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Castro et al. Mini-invasive Surg 2020;4:47 I http://dx.doi.org/10.20517/2574-1225.2020.14 Page 5 of 13

Figure 1. Contrast image of post endoscopic gastroplasty

water to ablate the duodenal mucosa circumferentially. This therapy has shown positive outcomes in
management for diabetes [14,28,29] . The hypothesis behind it is that through duodenal mucosal ablation,
[14]
there will re-epithelialization with normal mucosa . A prospective multicenter trial showed sustained
improvement of glycated hemoglobin (HbA1c) at 12 months in 37 patients with type 2 diabetes (T2D) who
[28]
underwent DMR . DMR has shown improvement in glycaemic control in patients with T2D; however, the
mechanisms of how glycemic control is achieved are still under study.

Endoscopic sleeve gastroplasty
The endoscopic sleeve gastroplasty is a procedure whose technique has been modified to achieve better
results. The procedure is done with the use of The Overstitch (Apollo Endosurgery, Austin, TX) suturing
device which was recently approved by the FDA. The procedure consists of the placement of transmural
sutures in a triangular fashion such that it creates a tubular shape similar to sleeve gastrectomy [Figure 1] [14,30] .
A prospective study that included 154 patients, evaluated total body weight loss (TBWL) at 1, 3, 6, 12
and 24 months after endoscopic gastroplasty using The Overstitch (Apollo Endosurgery, Austin, TX). At
2 years of follow-up, 85.7% of patients surpassed the threshold of 25%EWL, suggested by the American
[30]
Society for Gastrointestinal Endoscopy (ASGE) and the ASMBS , 193 patients from 7 centers underwent
endoscopic sleeve gastrectomy using The Overstitch device and were followed up at 6 months and 1 year
after the procedure. There was a BMI decrease of 5 and 6 points at 6 months and 1 year, respectively.
Most adverse events were mild and included nausea and emesis. Two severe adverse events were reported
that required surgical intervention, one patient presented with a perigastric hematoma 1 week after the
[31]
procedure and the second patient was found to have a leak 3 days after the procedure . As anatomy is not
altered with this procedure, it allows for reintervention if required. This procedure has proven to be feasible
with positive long-term outcomes [30,31] ; however, there has yet to be a consensus of whether this procedure
should be considered over other primary bariatric procedures.

INNOVATIONS IN THE MANAGEMENT OF COMPLICATIONS
Although low in incidence, patients may present with complications after bariatric surgery. It is important
to do a thorough evaluation of the patient to determine the diagnosis and advocate proper management.