Society for Surgery of the Alimentary Tract
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Stephanie Joseph*7,1, Christopher McGowan6, Pichamol Jirapinyo2, Allison R. Schulman3, Adarsh M. Thaker4, Barham K. Abu Dayyeh5, Julia R. Amundson7,8, Christopher J. Zimmermann7, Vanessa N. VanDruff8, Simon Che7, Shun Ishii7, Michael Ujiki7
1Surgery, Wayne State University School of Medicine, Detroit, MI; 2Brigham and Women's Hospital, Boston, MA; 3University of Michigan, Ann Arbor, MI; 4University of California Los Angeles, Los Angeles, CA; 5Mayo Foundation for Medical Education and Research, Rochester, MN; 6True You Weight Loss, Cary, NC; 7NorthShore University HealthSystem, Evanston, IL; 8University of Chicago Division of the Biological Sciences, Chicago, IL

Endoscopic sleeve gastroplasty (ESG) is an innovative minimally invasive bariatric procedure that has shown to be effective in achieving appropriate weight loss in moderately obese patients. It is a safe procedure with few adverse events documented. The steps to perform an ESG have been described by individual endoscopists performing this procedure, however, a true consensus of how to complete an ESG has not yet been established. This study will focus on establishing those steps with a panel of experts.

The Modified Delphi Method was used with the goal of establishing the key procedural steps of an ESG. A panel of 8 experts was selected of which 6 participated. The panel was selected based on their experience with performing the procedure and consisted of 1 bariatric surgeon and 5 interventional gastroenterologists. A neutral facilitator was designated and produced a skeletonized initial version of the key steps that was sent to each of the experts. Each survey began with the experts rating the given steps on a Likert scale of 1-5, with 1 being the most inaccurate and 5 being the most accurate. The final product was also rated. The survey continued with open-ended questions designed to revise and polish the key steps. Areas of discrepancy were addressed with binary questions and majority vote. Respondents were given 10 days to complete each survey. At the end of each round, the survey was then redistributed with updated key steps and questions. This process was continued for a predesignated three rounds.

Of the 8 experts that were queried 6/8, 5/8, and 5/8 replied to each round, respectively. The given ratings for the accuracy of the steps in each round were 4.2, 4.6, and 4.4. The final rating was 4.8. While expert opinion varied around smaller portions of the procedure, such as the placement of an overtube and the shape of each suture line, there was consensus on the need for full-thickness bites and an appropriate swirling of the tissue with the helix device. Whether or not to include the fundus in the gastroplasty was an additional area of discrepancy. 4/5 of the experts agreed that the fundus should remain intact. The final protocol consisted of 20 steps curated from the summarized responses of the experts (Table 1).

Using the Modified Delphi method, we have described 20 key steps to a safe, effective ESG. Establishing the key steps to the ESG will standardize performance across institutions and practitioners. Furthermore, these findings allow for the generation of educational assessment tools to facilitate training and increase the adoption of ESG by endoscopists.

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