up with excess weight loss (EWL) or malnutrition. Thus, an alternate procedure was always needed that would offer more durable weight loss compared to diet and pharmacotherapy alone but less invasive than the bariatric surgical interventions and endoluminal bariatric surgery has emerged as an alternative therapy of choice for such patients both as primary and secondary therapy of obesity.
Although the endoluminal and transgastric procedures in the treatment of obesity are still in its infancy, but will eventually provide valuable approaches to various group of patients with more effectiveness compared to lifestyle modifications alone or medications.1 The American Society of Gastrointestinal Endoscopy (ASGE) in its recent position statement has also endorsed that endoluminal bariatric therapy in conjunction with multidisciplinary weight loss program may be accepted for long-term weight treatment.2
Presently, the endoscopic bariatric procedures are being used in one of the following indications where it has shown beneficial results:2
  • An early pre-emptive intervention in patients who are in early stage of obesity and do not qualify for bariatric surgery
  • Bridge therapy to reduce operative risk for various bariatric and nonbariatric surgeries in a severely obese patient
  • Primary metabolic treatment, these procedures focus on treating the co-morbid conditions associated with obesity
  • Primary bariatric treatment in the traditional surgical group and with efficacy and result that may match the conventional bariatric surgery
  • Finally, endoluminal therapy probably would be used most commonly in revisional surgery for patient regaining weight after bariatric surgery.
The endoluminal devices and therapies presently being used differ significantly in size, shape, duration of use, and also on their mechanism of producing the desired effect. Most of the devices are based on the same principles, aims, and objectives that are followed in bariatric surgery to achieve the desired results. The main mechanisms by which these devices become effective are by delaying gastric emptying, reducing the gastric volume, by various types of restrictive procedures to prevent absorption of nutrients, and finally by inducing malabsorption with endoscopic bypass, a mechanism similar to Roux-en-Y bypass surgery.
The endoscopic treatment options that are currently most popular can be divided into following categories with various newer procedures that are being added to this list of procedures (Figs. 1A to D).
  • Space occupying devices: Intragastric balloon (IGB) and similar other device working on the principle of IGB
  • Restrictive procedures: Various types of endoscopic suturing and stapling procedures attempting to restrict the food intake by reducing the capacity and size of stomach
  • Bypass liners
  • Electrical stimulation
  • Aspiration therapy
  • Newer emerging therapies.
Although most of the endoscopically placed devices and procedures seem to be temporary, some of these are also permanent and irreversible.
Space-occupying Devices
The idea of using an endoscopically placed intragastric device for control of obesity was first described in 1982 and since then various devices have been tested to achieve weight reduction in obese patients.35The intragastric devices are based on the physiology of reducing the intragastric capacity and in addition to mechanical restriction, reduction in hunger due to hormonal modulation also leads to decreased energy intake.6 One more mechanism of action of these IGBs is to alter gastric motility and delaying gastric emptying.3
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Figs. 1A to D: Various common endoluminal procedures.
Randomized control trial of IGB has demonstrated an increase in retained gastric contents 2 hours after radiological meal ingestion in the balloon group compared with a control group 8 weeks after IGB placement.7 The Garren-Edwards Gastric Bubble (GERB), was approved for use by FDA in 1985 as an adjunct to diet, exercise, and behavioral therapy.
The GERB (American Edwards Laboratories California) was a polyurethane cylindrical device, with a removable air insufflation catheter. The Garren-Edwards balloon was used in United States till 1988 but controlled studies subsequently reported that it was not successful in inducing more weight loss than diet or behavioral modification alone.8 Moreover, several complications were reported that included gastric erosions, gastric ulcers, small bowel obstruction, Mallory-Weiss tear, and esophageal laceration.9 The Garren-Edwards balloon was later discontinued and is no longer used.
Several modifications of such balloons were used in subsequent years. It was presumed that the small volume of air used in bubble was responsible for failure to achieve the desired results, and material used in the balloons was the causative factor for the complications. The Taylor IGB (Dunlop Limited, England) and the Ballobes IGB (DOT ABS, Denmark) were later attempted endoscopically; while the Taylor balloon was inflated with 4550 mL of saline, the Ballobes balloon was inflated with approximately 475 mL of atmospheric air.
In the recent past, many newer versions of the balloons have emerged and have gained popularity as most of these are based on the fundamental design criteria laid down by 75 international experts in 1987 in Tarpon Springs.10 Three IGBs, the Orbera (Apollo Endosurgery Austin, Tx), the ReShape Integrated Dual Balloon System (ReShape Medical, San Clemente, CA), and the Obalon (Obalon Therapeutics, Carlsbad, CA) have been approved for use in United States by the US FDA (Fig. 2), and two more, the Spatz Balloon (Spatz FGIA, Great Neck, NY) and Elipse Balloon (Allurion Technologies, Wellesley, MA) are in the process of getting FDA approval.
Fluid-filled Single Balloons
These IGBs are fluid-filled balloon made of silicone and sit in stomach like a bezoar. As per FDA recommendation, it is required to remove the balloons after 6 months of implantation.11 The balloons are mostly single spherical or ovular shape that can typically be filled with saline from 500 mL to 750 mL (range 250–950 mL) and of the dual balloon each balloon can be filled up to 450 mL (Fig. 2).
The most widely used fluid filled balloon is Orbera, which was originally known as Bioenteric Intragastric Balloon (BIB, Allergen, Irving, California) (Fig. 3).
The balloon is deployed into the stomach either under conscious sedation or short general anesthesia. A predeployment upper gastrointestinal (GI) endoscopy is mandatory to rule out neoplasia, gastric or esophageal lesions and ulcers, previous gastric surgery, and large hiatal hernia before placing the balloon. The deflated balloon is properly lubricated and passed into the stomach alongside a standard upper endoscope or it can also be introduced directly along with the filling catheter down the esophagus into the stomach. Once inside the stomach, its position is verified endoscopically and thereafter it is filled with the desired amount of normal saline, usually 400–700 mL, with 2–10 mL of methylene blue solution added.
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Fig. 2: Available option of intragastric balloon.
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Fig. 3: Orbera intragastric balloon deployed in stomach.
In case of accidental rupture of balloon, the methylene blue gets absorbed and excreted in urine giving a greenish blue color to the urine.12 Majority of recent studies have found gastric balloon to be well tolerated and effective with very minimal side effects. Minor complications include nausea, vomiting, and pain in the first 72 hours but mostly resolve spontaneously. The more serious complications although rare include esophagogastric erosions and gastric ulcer,13 device rupture, and migration causing bowel obstruction and perforation which can be life-threatening.14
Most of the studies have found an EWL at the time of device removal in the range of 30–50%,15 but there are few studies that have reported weight regain on a long-term follow up after balloon removal.16
There had been attempts at placing successive balloons but the FDA has not approved such placement of successive implants.
Reshape Duo: Fluid-filled Dual Balloon
The Reshape procedure involves placing two intragastric equal sized silicon balloons that are attached to each other by a flexible tube (Reshape Medical Inc, San Clemente, CA). The two balloons can hold a combined 900 mL of saline and are placed endoscopically like the Orbera balloon but has an added advantage of protection against migration in the case of accidental deflation or rupture of one of the balloons.
Results of the largest randomized trial involving 326 patients, the REDUCE Pivotal Trial, where the device was removed at 24 weeks, have been very encouraging with a mean % EWL of 25.1% versus 11.3% in the sham group.17 The major complications observed in this trial was gastric ulcer (35%) even in 6patients who were on proton pump inhibitors followed by the device deflation that occurred in 6% of patients but no report of any migration.
The Spatz Adjustable Balloon
To avoid the undesirable complications of nausea and vomiting, an adjustable fluid-filled balloon Spatz (Spatz Medical, Great Neck, New York) has been introduced but presently we have limited data available on its safety and efficacy. The balloon is placed endoscopically but needs to be fixed to the tip of the scope and has an inflation tube attached to it that remains in the stomach and with the help of the tube, the balloon volume can be adjusted after taking the tube out endoscopically. The adjustable tube also helps easy withdrawal of the balloon when required. Although the balloon is not FDA approved, it is approved for use in Europe (Fig. 4). Results of one of the big study involving 73 patients has shown an EWL of 45.7% with reports of three cases needing surgical extraction of migrated and impacted inflation catheter.18 The balloon is designed to be kept in place for 12 months.
Obalon: Gas-filled Balloon
This is the first version of swallowable implantations device apart from the introduction of polymer pill. The Obalon Gastric balloon (OGB), Obalon Therapeutics, Carlsbad, California, comes as a gelatin capsule that can be swallowed and the capsule has a thin attached catheter that extrudes out of mouth to help inflate the balloon with nitrogen gas with the help of an inflation device. Although the balloon has a capacity of about 250 mL but up to three balloons placement have been reported in the literature with the balloon being removed endoscopically at 12 weeks. In the pilot study in Europe involving 17 patients, an EWL of 36% has been reported with no reported complications.19
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Fig. 4: Spatz balloon with adjustable tube.
Self-degradable Balloon Elipse
The Elipse balloon (Alturion Technologies, Wellesley, Massachusetts) is made of a thin film and is enclosed within a capsule. The capsule is swallowed under guidance of image intensifier and once it is in the stomach it can be distended up to 550 mL with a thin cord that is attached to the balloon. The balloon life is approximately 4 months and thereafter it ruptures on its own, gets completely deflated and passes down the GI tract. In a pilot study conducted on 8 patients, an EWL of 12.4% was observed.20
Polymer Pill
The polymer pill developed by BaroNova Therapeutics, Inc (Foster city, California) also works on the principle of space occupying devices. The pill is ingested or may also be delivered endoscopically and expands, and takes up the space in the stomach. It degrades and passes spontaneously after a week. The pill can be taken regularly and even the intervals can be titrated depending on the response.21
Transpyloric Shuttle and SatiSphere
The transpyloric shuttle (TPS BaroNova Inc, Goleta, California), a dumbbell-shaped device consists of one larger ball of 56 mm diameter connected to a smaller cylindrical bulb. The device is placed endoscopically over a tube and once developed the smaller sphere having weight enters the duodenal bulb and the larger bulb gets pulled causing intermittent obstruction and thus delaying gastric emptying. While the new generation TPS are under randomized trial in United States, the previous study involving 20 participants have shown good results with 25% EWL at 3 months and 41% at 6 months of the device placement.22 A device called SatiSphere that works on the principle of delaying the transit of food both in the distal stomach and the duodenum has multiple mesh spheres that are attached to a wire that is passed into the duodenum endoscopically (Fig. 5).
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Fig. 5: Transpyloric shuttle.
Aspiration Therapy
The aspiration of gastric contents with the help of a specially designed gastrostomy tube called A-tube and the Aspire Assist device (Aspire Bariatrics, King of Prussia, Pennsylvania) is based on the principle of removing 30% of each meal approximately 20 minutes after consumption of the meal (Fig. 6). The technique although surgical is simple like percutaneous gastrostomy and is FDA approved as it has been reported to be safe with minimum morbidity and complication with results of mean EWL of 40.8 % + 19.8% in two large series.23,24
The technique of placement of A-tube is similar to percutaneous endoscopic gastrostomy and on an average 80% of the weight loss could be achieved in the series mentioned here but the patient was advised to take food slowly and chew it properly and was also advised to take sufficient water with meals.
The most common and minor complication reported in the US pivotal trial included peristomal granulation tissue formation and irritation, nausea, abdominal pain, and bacterial and fungal infection of the A-tube.25
These procedures are mostly based on the principle of modifying gastric anatomy and achieving the low volume stomach by endoscopic means and thus doing gastroplasty endoscopically. The two procedures that are more popular and currently being used are primary obesity surgery endoluminal (POSE) that uses a device called incision less. Operating platform (USGI Medical, San Clemente, CA) and the endoscopic sleeve gastroplasty (ESG) are done with a device called Apollo OverStitch (Apollo Endosurgery, Austin, Texas). Both the devices are FDA approved. There are various other devices and techniques that are also being used to achieve restriction of food intake but are not very popular with less favorable outcome and these are transoral gastroplasty using the TOGA system (Satiety Inc, Palo Alto, CA) and articulating circular endoscopic (ACE) stapling procedure.
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Fig. 6: The Aspire Assist aspiration device.
9Whereas the TOGA system uses a device to suck tissue in the jaw and place full thickness staples along the lesser curvature of the stomach like vertical banded gastroplasty, the ACE stapler uses an endoscopic ACE stapler (Boston Scientific Corporation; Natick, MA) and as the stapler has complete retroflexion movement it is used to create eight plications in the fundus and two in the pyloric antrum to create gastroplasty and small stomach.
Endoscopic Sleeve Gastroplasty
The Apollo OverStitch is a double channel device and is FDA approved for tissue apposition and is used to place full thickness stitches along the greater curvature of stomach to achieve the shape and size of the stomach similar to sleeve gastrectomy (Fig. 7). The device is fixed to the end of the endoscope and has a curved needle driver to take sutures. With the help of device, closely placed sutures are placed from the pyloric antrum to the esogastric junction creating a neostomach (Fig. 8). One of the largest published series has reported a total body weight loss of 16.2% + 0.7%.26
Pose Procedure
A specially designed device, the Incisionless Operating Platform is used to create 8 or 10 full thickness plications in the fundus of the stomach. The device is a 54 Fr flexible tube having a control handle similar to an endoscope and can be maneuvered in various directions. With the help of an ultra slim scope passed through one of the four channels of the device, the visualization is achieved. The other channels are used to insert the special instruments for grasping (G-Lix) the fundic wall and for placing the tissue anchors (Fig. 9).
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Fig. 7: The Apollo OverStitch device with the endogastroplasty stomach.
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Fig. 8: The Apollo OverStitch device with the suturing needle and anchor release device.
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Fig. 9: The POSE device with four channels and tissue anchor placement.
Usually, two rows of plication anchors are needed to bring the whole fundus down to the level of gastroesophageal junction to achieve the desired results.27,28 The procedure has undergone a randomized controlled trial in the United States in patients with body mass index (BMI) between 30 kg/m2 and 34.9 kg/m2 and the procedure success rate reported was 99.5% with total weight loss reported to be 4.94% + 7.04% in the active subjects.29
A wide variety of prosthetic devices and incisionless anastomotic procedures have been developed and some of such products are also under development. The bypass liners are various types of tubular prosthesis mostly used to prevent nutrient absorption. Although EndoBarrier gastrointestinal liner is 11still considered a procedure under investigation but has the great potential for treatment of types 2 diabetes, obese people at risk of diabetes, and also a bridge therapy for patients with severe weight problems.
Duodenojejunal Bypass Liner
EndoBarrier (GI Dynamics, Inc, Lexington, MA) is a device made of ultrathin flexible Teflon Sleeve of 65 cm length that is anchored to the duodenal bulb with a barbed nitinol crown. This extends for about 60 cm into the small bowel and is deployed for duration of 6 months. The sleeve allows food to bypass the duodenum and proximal part of jejunum. The liner is deployed endoscopically in the jejunum with the help of a catheter and self-expanding anchor that gets fixed to the pylorus with 10 sharp barbs projecting from the nitinol crown.
The exclusion of the duodenojejunal nutrients due to the biliary and pancreatic juices flowing outside the sleeve and mixing with chyme only in the distal jejunum is the main mechanism of improvement of glycemic control in patient with diabetes and also weight loss. Over the years, the device is more commonly being used as an endoscopic metabolic procedure rather than a purely bariatric procedure.
The efficacy of gastroduodenal barrier sleeve has been studied extensively and various studies have mentioned the extra weight loss in the range of 30–40%. Although GI bleedings obstruction and pain abdomen has been reported, even serious complications like esophageal perforation and cholangitis are also reported.30 This incidence of cholangitis leading to development of liver abscess was the reason that the multicenter randomized trial in the United States, the ENDO trial, had to be stopped.30
Gastroduodenojejunal Bypass Liner
The gastroduodenojejunal bypass liner sleeve (Valen Tx Endoluminal Bypass, Valen Tx Inc, Hopkins, MN) is yet another tubular fluoropolymer sleeve device that is deployed by a hybrid technique utilizing both endoscopy and laparoscopy. The device is 120 cm long and extends from the stomach to the jejunum and thus stomach, duodenum, and proximal jejunum are bypassed.
There is very few data available in the literature about the efficacy of the sleeve and the only pilot study that involved 12 subjects and lasting 1 year, although reported an EWL of 35.9% but also reported device removal in 2 cases and in 4 out of the 12 candidates the device was seen to be partially detached making it less effective.31
Incisionless magnetic compression anastomosis with the extensive use of magnets in endosurgical techniques, the new techniques of creating magnetic compression anastomosis with the help of endoscopically deployed octagonal magnets (IAS, GI Windows, Boston) have been developed and gastrojejunostomy and gastroileostomy are now feasible with these devices. In this technique, the two octagonal endoscopically placed smart magnets 12get self assembled and the magnetic compression between the two magnetic rings create a large opening by necrosis of the intervening tissue.32 It is believed that the early entry of nutrients in terminal ileum shall induce the ileal break phenomenon which will induce food intake and improve the glycemic status.33
Duodenal Mucosal Resurfacing
Duodenal mucosal resurfacing (Fractyl Laboratories, Cambridge, MA) utilizes a device called Revita that is used initially to lift the duodenal mucosa with saline followed by radiofrequency ablation (Fig. 10) of the mucosa below the level of ampulla of vater.
Apart from the radiofrequency ablation, recirculating hot water balloons have also been used,34 with the objective of destroying the diseased duodenal mucosa and it is hypothesized that the re-epithelized normal mucosa shall result in improving the glycemic status of the patient due to enteroendocrine changes in the re-epithelized cells.
Revisional Therapies after Weight Regain
Various newer endoscopic revisional therapies are proposed for weight regain after Roux-en-Y bypass and other bariatric procedures. Most of those are based on the anatomical factors of weight regain although the genetic, behavioral, and physiological factors need to be ruled out. The anatomical factors commonly attributed to such weight regain are dilated pouch, dilated stoma, fistula to gastric remnant, and short Roux loop.
The common procedures proposed and being performed for stoma narrowing with proven technical feasibility and safety are sclerotherapy (Fig. 11), Endoclinch, Apollo Over Stitch, and very recent one, the OTSC clips.35 In one of the largest study, 94 patients with dilated gastrojejunal stoma with mean stoma diameter of 35 mm, the stoma could be reduced to 8 mm after OTSC clips (80% reduction), and at the end of 1 year, the mean BMI dropped from 45.8 to 27.4 (Fig. 12).36
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Fig. 10: The Revita device for mucosal resurfacing.
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Figs. 11A to D: Sclerotherapy for Roux-en-Y stoma narrowing.
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Fig. 12: The OTSC clips for revision bariatric surgery.
14Endoscopic suturing for late dumping syndrome for dilated gastric pouch is feasible and safe and has been studied extensively and one of the recent study encompassing 14 patients who underwent this, in 13 of the 14 patients no dumping was observed after 1 month of endoluminal surgery.37
Endoscopic bariatric therapy is a comparatively new technique and technology in the hand of an endosurgeon. Although more than four devices and procedures have received FDA approval for use in the United States, there are various other newer versions of those devices that are undergoing randomized controlled trials to develop and mimic a procedure that mimics a bariatric surgical procedure and gives similar outcome. The ASGE and the American Society for Metabolic and Bariatric Surgery (ASMBS) has given guidelines for newer novel procedures before considering those procedures for clinical use.
The two main criteria of this threshold are that the device associated risk and complication should not exceed 5% and the EWL of 25% must be achievable at the end of 12 months.38 One more observation about the endoscopic procedures is that the results and weight loss achieved may be temporary and transient and thus most of these procedures cannot be recommended as a standalone procedure and must be considered along with a multimodal regimen.
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