ROBOTIC ENDOLUMINAL SLEEVE GASTROPLASTY: PROCEDURE DEVELOPMENT AND TECHNICAL FEASIBILITY

Background: Endoscopic Bariatric Therapy has emerged as an alternative minimally invasive treatment for patients with obesity. Endoscopic Sleeve Gastroplasty (ESG) can provide good weight loss outcomes with a low adverse event rate. Basic principles of ESG involve suturing the anterior, greater curvature and posterior walls of the stomach using an endoscopic full-thickness suturing device. This reduces the length and width of the stomach leading to volume reduction and alteration of gastric emptying, with resultant weight loss and co-morbidity resolution. However, due to procedural and device complexities, the learning curve is long, limiting adoption of the conventional technique. Similar to surgery, robotic platforms may address many of the procedural challenges and allow more patients to benefit from this less invasive approach. The multi-articulating instruments may better standardize the procedure and allow endoscopists with less experience and lower skill to perform high quality procedures. And by achieving consistent full-thickness surgical-quality suture placement, this may result in more durable restriction and improved weight loss outcomes.

Endoscopic Methods: We demonstrate a novel approach to ESG using a fully-robotic endoscopic system in a porcine stomach model. It consists of an 18 mm robotic overtube with 6 channels, including two 7 mm channels for the major articulating instruments, and channels for optics, insufflation, and accessory devices. This preclinical work is in preparation for an upcoming bariatric clinical trial. The 1^st suture was placed at the level of the incisura using a running suture. The suture was started on the posterior wall, moving to the greater curvature, then to the anterior wall. Following this a running suture was placed using a continuous ‘v’ pattern moving from posterior, along the greater curvature, to the anterior surface and back. This suture serves to reduce both the width and length of the stomach, similar to the ‘u’ suture pattern in conventional ESG. Lastly, we finished the procedure with the continuous reinforcing suture from the distal to proximal stomach, opposing the anterior and posterior surfaces, medial to the existing plications in a “zigzag” configuration. This reinforcement will help reduce the tension on the underlying running sutures, and also further narrow the lumen. At the end of the procedure, the gastric lumen was reduced by over 50% compared to the pre-procedural state.

Conclusion: This video demonstrates the technical feasibility of a fully-robotic endoluminal sleeve gastroplasty. This endoscopic robotic system has potential to enhance procedural performance allowing a broader range of endoscopists to offer the technique. Clinical studies are now being planned to assess the safety and efficacy of this novel procedure.