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

Background and 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 recently developed fully endoscopic one-anastomosis gastric bypass (OAGB) procedure. 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 and a duodenal exclusion device (DED). ESG at baseline was followed by the OAGB procedure at weeks 8 to 10 and necropsy at week 14. Results: In all 4 pigs, endoscopic gastroenterostomy realizing OAGB was possible after ESG. In 1 pig, all study procedures from day 0 to week 14 occurred as intended, with normal health and normal necropsy observations, confirming the 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. Necropsy was then performed, showing limb lengths ranging from 110 cm to 170 cm, with no inflammation or leaks. Conclusions: ESG followed by an endoscopic OAGB procedure with a controlled bypass length was technically feasible. One of 4 test animals died shortly after GJ-LAMS placement and before duodenal exclusion.