Training in Bariatric Endoscopy

Obesity has become a worldwide pandemic that has tripled in the past 40 years, affecting children and adults and resulting in various obesity-related comorbidities.¹ In a CDC report from 2016, the prevalence of adult obesity was near 40% with an estimated annual medical cost in the United States of $147 billion.² Although bariatric surgery has yielded promising results in combatting obesity, acute and chronic complications such as surgical leaks and weight regain are not uncommonly encountered. In addition, many patients are not suitable candidates for bariatric surgery or are interested in less-invasive options for weight loss. Bariatric endoscopy is an emerging subspecialty that has revolutionized the approach to patients with complications of bariatric surgery and those with obesity seeking nonsurgical weight loss therapies. It encompasses a wide array of diagnostic and therapeutic procedures ranging from diagnostic endoscopy prebariatric surgery to primary endoscopic weight loss procedures. Training in bariatric endoscopy is imperative to develop the skills necessary to understand complex bariatric anatomy and allow for safe interventions for various pathologies. Because bariatric endoscopy evolved over the past several years, there has been an increasing need for establishing well-defined training programs. We summarize the important elements for training in bariatric endoscopy and establishing a bariatric endoscopy training program.

UNDERSTANDING OBESITY PATHOPHYSIOLOGY, POSTBARIATRIC ANATOMY, AND POSTBARIATRIC SURGERY COMPLICATIONS

Individuals interested in bariatric endoscopy are expected to comprehend the current theories regarding obesity pathophysiology (environmental and genetic influences), obesity severity based on body mass index, common obesity-related comorbidities, hormonal changes associated with obesity, and common gastroenterological and liver-related conditions such as fatty liver disease and gastroesophageal reflux disease. Trainees should understand the various types of bariatric surgery, including those from the past decades no longer commonly performed such as laparoscopic adjustable gastric bands to the more common procedures performed by bariatric surgeons nowadays such as sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB). Trainees should acknowledge the important anatomical landmarks seen on endoscopy in postbariatric surgery patients such as the gastrojejunal anastomosis (GJA) and jejuno-jejunal anastomosis seen in patients with RYGB. They should also appreciate important measurements recommended during endoscopy such as the size of the gastric pouch and diameters of GJA in patients with RYGB. Finally, trainees should be able to recognize endoscopic complications seen in bariatric surgery patients and understand endoscopic treatment options. These include acute complications such as post-RYGB or GS postsurgical leaks and chronic complications such as weight regain and gastrogastric fistula in RYGB patients and Barrett's esophagus in patients with sleeve gastrectomy.

INFRASTRUCTURE, PATIENT SELECTION, TRAINEES, AND EDUCATORS

Training in bariatric endoscopy should take place in hospitals with a large volume of bariatric surgeries or centers with a large volume of referral of patients with a history of bariatric surgery. Endoscopy units should be equipped with fluoroscopy for unique cases requiring its use such as in patients with postbariatric surgery leaks. Patient population includes those with a history of bariatric surgery with acute or chronic complications or patients with obesity and obesity-related comorbidities looking for less-invasive means for weight loss. Trainees should be gastrointestinal (GI) fellows in their third or fourth years of general GI training who have mastered the basic and essential endoscopic skills or faculty interested in bariatric endoscopy with a passion for treating this unique patient population. Bariatric endoscopy training can be embedded into the third year of GI fellowship programs or as stand-alone training year for those who have graduated fellowship but are interested in bariatric endoscopy. It is important to note that general GI fellowship programs have different structures for training and that programs which allow schedule flexibility during the third year can incorporate bariatric training if faculty, staff, and resources for training are available.

Trainees are encouraged to attend obesity medicine clinics, rotate on bariatric surgical services, study radiological examinations of patients with bariatric anatomy, and attend multidisciplinary bariatric meetings. Mentors and educators in bariatric endoscopy programs should be well versed in the science of obesity and the anatomy of postbariatric patients. They should understand the different types of bariatric surgery complications and up-to-date data on how to approach them. Most importantly, mentors and educators should show advanced endoscopic skills and demonstrate effective teaching techniques. Expertise in advanced endoscopy is not usually required but may be useful for the management of select complications such as biliary disease. Frequent assessment and feedback for trainees is crucial to assist with their development as experts in bariatric endoscopy.

UNDERSTANDING ENDOSCOPIC WEIGHT LOSS THERAPIES AND ENDOSCOPIC INTERVENTIONS FOR BARIATRIC SURGERY COMPLICATIONS

Trainees are expected to understand all options available for the patient with obesity seeking nonsurgical weight loss therapies. These include dietary and lifestyle modifications and weight loss medications. Currently, there are 5 FDA-approved prescription medications for the treatment of obesity (orlistat, Phentermine, phentermine-topiramate, naltrexone-bupropion, and liraglutide). Trainees should understand the mechanism of action of these drugs, indications, suitability for particular patient populations, risks, and weight loss expectations. For endoscopic weight loss therapies, trainees should familiarize themselves with both FDA-approved and investigational endoscopic procedures that exist to assist with primary weight loss. These include, but are not limited to, endoscopic sleeve gastroplasty, gastric plication, intragastric balloons, aspire to assist therapy, transpyloric shuttle, duodenal resurfacing therapy, and duodenal-jejunal bypass liners. Trainees should understand the mechanism by which these procedures promote weight loss, the endoscopic techniques involved, possible complications encountered and how to troubleshoot them, and weight loss expectations. For RYGB patients with weight regain, trainees should familiarize themselves with endoscopic suturing and plication platforms to reduce the size of the pouch and GJA diameter. Finally, trainees should familiarize themselves with endoscopic procedures to correct acute and chronic complications of bariatric surgery. These include but are not limited to the placement of esophageal stents and plastic double pigtail catheters for the treatment of acute and chronic leaks, sequential dilatory therapy for sleeve stenosis, endoscopic management of gastrogastric fistula, and high-dose open-capsule proton-pump inhibitors for patients with GJA ulcers.

SIMULATORS, COURSES, AND EDUCATIONAL WORKSHOPS

Endoscopic simulators such as those developed for endoscopic suturing or tissue plications are important aspects of a bariatric endoscopy training program. These can provide trainees with skills necessary to better understand the essential steps required with these procedures and anticipate device malfunctions and how to troubleshoot them. Endoscopic simulators can improve accuracy and allow for a safer use of these novel instruments in patients. Currently available simulators for bariatric endoscopy procedures are ex vivo simulators or those provided by companies. There remains a need for more simulators for bariatric endoscopy training, mainly focusing on how to use the devices for suturing and placement of tissue plications. Courses sponsored by regional or national meetings or conferences (such as the ACG annual postgraduate course) are important for trainees to attend to learn from leaders in endoscopic bariatric procedures, whereas workshops allow time for hands-on involvement with various endoscopic weight loss procedures. Many workshop programs, such as those sponsored by the American Society of Gastrointestinal Endoscopy incorporate ex vivo or live animal models into their courses to allow a better understanding of the devices and procedures used in bariatric endoscopies, such as endoscopic suturing.³ Trainees are encouraged to attend these courses and workshops to gain experience and knowledge with these devices.

Training in bariatric endoscopy and establishing a training program in bariatric endoscopy require dedication and commitment from various participating parties, mainly trainees and educators. Although developing technical endoscopic expertise is essential, training in bariatric endoscopy requires a substantial cognitive component that is best obtained through working in a multidisciplinary setting with a variety of healthcare providers. Although there are relatively few established training programs at this time, we anticipate the increased volume and broader adoption of these endoscopic bariatric and metabolic therapies will lead to more readily available training opportunities and programs in the near future.