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DOI: 10.1055/a-2094-9794
Convergence of endobariatrics and endohepatology for evaluation and treatment of obesity and nonalcoholic fatty liver disease
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Endohepatology is an emerging field that utilizes diagnostic and therapeutic endoscopic ultrasound (EUS) to manage liver disease. In recent years, endoscopic sleeve gastroplasty (ESG) has emerged as a safe and effective approach to treating obesity and nonalcoholic fatty liver disease (NAFLD) [1]. We present a combined approach of endobariatrics and endohepatology with the concept of a “one-stop shop” to evaluate portal hypertension, obesity, and associated NAFLD treatment.
A 53-year-old woman with a body mass index of 47.4 kg/m2 and NAFLD was referred for evaluation for ESG. The patient was previously denied bariatric surgery after screening endoscopy revealed features of esophageal varicosities ([Fig. 1]). A decision was made to perform an assessment of portal hypertension and obtain a liver biopsy prior to ESG.
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EUS-guided portal pressure measurement directly measures the portal pressure gradient ([Fig. 2], [Fig. 3], [Video 1]) [2]. A transgastric, transhepatic puncture with a 25-gauge fine-needle aspiration needle equipped with a compound manometer (Cook Medical, Bloomington, Indiana, USA) was performed into the middle hepatic vein, and a portal vein was identified in order to measure the portal vein pressure. [Table 1] presents the portal pressure measurements. A liver sample from the left lobe was obtained via a transgastric puncture using a 19-gauge fine-needle biopsy needle, and pathology demonstrated moderate macro- and microsteatosis without significant fibrosis ([Video 1]).
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Video 1 Endoscopic ultrasound-guided portal pressure measurement and liver biopsy to evaluate nonalcoholic fatty liver disease, and endoscopic sleeve gastroplasty to treat class III obesity.
Qualität:
Argon plasma coagulation was used to mark and induce de-epithelialization to promote tissue apposition [3]. A ‘U’ pattern was adopted using an endoscopic suturing device (OverStitch; Apollo Endosurgery, Inc., Austin, Texas, USA), starting at the incisura-anterior surface, followed by the greater curvature and then the posterior wall ([Fig. 4], [Video 1]).
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At 1-year follow-up, the total weight loss percentage was 27 %, and FibroScan (Echosens, Paris, France) showed no steatosis or fibrosis.
Our case demonstrates the successful convergence of endohepatology and endobariatric techniques for evaluating portal hypertension with the measurement of portal pressure, diagnosis of NAFLD with EUS-guided liver biopsy, and treatment of obesity with ESG. These procedures work in parallel, allowing for a comprehensive, one-stop approach to diagnosing and managing NAFLD and obesity.
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E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).
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Publikationsverlauf
Artikel online veröffentlicht:
27. Juni 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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References
- 1 Hajifathalian K, Mehta A, Ang B. et al. Improvement in insulin resistance and estimated hepatic steatosis and fibrosis after endoscopic sleeve gastroplasty. Gastrointest Endosc 2021; 93: 1110-1118
- 2 Samarasena J, Chang KJ. Endo-hepatology: a new paradigm. Endosc Ultrasound 2018; 7: 219-222
- 3 Krishnan A, Shah-Khan SM, Hadi Y. et al. Use of a novel endoscopic tack and suture system for the management of pancreatocolonic fistula. VideoGIE 2022; 7: 455-457