Amanda Wilde (Host): Welcome to MD Cast by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content, and a valuable learning tool for world-class healthcare. I'm Amanda Wilde.

Learn about endoscopic sleeve gastroplasty with Dr. Salvatore Docimo. Dr. Docimo is Professor of Surgery, Section Chief of Abdominal Wall Surgery and Complex Hernia Repair at Tampa General Hospital, and he is also a bariatric surgeon. He leads the Endobariatrics Initiative for the Obesity Center at Tampa General Hospital. Dr. Docimo, thank you so much for being here.

Dr. Salvatore Docimo: Amanda, thank you so much for the invite. It's my pleasure, my honor to be here.

Host: Well, you have a number of other titles at Tampa General Hospital and USF, but we have shortened that for brevity so as to devote more time to our topic, which is endoscopic sleeve gastroplasty, which is part of endoscopic bariatrics. So, let's start there first, what is endoscopic bariatrics?

Dr. Salvatore Docimo: Sure. So, this is a new procedure, which effectively has been around for a few years. But more recently, we've had the ability to offer it to our patients here at Tampa General Hospital. And effectively, what it is is it is a procedure that is performed completely through the mouth. So, it's a transoral procedure, and the goal of the procedure is to mimic what was known as a sleeve gastrectomy, or is known as a sleeve gastrectomy. And most individuals in the community, amongst our peers, our colleagues, they all know what a sleeve gastrectomy is. It's a very effective bariatric procedure, which is truly is a workhorse when battling the disease of obesity.

We've taken that step further now where we've effectively eliminated the recovery and the pain of a transabdominal sleeve gastrectomy and what we do in an endoscopic sleeve gastroplasty is we actually insert and go down the mouth through the esophagus into the stomach with a suturing device that's affixed to the end of a gastroscope. While we're in the stomach, we blow the stomach up with gas and we traverse the mouth, go down the esophagus into the stomach. We blow the stomach up with gas. And at that point, we put plication sutures in, and then we essentially just cinch the stomach down to mimic a sleeve gastrectomy. The results have been pretty significant from our eyes in terms of it almost reaches the same exact outcomes as a sleeve gastrectomy without all the morbidity and recovery time of a robotic or laparoscopic sleeve gastroplasty.

So, this is exciting. We're really on the cusp of newer technologies. And honestly, when we talk about the disease of obesity, obesity is running rampant, certainly through our country, certainly throughout the world. And we really need to be able to battle the disease from all aspects. We need to offer obesity medications, we need to offer traditional surgeries. And now, we even need to offer, and we are offering endoluminal bariatric procedures as well. So, we are battling and we are fighting disease from every which way possible.

Host: So, you're using all the tools at your disposal. Specifically, how are endoscopic sleeves used as a primary weight loss procedure?

Dr. Salvatore Docimo: So, primary procedures in terms of bariatric procedures are those initial procedures that are used for the first time for a patient in order to try to battle their disease of obesity. So even for individuals who have never had a sleeve before, have never had bariatric surgery, they might have tried medications before and they're just not working. We can actually use an ESG or an endoscopic sleeve gastroplasty as their first-line treatment for obesity.

Other endoluminal or endobariatric procedures have been used before, but mainly as revisional procedures, specifically after, let's say, a Roux-en-Y gastric bypass. A patient comes to your office, they're gaining weight. We can offer them what's called a TOR procedure or a transoral outlet reduction procedure, and that's what we consider a revisional procedure, because they've already had a bariatric procedure before. An ESG is going to be the first-line of defense, the first go. After the ESG, then we can see how the patient is doing and whether or not we need to also add on weight loss medications or not. It's a go-to option for our patients who may be a little hesitant about receiving or undergoing traditional surgery.

Host: How can endoscopic sleeve gastroplasty be used as a bridge to other surgeries other than the TOR procedure you just described?

Dr. Salvatore Docimo: There's a lot of situations that unfortunately our patients find themselves in where the disease of obesity is prohibiting them from getting a final or destination procedure. Some examples: transplant procedures, so liver, heart, kidney transplants, knee replacements, even complex abdominal wall reconstructions for very massive eventual hernias, which I see often in my practice, a lot of times the disease of obesity is a prohibitive. So, patients who have higher BMI levels, you know, in the 40s and the 50s, sometimes even higher, they can't get these life-saving procedures. And unfortunately, sometimes we can't even get them safely to traditional bariatric surgery.

What the ESG offers to them is it offers a less invasive option for them. So. I'll give you one perfect example. Patient comes in and they need a heart transplant and they simply will not tolerate undergoing traditional surgery where they have to insufflate the abdomen, we have to dock a robot, it may be a little bit more time-consuming. What we can now offer the patient is we can offer them an endoscopic sleeve gastroplasty or an ESG, which avoids the traditional morbidity of undergoing a traditional surgery. And we can get them to a point where their disease of obesity is no longer hindering them to get their destination surgery, which may be that heart transplant, that abdominal wall reconstruction for hernia or the knee replacement. So, it really gives the patient another option to get those, which in some cases is truly a life-saving procedure.

Host: You mentioned this is such an exciting time of development and advancement of techniques. What are the changes and outcomes that you've been seeing along with that development?

Dr. Salvatore Docimo: We've seen the results before, specifically of a trial called the MERIT study, or MERIT Trial. And the results were nearly comparable to a traditional sleeve gastroplasty. And as I mentioned before, the laparoscopic or robotic sleeve has really been the workhorse of bariatric surgery for the last decade or so. So essentially, we've gotten pretty good at doing these sleeves. We can get the patients hopefully in and out of surgery as soon as possible. Hopefully, we get them really great results. We're really at the top of our game in regards to a sleeve.

The fact that this newer procedure is getting results nearly as good as a sleeve really tells us that we are on the cusp of something excellent, right? We're offering a procedure that we don't have to make incisions on a patient's abdomen. We're offering a procedure that's less invasive, and yet we're still getting very similar results to a traditional surgical procedure. So, it's really an exciting time. And honestly, I think the biggest thing for us is we're giving those patients who had no hope some hope. They have hope now, right? Instead of saying, "I've gone to a couple surgeons before. They said I can't lose enough weight. I can't get the surgery that I really, really need." They lose hope. They have nowhere to turn. Now, these patients are going to have the ability to turn to us. We're going to have the ability to, at least, like in my mind, give them another option, give them some hope that we can help them fight the disease of obesity, get them down to a BMI level where now they can get that final surgery that they've been really longing for.

Host: So, you can help more patients who are struggling with this disease.

Dr. Salvatore Docimo: Exactly. The one thing that we really wanna teach our colleagues and help really drive the point home is that this is really truly a disease. Obesity has been designated disease for some times. But unfortunately, there are still those underlying sense of, hey, if a patient eats a little bit less, exercise a little bit more, you know they're going to lose all that weight. That's not true, right? The biology behind obesity is much more complex than what we thought it was. The more and more that we studied the disease of obesity, we see that simply reducing caloric intake, simply exercising more, sometimes that's just not enough, right? It's not enough battle to the disease of obesity, take cancer, for instance. You can exercise every day, you can eat healthy, you can have the best genetics and, unfortunately, we still see these types of patients form cancer cells. So, sometimes the biology of a disease, no matter what you do, it's going to occur.

So, I think having all these different methodologies to battle this disease only really elevates our Bariatric Center of Excellence, our obesity center here at TGH, and we're simply going to be able to offer so many more options for our patients. It's really, truly exciting time for us.

Host: Well, thank you, Dr. Salvatore Docimo, for your inspiring work and for explaining endoscopic sleeve gastroplasty today.

Dr. Salvatore Docimo: Amanda, thank you so much for the invitation. Thanks again for your time.

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