**4.2 ESG (endoscopic sleeve gastrectomy) with the Apollo OverStitch™**

The Apollo OverStitch™ (Apollo Endosurgery, Austin, TX) is an endoscopic suturing device that applies full-thickness sutures in a variety of patterns. The system attaches to a double-channel endoscope and utilizes a curved needle driver. The OverStitch Sx™ is available for using single working channel endoscopes.

Results: In the meta-analysis of Gys and colleagues from 2019 eight clinical trials (1721 patients, 2014–2019) were included with 6–24 months follow-up. Average pooled EWL at 12 months was 68.3% [12]. In the recent meta-analysis of Singh and colleagues pooled EWL after 12 months was 61.84% [11].

Complications: In the analysis of Gys et al. major adverse events were described in 18 patients: pneumothorax (*n* = 2), perigastric collection (*n* = 8), pulmonary embolism (*n* = 2), intraluminal bleeding (*n* = 5), and leakage (*n* = 1). Singh et al. described a pooled incidence of serious adverse events of 2.26%.

#### **4.3 RESTORe with the EndoCinch device**

Endoluminal Vertical Gastroplasty (EVG) is performed using the EndoCinch suturing device (C.R. Bard, Inc., Murray Hill, NJ). Since 2004 this device is used to treat obesity. The RESTORe System (Bard/Davol, Warwick, RI) is an updated version of the EndoCinch device. It is capable of deeper tissue acquisition and suture reloading inside the patient. During this procedure, in addition to an anterior to posterior plication in EVG, the greater curvature is also incorporated to mimic LGP.

*Bariatric Surgery—from the Non-surgical Approach to the Post-Surgery Individual Care… DOI: http://dx.doi.org/10.5772/intechopen.95259*

Results: In 2008, Fogel performed EVG in 64 patients using a continuous running suture along the lesser curvature. No serious adverse events were reported and weight loss at 1 year was 58.1% EWL [14].

Complications: No significant adverse events were seen. Twelve-month endoscopy revealed partial or complete release of plications in 13 of 18 patients.

#### **4.4 TOGA (transorale Gastroplasie)**

TOGA (Satiety Inc., Palo Alto, CA) is an endoscopic stapling device first introduced in 2008. TOGA creates a stapled sleeve and a restricted outlet. Similar to VBG, TOGA is associated with decreased ghrelin and increased GLP-1 levels.

Results: A sham-controlled trial including 67 patients showed 52.2% EWL (in patients with BMI < 40) and 41.3% EWL (in those with BMI ≥ 40) after one year [15].

Complications: Two cases of respiratory distress and an asymptomatic pneumoperitoneum from esophageal and gastric perforations that was treated conservatively however were reported.

#### **4.5 TERIS (trans-oral endoscopic restrictive implant system)**

TERIS (Barosense, Redwood City, CA) is an endoscopically implanted device introduced by Biertho and colleagues in 2009. A prosthetic diaphragm is placed at the gastric cardia to create a small reservoir with a 10-mm orifice. To anchor the device full thickness plications are used.

Results: In a study including 18 patients (mean BMI 42.1 kg/m2 ) Verlaan et al. reported about a median EWL after six month of 30.1% [16].

Complications: Three SAEs occurred, one gastric perforation and two cases of pneumoperitoneum. Because of the poor durability of the system the company decided to discontinue the TERIS system and to further develop the successful parts of it, such as the articulating circular endoscopic (ACE) stapler.

#### **4.6 ACE-stapler (articulating circular endoscopic stapler)**

The ACE stapler (Boston Scientific Corporation, Natick, MA) is an endoscopic stapler. This device consist of a head capable of both 360-degree rotation and complete retroflexion. A 5-mm endoscope enables visualization; the device is 16 mm in diameter. This device use vacuum suction to mobilize gastric tissue; firing the stapler creates a full-thickness plication using a 10-mm plastic ring with 8 titanium staples. A defined number of plications is done in the fundus and antrum.

Results: Verlaan et al. [17] reported about 17 patients (BMI 40.2 kg/m<sup>2</sup> ) et al. reported in a prospective safety and feasibility study of gastric volume reduction. Median EWL was 34.9%.

Complications: The most common adverse event was abdominal pain (7 patients); sore throat, diarrhea, nausea, constipation, and vomiting were also reported. All were self-limited.

#### **4.7 Endomina system**

The Endomina suturing system (Endo Tools Therapeutics, SA-ETT, Gosselies, Belgium) is a triangulation platform to perform large plications with transmural sutures and serosa-to-serosa apposition to reduce the gastric volume.

Results: Two studies (62 patients) by Huberty et al. reported 29% EWL at 12 months [29, 30].

Complications: No major adverse events were reported.
