Endoscopic management of obesity: Impact of endoscopic sleeve gastroplasty on weight loss and co-morbidities at six months and one year.

INTRODUCTION: Endoscopic sleeve gastroplasty (ESG) is one of the new minimally invasive endoscopic treatments aimed at inducing weight loss. Its effectiveness in terms of weight loss is proven. Gastric volume reduction and delayed gastric emptying are the mechanisms that drive weight loss. However, potential benefits for co-morbidities in relation to weight loss after ESG are still being investigated. This study aims to evaluate the effect of ESG procedures on major obesity-associated co-morbidities, and on some biological parameters. PATIENTS AND METHODS: This is a series of consecutive cases from a prospective observational study carried out in a specialized center that follows a standardized care pathway for the multimodal management of obesity. Patients who have undergone ESG with endoscopic and laboratory follow-up at six and twelve months after this intervention were included in the study. Prospectively recorded data on weight loss, co-morbidities and laboratory parameters at six and twelve months after surgery was analyzed retrospectively. Changes in body mass index (BMI), absolute weight loss (AWL), percent of excess weight loss (%EWL) and percent total weight loss (%TWL) were assessed at six and twelve months. Reduction in various obesity-related co-morbidities (arterial hypertension [AHT], type 2 diabetes mellitus [T2DM], gastroesophageal reflux disease [GERD], obstructive sleep apnea syndrome [OSAS] and dyslipidemia was also evaluated at six and twelve months. Changes in blood glucose, liver function tests and lipid blood tests were also analyzed at six and twelve months. RESULTS: From October 2016 to July 2021, 99 of the 227 patients who underwent ESG in our unit (43.6%) subsequently underwent a complete endoscopic and laboratory follow-up at six and twelve months. The initial BMI was 42.7±7.8kg/m2 and age was 45±12.7 years. Seventy-four patients (74.8%) were female. Total weight loss (%TWL) and excess weight loss (%EWL) were 16.6±7.4% and 43.3±21.2%, respectively, at six months, 16.6±9.6% and 42.9±25.6%, respectively, at one year. At six and twelve month follow-up, a statistically significant reduction was observed for the rates of T2DM (30.8 and 32.7%), hypertension (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). A statistically significant difference was found in the reduction in blood glucose between the pre-operative period and six months post-operatively (P<0.01) and between the pre-operative period and twelve months post-operatively (P<0.01). The reduction in triglycerides and total cholesterol between the pre-operative values and at six months was statistically significant (P<0.01) as was the reduction at twelve months (P<0.01) (P=0.017). For liver function tests, the reduction in AST was statistically significant at six and twelve months after ESG (P=0.048) (P=0.048) as was ALT (P<0.01) (P<0.01) respectively. From October 2016 to July 2021, of the 227 patients who underwent ESG, 99 (43.6%) had follow-up gastro-duodenoscopy at 6 and 12 months. %TWL and %EWL were respectively 16.6±7.4% and 43.3%±21.2 at 6 months, 16.6±9.6% and 42.9±25.6% at one year. Statistically significant reduction rates at 6 and 12 months were observed in T2DM (30.8 and 32.7%), AHT (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). Moreover, glycemic levels were statistically significantly reduced between the pre-operative period and 6 months post-operative (1.11±0.22mg/L vs. 1.01±0.17mg/L, P<0.01), and between the pre-operative period and 12 months post-operative (1.11±0.22mg/L vs. 1.06±0.32mg/L, P<0.01). A statistically significant reduction was also observed in triglycerides and total cholesterol levels at 6 months (1.52±0.74mmol/L vs. 1.14±0.52mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.85±0.36mmol/L, P<0.01) and at 12 months (1.52±0.74mmol/L vs. 1.18±0.67mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.82±0.39mmol/L, P=0.017) and in AST (27.2±11.7 IU/L vs. 23.7 IU/L; P=0.048) (27.2±11.7 IU/L vs. 24.7±14.65 IU/L, P=0.048) and ALAT levels (34±21.32 IU/L vs. 22.3±10.4 IU/L, P<0.01 and 34±21.32 IU/L vs. 27.07±25 IU/L, P<0.01) at 6 and 12 months after ESG, respectively. CONCLUSION: ESG is a well-tolerated and safe surgical procedure that is effective in terms of weight loss and reduction of obesity-related co-morbidities at six months and one year. This procedure could thus be adopted on a broader clinical scale and be more widely promoted as an effective treatment for morbid obesity.

Laser ablation in biliary tree: analysis of the intraductal and superficial thermal effects during the treatment.

The treatment of choice for the unresectable cholangiocarcinoma is based on biliary decompression procedures. Despite stent placement is the standard of care, it is related to well-known complications. Hence, alternative techniques were proposed. Ideally, they should guarantee an adequate intraductal disobstruction, without injuring the surrounding tissues.This pre-clinical study aims to investigate the thermal effects of the laser ablation (LA) in the biliary tree, in terms of intraductal and surrounding tissue temperature achieved with different laser settings. The common bile ducts (in their upper and lower portions) of two pigs were ablated for 6 minutes with a diode laser at 3 W and 5 W. A custom-made laser applicator was used to obtain a circumferential ablation within the ducts. The intraductal temperature (Tid) was monitored by means of a fiber Bragg grating (FBG) sensor, while an infrared thermal camera monitored the T distribution in the surrounding tissues (Tsup). A maximum T difference of 65 °C and 57 °C was evidenced between the two power settings for the Tid measured in the upper and lower ducts, respectively. The mean difference between Tid and the averaged Tsup values was evaluated. At 5 W, a difference of 37±3 °C and 44±10 °C were obtained for the upper and lower ducts, respectively. At 3 W, a T difference of 2±1 °C was obtained for the upper biliary duct, while a difference of 8±1 °C was documented for the lower duct. Based on the results obtained in this preliminary study, the possibility to equip the laser probe with temperature sensor can improve the control and the safety of the procedure; this solution will guarantee the monitoring of the treatment while preserving the lumen and the surrounding structures.

Treatment of giant paraesophageal hernia: pro laparoscopic approach.

PURPOSE: Giant paraesophageal hernias (GPEH) are relatively uncommon and account for less than 5% of all primary hiatal hernias. Giant Secondary GPEH can be observed after surgery involving hiatal orifice opening, such as esophagectomy, antireflux surgery, and hiatal hernia repair. Surgical treatment is challenging, and there are still residual controversies regarding the laparoscopic approach, even though a reduced morbidity and mortality, as well as a shorter hospital stay have been demonstrated. METHODS: A Pubmed electronic search of the literature including articles published between 1992 and 2016 was conducted using the following key words: hiatal hernia, paraesophageal hernias, mesh, laparoscopy, intrathoracic stomach, gastric volvulus, diaphragmatic hernia. RESULTS: Given the risks of non-operative management, GPEH surgical repair is indicated in symptomatic patients. Technical steps for primary hernia repair include hernia reduction and sac excision, correct repositioning of the gastroesophageal junction, crural repair, and fundoplication. For secondary hernias, the surgical technique varies according to hernia type and components and according to the approach used during the first surgery. There is an ongoing debate regarding the best and safest method to close the hiatal orifice. The laparoscopic approach has demonstrated a lower postoperative morbidity and mortality, and a shorter hospital stay as compared to the open approach. A high recurrence rate has been reported for primary GPEH repair. However, recent studies suggest that recurrence does not reduce symptomatic outcomes. CONCLUSIONS: The laparoscopic treatment of primary and secondary GPEH is safe and feasible in elective and emergency settings, especially in high-volume centers. The procedure is still challenging. The main steps are well defined. However, there is still room for improvement to lower the recurrence rate.