Author:

Prof Anjan Dhar

Acknowledgements:

Mr Akeil Samier, Consultant Upper GI & Bariatric Surgeon

Sheryl Cameron, Bariatric Specialist Nurse

Adrienne Newbery, Endoscopy Unit Senior Sister

Lenuta Sut, Endoscopy Unit Clinical Sister

Rory Telfer, Market Development Manager, Endobariatrics, Boston Scientific Corporation

James King, Endobariatrics Trainer, Boston Scientific Corporation

Introduction

Obesity is a growing epidemic in the United Kingdom as it is in the developed world and the Level 3 Surgical Bariatric Service is unable to cope with the demand of patients who need weight reduction surgery. An estimated 26% men and 29% women are obese in the UK, leading to an increased risk of Type 2 diabetes, cardiovascular risk, heart disease, strokes and cancer. The estimated NHS spending on obesity and overweight related chronic healthcare problems is around 8 billion pounds at present, rising to 50 billion by 2050. Furthermore, the current bariatric surgical service has significant capacity restrictions, and is able to only carry out weight loss reduction surgery in 10% of patients who were obese.  The current guidelines allow only patients with severe obesity (BMI > 40) to be eligible for bariatric surgical procedures.  The cardiovascular morbidity of patients who are obese with a BMI between 30-40 has also been shown to be similar to those who are morbidly obese with a BMI greater than 40.  There is therefore a growing need for newer treatment options to tackle moderate to severe obesity. 

The challenges to the service and the need for change

Over the last 5 years our bariatric surgeons realised that they were unable to provide weight loss reducing surgery to most patients with moderate to severe obesity since the number of patients who had morbid obesity was overwhelming the service.  There was therefore a perceived need to incorporate other modalities of weight reduction into our metabolic service.  This included drug therapies such as GLP-1 agonists which were in the process of being NICE appraised and approved for management of moderate obesity and diabesity.   Endoscopic weight reduction strategies such as intra-gastric balloons and endoscopic sutured gastroplasty (ESG, Apollo Overstitch) had already been shown to be effective in achieving a total body weight loss of between 12-15%, sustained over 3-5 years, in a number of European and American studies.(SLEEVE and MERIT Studies)

Endoscopic sutured gastroplasty was available in a few tertiary University Teaching Hospitals in the London area but there was no NHS service anywhere in the North of England.  We therefore made a business case to incorporate endoscopic sutured gastroplasty into our bariatric service.  A full costings business case was submitted to the County Durham and Darlington NHS foundation trust in 2019 with a structured programme for training and implementation of the service over the next 2-3 years.

Our structured training programme to overcome the challenge

At County Durham and Darlington NHS foundation trust, we developed a multi-disciplinary team for metabolic endoscopy which comprised of an experienced consultant gastroenterologist, a consultant bariatric surgeon, a bariatric specialist nurse, a dietitian, a psychologist, and two band 7 senior endoscopy sisters.  We partnered with our industry collaborated, Apollo Endo-surgery, to develop a comprehensive training programme which included familiarisation with the Apollo Overstitch System in “dry lab” training sessions, followed by “wet lab” suturing in pig stomachs. This was followed by observer ships to established centres for endoscopic sutured gastroplasty to watch the procedure being carried out live by experienced operators.  Finally, we started doing live cases at Darlington Memorial Hospital in 2022, where the first few sessions where supervised by an in theatre Proctor, from the UK and Rome.  We were fortunate to have Professor Bu Hayee, Professor of Gastroenterology at the King's College Hospital London and Dr Vincenze Bove from Rome to proctor us for our first few cases.  

We then moved to remote proctoring through live video links for the next few cases to gain complete independence in 2023.

Our outcomes

Between 2022 in 2023, we have carried out endoscopic sutured gastroplasty sessions every 6-8 weeks, doing 2-3 cases in the theatre under general anaesthesia in a session.  We have so far done 9 cases with excellent outcomes with significant total body weight loss ranging between 10-12%.  There have been no procedural complications.  Each procedure as taken between 90-120 minutes.

This success of our metabolic endoscopy programme has been reported in the local newspaper (the Northern Echo) and has also be showcased in a video clip at BBC looked North.  The programme has been recognised by our Integrated Care Board (ICB) as an innovative programme to provide a novel weight reduction technique to our local population.

To the best of our knowledge from, this is the 1st endoscopic weight reduction service in the whole of the North of England, in the NHS, which is outside London teaching hospitals.

Learning Points and how other teams can gain from our experience

In addition to the placement of intra-gastric balloons, our endoscopic sutured gastroplasty programme has demonstrated the success of a structured training programme to learn an advanced endoscopic technique and implement this into current NHS service to meet the growing needs of the local population.   It has also shown that a team based approach with industry collaboration is crucial to the success of any modern advanced therapeutic endoscopy service.

It is also important recognise that any advanced therapeutic endoscopy programme requires Proctor ship and this includes both national, international Proctors, who need to be present in the local endoscopy unit or operating theatre to start with, followed by electronic technology to have remote Proctoring before independence can be achieved to carry out these procedures safely and successfully.