**10. OTSC-clip to reduce pouch-outlet and the new BARS device**

The OTSC®-clip (Ovesco AG, Tübingen, Germany) is made of super-elastic shape memory alloy (Nitinol) which re-takes its former unbent shape after the clip is released and thus exerts a constant compression on the tissue between the jaws of the clip. In 2020 Ovesco created a new product to reduce pouch-outlet named BARS device (Bariatric Reduction System).

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

Results: Heylen and colleagues [59] reported about 94 patients who underwent reducing of a post-RYGB pouch-outlet. After one year mean BMI was 27.4 kg/m2 . Di Lorenzo published 2020 results of a clinical trial with BARS device in 6 patients [60]. Authors reported about safely performed procedures with a mean procedure time of 52min and a mean weight loss of 6kg at a 3-month FU.

Complications: No SAEs occurred. Some patients complained of a sore throat for 24 h after the intervention. In five patients with post-interventional dysphagia, a gastroscopy had to be performed. Two of patients required endoscopic dilatation.

#### **10.1 StomaphyX device**

The transoral StomaphyX device (EndoGastric Solutions) is a minimally invasive technique for revision after RYGB. Procedure seems to be safe and effective.

Results: 2014 Eid et al. [61] published a randomized clinical trial with 45 patients treated with StomaphyX and 25 patients in the sham group. The primary efficacy end point was reduction in pre-RYGB excess weight by 15% or more excess BMI. Patients undergoing StomaphyX treatment experienced significantly greater reduction in weight and BMI. Enrollment was closed prematurely because preliminary results indicated failure to achieve the primary efficacy end point in at least 50% of StomaphyX-treated patients.

Complications: There was one causally related adverse event with StomaphyX that required laparoscopic exploration and repair.

#### **10.2 APC for pouch-outlet reducing**

APC is a non-contact technique involving the application of an electrical current to tissues through ionized argon gas (argon plasma). It has also been successfully used in the treatment of the enlargement of the anastomosis after gastric bypass.

Results: Quadros and colleagues [62] published 2020 a randomized controlled trial with APC treatment and sham group. Authors reported about a significant weight decrease in the first months after APC.

Complications: No SAEs were reported.

#### *10.2.1 Choledocholithiasis*

The bariatric procedure can be lithogenic due to a hypersecretion of bile and the strong weight loss. A postoperative incidence of cholecystolithiasis in 50% has been described for RYGB. The current guidelines recommends primary cholecystectomy (CHE) in preoperative, symptomatic cholecytolithiasis and, if applicable, in preoperatively known gallstone disease [1]. Simultaneous CHE is not recommended in patients without gallstones. In case of a possibly resulting choledocholithiasis, RYGB is a challenge for the endoscopist. In these cases, laparoscopically assisted ERCP (LA ERCP) or double balloon enteroscopy for the establishment of ERCP (DB ERCP) has become established [41]. Furthermore, there is the possibility to place the duodenoscope laparoscopically assisted via a gastrostomy of the suspended stomach.

## **11. Conclusion**

This overview about the role of endoscopic diagnostic and interventions in obese patients with requiremet of bariatric procedures is certainly not complete and possibly some new and specialized techniques are not listed. Nevertheless we could show the immensely dimension of endoscopy in this field. Endoscopy is an essential part of diagnostics and therapy in the treatment of bariatric patients this applies to the pre- and postoperative phase. As bariatric endoscopy or endoscopic bariatric therapy, a large number of interventions have already been developed, which impress by their minimal invasiveness, low complication rates, manageable costs and good tolerability. Further revolutionary advances in the field of bariatric endoscopy can be expected in the medium term. Interventional endoscopy requires a high level of expertise and a learning curve. It can be expected an increasing number of primary bariatric endoscopic procedures will be performed and bariatric surgery will be relegated to the background due to peri-interventional complications and higher invasiveness.
