Gastrointestinal Physiological Changes and Their Relationship to Weight Loss Following the POSE Procedure.

BACKGROUND: Primary Obesity Surgery Endolumenal (POSE) is a novel bariatric endoscopic procedure that has been shown to reduce weight safely through 12 months. The study investigated potential mechanisms of weight loss following POSE. METHODS: Patients with class I-II obesity received transmural plications in the gastric fundus and distal gastric body. Patients were evaluated at baseline and at 2- and 6-month follow-up with gastric-emptying (GE) scintigraphy, a validated test of intake capacity (kcal) and plasma glucose homeostasis hormones/gastrointestinal peptides. Weight was recorded through 15 months. Mean data and 95% CIs are reported. Regression modeling assessed variables that influenced total weight loss (%TWL) and excess weight loss (%EWL). RESULTS: POSE was performed on 18 patients (14 F/4 M); mean age 39 years (34-44), body mass index (BMI, kg/m(2)) 36 (95% CI, 35; 37). At 15 months (n = 15), mean TWL was 19.1 ± 6.6% (15.5; 22.8) and EWL was 63.7 ± 25.1% (49.8; 77.6). At 2 and 6 months (n = 18), intake capacity decreased significantly from 901 (685; 1117) to 473 (345; 600) and 574 kcal (418; 730), respectively (p < 0.001). At 2 months, GE was delayed but returned to baseline levels at 6 months (n = 18). Glucose/insulin ratio improved (p < 0.05). Postprandial decrease in ghrelin was enhanced (p = 0.03) as well as postprandial increase in PYY (p = 0.001). The best model for EWL prediction 15 months after POSE (R (2): 66%, p = 0.006) included pre-POSE BMI, post-POSE GE, and postprandial PYY increase. CONCLUSIONS: The POSE procedure was followed by significant sustained weight loss and improved glucose homeostasis and satiation peptide responses. Weight loss following POSE may be mediated through changes in gastrointestinal neuro-endocrine physiology.

Early experience with the Incisionless Operating Platform™ (IOP) for the treatment of obesity : the Primary Obesity Surgery Endolumenal (POSE) procedure.

BACKGROUND: We report our initial experience and 6-month outcomes in a single center using the per-oral Incisionless Operating Platform™ (IOP) (USGI Medical) to place transmural plications in the gastric fundus and distal body using specialized suture anchors (the Primary Obesity Surgery Endolumenal [POSE] procedure). METHODS: A prospective observational study was undertaken with institutional Ethics Board approval in a private hospital in Barcelona, Spain. Indicated patients were WHO obesity class I-II, or III, where patients refused a surgical approach. RESULTS: Between February 28, 2011 and March 23, 2012, the POSE procedure was successfully performed in 45 patients: 75.6 % female; mean age 43.4 ± 9.2 SD (range 21.0-64.0). At baseline: mean absolute weight (AW, kg), 100.8 ± 12.9 (75.5-132.5); body mass index (BMI, kg/m(2)), 36.7 ± 3.8 (28.1-46.6). A mean 8.2 suture-anchor plications were placed in the fundus, 3.0 along the distal body wall. Mean operative time, 69.2 ± 26.6 min (32.0-126.0); patients were discharged in <24 h. Six-month mean AW was 87.0 ± 10.3 (68.0-111.5); BMI decreased 5.8 to 31.3 ± 3.3 (25.1-38.6) (p < 0.001); EWL was 49.4 %; TBWL, 15.5 %. No mortality or operative morbidity. Minor postoperative side effects resolved with treatment by discharge. Patients reported less hunger and earlier satiety post procedure. Liquid intake began 12 h post procedure with full solids by 6 weeks. CONCLUSIONS: At 6-month follow-up of a prospective case series, the POSE procedure appeared to provide safe and effective weight loss without the scarring, pain, and recovery issues of open and laparoscopic bariatric surgery. Long-term follow-up and further study are required.

Endoscopic staging of low-grade gastric MALT lymphoma.

INTRODUCTION: Endoscopic ultrasonography (EUS) has already proven useful in the assessment of submucosal lesions, and the staging of gastrointestinal cancer, particularly gastric MALT-type lymphoma. The goal of this paper was EUS staging. PATIENTS AND METHOD: 24 patients (10 females, 14 males) with a median age of 56 years and possibly gastric MALT lymphoma (25 cases) were studied using videoendoscopy, biopsies, and echoendoscopy with 7.5- and 20-MHz radial EUS, and also with 12- and 20-MHz miniprobes (MPs). Nineteen patients were definitely evaluated (7 females, 12 males) as having 20 MALT-type lymphomas, as five patients were post-hoc disregarded when an invasive, high-grade gastric lymphoma (3c) or plasmocytoma (2c) was subsequently demonstrated. Of these 19 patients, all had T1 lesions except for two with T2 lesions; one patient had a gastroduodenal T1 lymphoma. Echographic findings with MPs were compared to EUS (gold standard) and histology both before and after eradication. Then, patients were followed up every 1-3-6 months using videoendoscopy and MPs. RESULTS: Echoendoscopy correctly identified T stages in 90% of cases. MPs identified T stages in 88% of cases, and N stages in 33% of cases, with results being slightly inferior to those obtained with conventional EUS (91 vs. 45%); they were consequently used for follow-up. After eradication, all but two patients are in complete remission and have been followed every 1-3-6 months using MPs without echographic abnormalities, except for a patient who relapsed.

Estadificación por ecoendoscopia en el linfoma gástrico tipo MALT de bajo grado / Endoscopic staging of low-grade gastric malt lymphoma

Introducción: la ultrasonografía endoscópica (USE) ha demostrado ya su utilidad en la evaluación de las lesiones submucosas, en la estadificación del cáncer digestivo en general, y del linfoma gástrico tipo MALT en particular. El objetivo de este trabajo fue la estadificación por USE. Pacientes y método: veinticuatro enfermos (10 mujeres y 14 varones) con edad media de 56 años y con posible linfoma gástrico tipo MALT (25 casos) fueron estudiados con videoendoscopia, biopsias y ecoendoscopia con USE radial de 7,5 y 20 MHz, y con minisondas (MS) de 12 y 20 MHz. Se evaluaron definitivamente 19 pacientes (7 mujeres y 12 varones) con 20 MALT, ya que cinco enfermos se desestimaron por demostrarse a posteriori que presentaban un linfoma gástrico invasivo de alto grado (3c) o un plasmocitoma (2c). De los 19 pacientes todos eran T1 menos dos pacientes que eran T2, y otra presentaba un linfoma T1 gastroduodenal. Los hallazgos ecográficos de las MS fueron comparados con la USE (gold standard) y con la histología antes y después de la erradicación. Después, fueron seguidos cada 1, 3 y 6 meses mediante videoendoscopia y MS. Resultados: la ecoendoscopia identificó el estadio T correcto en el 90% de los casos. Las MS identificaron el estadio T en el 88% de los casos y la N en el 33% de los casos, con resultados discretamente inferiores a los obtenidos con la USE convencional (91 y 45%), por lo que se utilizaron en el seguimiento. Después de la erradicación, todos menos dos están en remisión completa y han sido seguidos cada 1, 3 y 6 meses con las MS sin observar anomalías ecográficas, excepto una paciente que hizo una recidiva

Introduction: endoscopic ultrasonography (EUS) has already proven useful in the assessment of submucosal lesions, and the staging of gastrointestinal cancer, particularly gastric MALT-type lymphoma. The goal of this paper was EUS staging. Patients and method: 24 patients (10 females, 14 males) with a median age of 56 years and possibly gastric MALT lymphoma (25 cases) were studied using videoendoscopy, biopsies, and echoendoscopy with 7.5- and 20-MHz radial EUS, and also with 12- and 20-MHz miniprobes (MPs). Nineteen patients were definitely evaluated (7 females, 12 males) as having 20 MALT-type lymphomas, as five patients were post-hoc disregarded when an invasive, high-grade gastric lymphoma (3c) or plasmocytoma (2c) was subsequently demonstrated. Of these 19 patients, all had T1 lesions except for two with T2 lesions; one patient had a gastroduodenal T1 lymphoma. Echographic findings with MPs were compared to EUS (gold standard) and histology both before and after eradication. Then, patients were followed up every 1-3-6 months using videoendoscopy and MPs. Results: echoendoscopy correctly identified T stages in 90% of cases. MPs identified T stages in 88% of cases, and N stages in 33% of cases, with results being slightly inferior to those obtained with conventional EUS (91 vs. 45%); they were consequently used for follow-up. After eradication, all but two patients are in complete remission and have been followed every 1-3-6 months using MPs without echographic abnormalities, except for a patient who relapsed

Our cumulative experience with transendoscopic miniprobes.

INTRODUCTION: Transendoscopic miniprobes (TEMPs) have nowadays precise indications, but may become a diagnostic alternative to both radial and sectorial endoscopic ultrasonography (EUS) in the near future. PATIENTS AND METHODS: From November 1996 to July 2004 we carried out 620 examinations using TEMPs (124 during the last 12 months in 2003, with currently a mean of 11 examinations/month). Twenty explorations were performed with radial, 12.5 MHz (20 mm penetration), 6.2 F (2 mm diameter), 950 mm or 2000 mm Microvasive Endosound probes. Twenty explorations were performed using a 12 MHz (29 mm mean penetration) or 20 MHz (18 mm penetration) Olympus UM-2R/3R, or with a 12 MHz UM-DP12-25R or 20 MHz UM-DP20-25 R DPR-fitted Olympus probe, 2.5 mm in diameter and 2050 mm in length. A 20 MHz, 2.2 mm, wire-guided G20-29R was used for intraductal studies. In all, 580 examinations were carried out with both radial and linear, 12 MHz (240 E) or 20 MHz (60 E) Fuji probes, 2.6 mm in diameter and 1900 mm in length; and with a 7.5 MHz, 2.6 mm radial balloon microprobe with the well-known "preload" system that we have been using during the 1999-2004 period (280 E). Here we used a 3.2 mm working channel, whereas a 2.8 mm working channel was used with the remaining TEMPs. RESULTS: Twenty GI-tract examinations were performed with one Microvasive probe, which broke down when attempting its passage through the papilla. Currently we use a 20 MHz, 2.2 mm Olympus G20-29R guided microprobe for intraductal studies. We performed 100 gut examinations using one single Fuji TEMP (12 or 7.5 MHz). Organs explored included: esophagus and stomach, 60%; rectum and colon, 30%; other (duodenum, papilla, bile ducts), 10%. INDICATIONS: cancer staging, 35%; submucosal lesions, 30%; other, 35% (including 20% of esophageal non-tumoral conditions). COMPLICATIONS: aspiration, perforation, and mortality, 0%. Morbidity, 10%, at the expense of abdominal pain as induced by endoscopy itself. All strictures were successfully passed, except for one malignant stenosis in the rectum. CONCLUSIONS: During a 93-month period (1996-2004) we performed 620 explorations with TEMPs, with a current average of 11 examinations/month. TEMP durability is around 100 gut explorations. The esophagus and stomach were examined in 60% of cases. Primary indications included gut cancer staging and submucosal lesions (65%). Perforation and mortality rates amounted to 0%.

Nuestra experiencia acumulada con las minisondas transendoscópicas / Our cumulative experience with transendoscopic miniprobes

Introducción: las minisondas transendoscópicas (MST) poseenhoy en día unas indicaciones precisas, pero podrían ser en elfuturo una alternativa a la Ultrasonografía Endoscópica (USE) radialy sectorial en el área diagnóstica.Pacientes y método: desde noviembre de 1996 hasta juliodel 2004, hemos realizado 620 exploraciones con MST (124 enlos últimos 12 meses del año 2003; con una media de 11 exploraciones/mes actualmente).Veinte exploraciones se realizaron con una Microvasive Endode 7,5 MHz y 2,6 mm de diámetro con el sistema conocido de“pre-carga”, que utilizamos desde 1999-2004 (280 E). El canal detrabajo utilizado fue de 3,2 mm, mientras que en con el resto delas MST se utilizó un canal de trabajo de 2,8 mm.Resultados: con la misma MST de Microvasive se realizaron20 exploraciones del tracto digestivo rompiéndose al intentar introducirlapor la papila.Actualmente utilizamos Olympus G20-29R de 20 MHz, 2,2mm, con guía, para el estudio intraductal.Con la misma MST de Fuji (12 ó 7,5 MHz) hemos realizado100 exploraciones del tracto digestivo.Órgano a explorar: el esófago y el estómago 60%, el recto y elcolon el 30%, miscelánea (duodeno, papila, vía biliar) 10%.Indicación: estadificación del cáncer 35%, lesión submucosa30%, miscelánea 35% (incluyendo un 20% de patología esofágicano tumoral).Complicaciones: aspiración, perforación y mortalidad del 0%.Morbilidad del 10% a expensas del dolor abdominal provocadopor la realización de la endoscopia.Todas las estenosis se pudieron atravesar, menos una estenosismaligna rectal.Conclusiones: en un periodo de 93 meses (1996-2004) hemosrealizado 620 exploraciones con MST, actualmente con unpromedio de 11 exploraciones/mes. La durabilidad de la MSTestá alrededor de las 100 exploraciones del tracto digestivo. En el60% de los casos se exploró el esófago y el estómago. La indicacionesfundamentales fueron la estadificación del cáncer del tubodigestivo y las lesiones submucosas (65%). Los porcentajes de perforacióny mortalidad fueron del 0%

Introduction: transendoscopic miniprobes (TEMPs) havenowadays precise indications, but may become a diagnostic alternativeto both radial and sectorial endoscopic ultrasonography(EUS) in the near future.Patients and methods: from November 1996 to July 2004we carried out 620 examinations using TEMPs (124 during thelast 12 months in 2003, with currently a mean of 11 examinations/month). Twenty explorations were performed with radial,12.5 MHz (20 mm penetration), 6.2 F (2 mm diameter), 950 mmor 2000 mm Microvasive Endosound probes. Twenty explorationswere performed using a 12 MHz (29 mm mean penetration)or 20 MHz (18 mm penetration) Olympus UM-2R/3R, orwith a 12 MHz UM-DP12-25R or 20 MHz UM-DP20-25 R DPRfittedOlympus probe, 2.5 mm in diameter and 2050 mm inlength. A 20 MHz, 2.2 mm, wire-guided G20-29R was used forintraductal studies.In all, 580 examinations were carried out with both radial andlinear, 12 MHz (240 E) or 20 MHz (60 E) Fuji probes, 2.6 mm indiameter and 1900 mm in length; and with a 7.5 MHz, 2.6 mmradial balloon microprobe with the well-known “preload” systemthat we have been using during the 1999-2004 period (280 E).Here we used a 3.2 mm working channel, whereas a 2.8 mmworking channel was used with the remaining TEMPs.Results: twenty GI-tract examinations were performed withone Microvasive probe, which broke down when attempting itspassage through the papilla.Currently we use a 20 MHz, 2.2 mm Olympus G20-29R guidedmicroprobe for intraductal studies.We performed 100 gut examinations using one single FujiTEMP (12 or 7.5 MHz).Organs explored included: esophagus and stomach, 60%; rectumand colon, 30%; other (duodenum, papilla, bile ducts), 10%.Indications: cancer staging, 35%; submucosal lesions, 30%;other, 35% (including 20% of esophageal non-tumoral conditions).Complications: aspiration, perforation, and mortality, 0%.Morbidity, 10%, at the expense of abdominal pain as induced byendoscopy itself.All strictures were successfully passed, except for one malignantstenosis in the rectum.Conclusions: during a 93-month period (1996-2004) weperformed 620 explorations with TEMPs, with a current averageof 11 examinations/month. TEMP durability is around 100 gutexplorations. The esophagus and stomach were examined in 60%of cases. Primary indications included gut cancer staging and submucosallesions (65%). Perforation and mortality rates amountedto 0%

[Echo-endoscopy: the clinical implications after a period of more than 16 years of its existence]. / Ecoendoscopia: implicaciones clínicas después de un período de más de 16 años de existencia.

Endosonography is an imaging diagnostic technique recently introduced in our country. It allows us to perform an ultrasound from within the digestive tube. Because of the transducer proximity to the gut wall and the high frequency of emission we are able to visualize with great resolution small lesions as well as differentiate the five layers of the gastric wall and examine structures close to the digestive lumen with a 7 to 8 cm penetration. This is a brief introduction to the basic pillars of endosonography and its main indications, well defined after sixteen years of clinical practice.

[The value of endoscopic ultrasonography in the study of submucosal tumors of the digestive tract]. / Valor de la ultrasonografía endoscópica en el estudio de los tumores submucosos del tracto digestivo.

Twenty-one consecutive patients with 24 possible submucosal lesions of the digestive tract were studied. Endoscopic ultrasonography (EUS) differentiated between 17 true positive submucosal tumors and 3 true negative extrinsic compressions. False positives were interpreted in 3 cases and in one patient no lesion was echoendoscopically observed (false negative). The sensitivity was 94%, the specificity 50% and the positive and negative predictive values were 82% and 75%, respectively. In conclusion, EUS may be the method of choice for the study of submucosal tumors since it allows visualization of the five layers of the wall of the digestive tract in which a tumor may originate, determination of its sonographic features, depth and exact size, in addition to the invasion of neighboring organs. Moreover, EUS may aid in collecting material for cytology and microscopy by fine needle aspiration puncture (FNAP) by EUS.