Feasibility of a fully endoscopic one-anastomosis gastric bypass procedure following endoscopic sleeve gastroplasty in pigs

Background & Aims Endoscopic sleeve gastroplasty (ESG) has become an adopted endoscopic gastric volume reduction procedure, whereas endoscopic gastric bypass is a recent experimental procedure. We assessed the feasibility and safety of combining ESG with a fully endoscopic one-anastomosis gastric bypass (OAGB) recently developed. Methods This was a 14-week prospective follow-up of 4 growing pigs using a dedicated gastrojejunal lumen-apposing metal stent (GJ-LAMS) to create a gastrojejunal anastomosis (GJA) and a duodenal exclusion device (DED). ESG at baseline was followed by the OAGB procedure at Week 8-10 and necropsy at Week 14. Results In all 4 pigs, endoscopic gastroenterostomy realizing OAGB was possible following ESG. In one pig, all study procedures from Day 0 to Week 14 occurred as intended, with normal health and normal necropsy observations, confirming feasibility of endoscopic OAGB after ESG. GJ-LAMS migration without DED placement occurred in a second pig. A third pig had an asymptomatic unintended gastrocolic anastomosis discovered at necropsy, and the fourth pig died on day 62 (6 days after GJ-LAMS placement) with the finding of ischemic volvulus on necropsy. At 14 weeks, all remaining stents were removed endoscopically uneventfully. Then necropsy was performed, showing no inflammation or leaks, and limb length ranging from 110 cm to 170 cm. Conclusion ESG followed by an endoscopic OAGB with controlled bypass length was technically feasible. One of 4 test animals died shortly after GJ-LAMS placement and before duodenal exclusion.