Endoscopic Sleeve Gastroplasty for Obesity: a Multicenter Study of 248 Patients with 24 Months Follow-Up

Success Predictors of Endoscopic Sleeve Gastroplasty

OBJECTIVE

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that proved to be safe and effective in obesity treatment. However, not all subjects respond to treatment in the same way, and, with a view to personalized care, it is essential to identify predictors of success or failure.

METHODS

A retrospective 2-year followed-up cohort of ESG subjects was analyzed to investigate the presence of any baseline or early indicators of long-term optimal or suboptimal ESG outcomes.

RESULTS

A total of 315 subjects (73% women) were included, with 73% of patients exhibiting an Excess weight loss percentage (%EWL) >25% at the 24 months. Neither demographic parameters (age and sex), smoking habits, and menopause in women nor the presence of comorbidities proved potential predictive value. Interestingly, the %EWL at 1 month after ESG was the strongest predictor of 24-month therapeutic success. Subsequently, we estimated an "early threshold for success" for 1 month-%EWL by employing Youden's index method.

CONCLUSIONS

ESG is a safe and effective bariatric treatment that can be offered to a wide range of subjects. Early weight loss seems to impact long-term ESG results significantly and may allow proper early post-operative care optimization.

Semaglutide vs Endoscopic Sleeve Gastroplasty for Weight Loss

Importance

Obesity is a disease with a large socioeconomic burden. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric procedure with wide global adoption. More recently, new weight-loss medications, such as glucagon-like peptide-1 receptor agonists (eg, semaglutide), have attracted increased attention due to their efficacy. However, their cost-effectiveness over an extended period compared with ESG is a critical gap that needs to be better explored for informed health care decision-making.

Objective

To assess the cost-effectiveness of semaglutide compared with ESG over 5 years for individuals with class II obesity.

Design, Setting, and Participants

This economic evaluation study, conducted from September 1, 2022, to May 31, 2023, used a Markov cohort model to compare ESG and semaglutide, with a no-treatment baseline strategy. The study comprised adult patients in the US health care system with class II obesity (body mass index [BMI] of 35-39.9). The base case was a 45-year-old patient with class II obesity (BMI of 37). Patients undergoing ESG were subjected to risks of perioperative mortality and adverse events with resultant costs and decrement in quality of life.

Interventions

Strategies included treatment with semaglutide and ESG.

Main Outcomes and Measures

Costs (2022 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100 000/QALY. A 5-year time horizon with a cycle length of 1 month with a 3% discount rate was used. Probabilities, costs, and quality-of-life estimates of the model were derived from published literature. One-way, 2-way, and probabilistic sensitivity analyses were also performed.

Results

The model found that ESG was more cost-effective than semaglutide over a 5-year time horizon, with an ICER of -$595 532/QALY. Endoscopic sleeve gastroplasty added 0.06 QALYs and reduced total cost by $33 583 relative to semaglutide. The results remained robust on 1-way and probabilistic sensitivity analyses. Endoscopic sleeve gastroplasty sustained greater weight loss over 5 years vs semaglutide (BMI of 31.7 vs 33.0). To achieve nondominance, the annual price of semaglutide, currently $13 618, would need to be $3591.

Conclusions and Relevance

This study suggests that ESG is cost saving compared with semaglutide in the treatment of class II obesity. On price threshold analyses, a 3-fold decrease in the price of semaglutide is needed to achieve nondominance.

Endoscopic sleeve gastroplasty as an early tool against obesity: a multicenter international study on an overweight population

BACKGROUND AND AIMS

Endoscopic sleeve gastroplasty (ESG) is an effective, minimally invasive gastric remodeling procedure to treat mild and moderate obesity. Early adoption of ESG may be desirable to try to halt progression of obesity, but there are few data on its efficacy and safety for overweight patients.

METHODS

This was a multicenter, international, analytical case series. Six U.S., 1 Brazilian, 1 Mexican, and 1 Indian center were included. Overweight patients according to local practice undergoing ESG were considered eligible for the study. The end points were percent total weight loss (%TWL), body mass index (BMI) reduction, rate of BMI normalization, and rate of adverse events.

RESULTS

One hundred eighty-nine patients with a mean age of 42.6 ± 14.1 years and a mean BMI of 27.79 ± 1.17 kg/m2 were included. All procedures were successfully accomplished, and there were 3 intraprocedural adverse events (1.5%). The mean %TWL was 12.28% ± 3.21%, 15.03% ± 5.30%, 15.27% ± 5.28%, and 14.91% ± 5.62% at 6, 12, 24, and 36 months, respectively. At 12 and 24 months, 76% and 86% of patients achieved normal BMI, with a mean BMI reduction of 4.13 ± 1.46 kg/m2 and 4.25 ± 1.58 kg/m2. There was no difference in mean %TWL in the first quartile versus the fourth quartile of BMI in any of the time points. However, the BMI normalization rate was statistically higher in the first group at 6 and 12 months (6 months, 100% vs 48.5% [P < .01]; 12 months, 86.2% vs 50% [P < .01]; 24 months, 84.6% vs 76.1% [P = .47]; 36 months, 86.3% vs 66.6% [P = .26]).

CONCLUSIONS

ESG is safe and effective in treating overweight patients with high BMI normalization rates. It could help halt or delay the progression to obesity.

Performance of Endoscopic Sleeve Gastroplasty by Obesity Class in the United States Clinical Setting

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) has gained popularity over the past decade and has been adopted in both academic and private institutions globally. We present outcomes of the largest cohort of patients from the United States undergoing ESG and evaluate these according to obesity class.

METHODS

We performed a retrospective analysis of adult patients who underwent ESG. Medical information was abstracted from the electronic record with weight records up to 2 years after ESG. Percent total body weight loss (%TBWL) at 6, 12, 18, and 24 months was calculated based on baseline weight at the procedure. SPSS (version 29.0) was used for all statistical analyses.

RESULTS

A total of 1,506 patients from 7 sites were included (501 Class I obesity, 546 Class II, and 459 Class III). Baseline demographics differed according to obesity class due to differences in age, body mass index (BMI), height, sex distribution, and race. As early as 6 months post-ESG, mean BMI for each class dropped to the next lower class and remained there through 2 years. %TWBL achieved in the Class III group was significantly greater when compared with other classes at all time points. At 12 months, 83.2% and 60.9% of patients had ≥10% and ≥15% TBWL for all classes. There were no differences in adverse events between classes.

DISCUSSION

Real-world data from a large cohort of patients of all BMI classes across the United States shows significant and sustained weight loss with ESG. ESG is safe to perform in a higher obesity class with acceptable midterm efficacy.

Medium-Term Weight Loss and Remission of Comorbidities Following Endoscopic Sleeve Gastroplasty: a Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to determine the short- and medium-term weight loss outcomes and comorbidity resolution following endoscopic sleeve gastroplasty. Our search identified 35 relevant studies containing data from 7525 patients. Overall, pooled short-term (12 months) total weight loss (TWL) was 16.2% (95% CI 13.1-19.4%) in 23 studies (n = 5659). Pooled medium-term TWL was 15.4% (95% CI 13.7-17.2%) in 10 studies (n = 4040). Diabetes resolution was 55.4% (95% CI 46-64%), hypertension resolution was 62.8% (95% CI 43-82%), dyslipidaemia resolution was 56.3% (95% CI 49-63%), and obstructive sleep apnoea resolution was 51.7% (95% CI 16.2-87.3%) in four studies (n = 480). This pooled analysis demonstrates that ESG can induce durable weight loss and resolution of obesity-associated comorbidities in patients with moderate obesity.

A phenotypic approach to obesity treatment

Obesity is a chronic disease that increases morbidity and mortality and adversely affects quality of life. The rapid rise of obesity has outpaced the development and deployment of effective therapeutic interventions, thereby creating a global health crisis. The presentation, complications, and response to obesity treatments vary, yet lifestyle modification, which is the foundational therapeutic intervention for obesity, is often "one size fits all." The concept of personalized medicine uses genetic and phenotypic information as a guide for disease prevention, diagnosis, and treatment and has been successfully applied in diseases such as cancer, but not in obesity. As we gain insight into the pathophysiologic mechanisms of obesity and its phenotypic expression, specific pathways can be targeted to yield a greater, more sustained therapeutic impact in an individual patient with obesity. A phenotype-based pharmacologic treatment approach utilizing objective measures to classify patients into predominant obesity mechanism groups resulted in greater weight loss (compared with a non-phenotype-based approach) in a recent study by Acosta and colleagues. In this review, we discuss the application of lifestyle modifications, behavior therapy and pharmacotherapy using the obesity phenotype-based approach as a framework.

Endoscopic Sleeve Gastroplasty: A Practice Pattern Survey

PURPOSE

Obesity is a complex, chronic disease that is strongly associated with complications which cost the US healthcare system billions of dollars per year. Endoscopic sleeve gastroplasty (ESG) has emerged as a safe and effective procedure for treatment of obesity, but without practice guidelines there are likely to be variations practice. We sought to describe current practice patterns amongst endoscopists who perform ESG to help define areas of focus for future research and guideline development.

METHODS

We conducted an anonymous cross-sectional survey to examine practice patterns related to ESG. The survey was organized in 5 sections: Endoscopic Practice, Training, and Resources; Pre-ESG Evaluation and Payment Model; Perioperative/Operative Period; Post-operative Period; and Endobariatric Practice Other Than ESG.

RESULTS

A variety of exclusion criteria were reported by physicians performing ESG. Most respondents (n = 21/32, 65.6%) would not perform ESG for BMI under 27, and 40.6% (n = 13/32) would not perform ESG on patients with BMI over 50. The majority of respondents (74.2%, n = 23/31) reported ESG was not covered in their region, and most reported patients covered residual costs (67.7%, n = 21/31).

CONCLUSIONS

We found significant variability with respect to practice setting, exclusion criteria, pre-procedural evaluation, and medication use. Without guidelines for the selection of patients or standards for pre- and post-ESG care, substantial barriers to coverage will remain, and ESG will remain limited to those who can meet out-of-pocket costs. Larger studies are needed to confirm our findings, and future research should be focused on establishing patient selection criteria and standards in practices to provide guidance for endobariatric programs.

Advances in endobariatrics: past, present, and future

The obesity epidemic in the USA and worldwide is well documented and continues to grow. Endoscopic metabolic and bariatric therapies may offer a less invasive approach than surgical intervention. This article will review advances in endobariatrics over the last several decades, addressing the past and current state of bariatric and metabolic endoscopy. Food and Drug Administration-cleared devices and interventions currently under investigation are described including gastric devices, gastric remodeling procedures, small-bowel devices, duodenal ablation, as well as procedures to address weight regain after bariatric surgery. Future studies evaluating gastric and duodenal combination therapy, adjunctive pharmacotherapy, as well as individualized precision-health algorithms are underway.

A pilot study of implementation of endoscopic sleeve gastroplasty (ESG) in Norway

BACKGROUND AND AIM

Bariatric surgery is the most effective treatment for obesity but is invasive and associated with serious complications. Endoscopic sleeve gastroplasty (ESG) is a less invasive weight loss procedure to reduce the stomach volume by full-thickness sutures. ESG has been adopted in many countries, but implementation at Scandinavian centres has not yet been documented. We performed a clinical pilot trial at a Norwegian centre with the primary objective to assess the feasibility of the ESG procedure.

PATIENTS AND METHODS

We included the first 10 patients treated with ESG at a Norwegian centre in a single-arm pilot study. The eligibility criteria were either a body mass index (BMI) of 40-49.9 kg/m2, BMI 35-39.9 kg/m2 and at least one obesity-related comorbidity, or BMI 30-34.9 kg/m2 and type 2 diabetes. Patient follow-up resembled the scheme used for bariatric surgery at the center, including dietary plans and outpatient visits.

RESULTS

All procedures were technically successful except for one patient who had adhesions between the stomach and anterior abdominal wall, related to a prior hernia repair, resulting in less-than-intended stomach volume reduction. Mean total body weight loss (TBWL) after 26 and 52 weeks was 12.2% (95% CI 8.1-16.2) and 9.1% (95% CI 3.3 - 15.0). One patient experienced a minor suture-induced diaphragmatic injury, which was successfully managed conservatively.

CONCLUSIONS

This first Scandinavian clinical trial of ESG, documenting the implementation of the procedure at a Norwegian center, demonstrated acceptable feasibility and safety, with large variations in individual weight loss during the 52-week follow-up period.

Deep sedation versus orotracheal intubation for endoscopic sleeve gastroplasty (ESG): preliminary experience

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an emerging bariatric procedure currently performed under general anaesthesia with orotracheal intubation (OTI). Several studies have shown the feasibility of advanced endoscopic procedures under deep sedation (DS) without impacting patient outcomes or adverse event rates. Our goal was to perform an initial comparative analysis of ESG in DS with ESG under OTI.

METHODS

A prospective institutional registry was reviewed for ESG patients between 12/2016 and 1/2021. Patients were stratified into OTI or DS cohorts, and the 1st 50 cases performed in each cohort were included for comparability. Univariate analysis was performed on demographics, intraoperative, and postoperative outcomes (up to 90 days). Multivariate analyses evaluated the relationship between anesthesia type, preclinical and clinical variables.

RESULTS

Of the 50 DS patients, 21(42%) underwent primary and 29 (58%) revisional surgery. There was no significant differences in Mallampati score across groups. No DS patient required intubation. DS patients were younger (p = 0.006) and lower BMI (p = 0.002) than OTI. As expected, DS patients overall and in the primary subgroup had shorter operative time (p ≤ 0.001 and p = 0.003, respectively) and higher rates (84% DS vs. 20% OTI, p ≤ 0.001) of ambulatory procedures. There were no significant differences in the sutures used between groups (p = 0.616). DS patients required less postoperative opioids (p ≤ 0.001) and antiemetics (p = 0.006) than OTI. There were no significant differences in 3-month postoperative weight loss across cohorts. There was no rehospitalization in either group. In primary ESG cases, we found DS patients were more likely younger (p = 0.006), female (p = 0.001), and had a lower BMI (p = 0.0027).

CONCLUSIONS

ESG under DS is safe and feasible in select patients. We found DS safely increased rates of outpatient care, reduced use of opioids and antiemetics, and provided the same results of postoperative weight loss. Patient selection for DS may be more clearer for durable weight loss.

Management of diabesity: Current concepts

The global prevalence of obesity is increasing rapidly with an exponential rise in incidence of type 2 diabetes mellitus in recent years. ‘Diabesity’, the term coined to show the strong interlink between obesity and diabetes, is the direct cons-equence of the obesity pandemic, and poses significant challenges in the management of the disease. Without addressing the clinical and mechanistic complications of obesity such as metabolic-associated fatty liver disease and obstructive sleep apnoea, a rational management algorithm for diabesity cannot be developed. Several classes of anti-diabetic medications including insulins, sulphonylureas, thiazolidinediones and meglitinides are associated with the risk of weight gain and may potentially worsen diabesity. Therefore, appropriate selection of antidiabetic drug regimen is crucial in the medical management of diabesity. The role of non-pharmacological measures such as dietary adjustments, exercise interventions and bariatric procedures should also be emphasised. Unfortunately, the importance of appropriate and optimal management of diabesity is often overlooked by medical professionals when achieving adequate glycemic control which results in inappropriate management of the disease and its complications. This review provides a narrative clinical update on the evidence behind the management of diabesity.

Outcomes and Trends of Endoscopic Bariatric Therapies (EBT) Among Minority Populations

INTRODUCTION

Endoscopic bariatric therapies (EBT) have emerged as effective options for weight loss. While the benefits of EBT have been documented, data regarding such therapies among minority populations remains scant. We aim to investigate EBT trends and outcomes in minority populations.

METHODS

Data were extracted from the 2015 to 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) databases. Intragastric balloon (IGB) and endoscopic sleeve gastroplasty (ESG) cases were identified, and procedure volume assessed by year and race/ethnicity. Measures of interest included year-to-year mortality, surgical complications, and 30-day adverse outcomes.

RESULTS

Of 966,646 cases in the MBSAQIP databases, 5209 (0.54%) IGB and ESG cases were included. 10.7% were black, and 81.6% were female patients. Compared to white patients, black and Hispanic patients were younger (p < 0.01) with a higher body mass index (p < 0.001). Mortality (0.03% vs. 0% vs. 0%, p = 0.99), reoperation (1.1% vs. 0.8% vs. 0.6%, p = 0.30), and reintervention (3.9% vs. 3.2% vs. 2.3%, p = 0.09) rates were similar between racial/ethnic cohorts. All complications were similar between racial/ethnic cohorts, except a higher rate of venous thromboembolism, in Hispanic (1.04%, p < 0.01) compared to black (0.18%) and white (0.21%) patients. IGB and ESG were predominantly performed in white and Hispanic patients, respectively. ESG was associated with a higher leak (0.6% vs. 0.02%, p < 0.01) and venous thromboembolism (VTE) (1.0% vs. 0.12%, p < 0.01) rate.

CONCLUSION

While EBTs have increased annually, they are performed less in black patients. Future studies are needed to identify access barriers for black patients. They are safely performed with similar outcomes in racial/ethnic cohorts, except for a higher VTE rate in Hispanic patients.

Four-year outcomes for endoscopic sleeve gastroplasty from a single centre in India

Background

Bariatric endoscopy has emerged for non-surgical treatment of obesity, providing a treatment option for weight loss and associated comorbidities. Outcomes of endoscopic sleeve gastroplasty (ESG) of 12 months have been published by our team and there is a need for longer follow-up period understanding the effects of ESG techniques.

Aim

This report emphasises on weight loss pattern in follow-up time points and monitors the post-procedure improvement in comorbidities with minimum 4-year follow-up of patients undergoing ESG at a single academic centre in India.

Subjects and Methods

This was a prospective cohort study. All procedures were performed by the same surgeon. Patients with a body mass index of >30 kg/m² (or >27 with comorbidities) underwent ESG for treatment of obesity. Patients were systematically followed yearly after their procedure. Data collected on the primary outcome and secondary outcomes were analysed and presented.

Results

612 patients (69.3% female) with a mean age of 40.70 ± 12.66 years and mean body mass index of 34.30 ± 5.05 kg/m² underwent ESG. Out of 612 patients, follow-up rates for a 1-2-3 and 4 years were 93.1%, 90.2%, 81.7% and 81.9%, respectively. The mean percentage total body weight loss was 18.19% (95% confidence interval [CI]: 17.72-18.57) and %EWL was 49.30% (95% CI: 48.91-49.68) with 90% of participants-maintaining a percentage of total weight loss of ≥5% and 70% of patients maintaining an EWL of ≥25% at 4 years, respectively. Resolution/improvement of comorbidities was 51.2% cases of T2DM, 65.8% cases of hypertension, 73.6% cases of dyslipidaemia and 89.9% remission were in obstructive sleep apnoea. No patient required an emergency intervention, and there was no mortality or significant morbidity.

Conclusions

This study shows acceptable results with ESG at 4 years in our unit. Regular monitoring by a multidisciplinary nurtures weight loss, resolution or improvement of comorbidities and improvement of quality of life with low perioperative complications. There is a need for more reports with this approach to determine the amount and duration of weight loss outcome and medical intervention.

The Efficacy Comparison of Endoscopic Bariatric Therapies: 6-Month Versus 12-Month Intragastric Balloon Versus Endoscopic Sleeve Gastroplasty

INTRODUCTION

Intragastric balloon (IGB) insertion and endoscopic sleeve gastroplasty (ESG) are known to be effective and safe in achieving weight loss. The aim of this study was to compare the effects of a 6-month IGB therapy, a 12-month IGB therapy, and ESG.

METHODS

We retrospectively analyzed the weight loss at IGB (Orbera) removal after 6 months (124 patients), at IGB (Orbera365) removal after 12 months (61 patients) and at 6 and 12 months after ESG (42 and 34 patients, respectively). Postprocedural care, including medication and diet, was the same for all procedures.

RESULTS

Mean TBWL in patients undergoing IGB placement for 6 and 12 months and ESG after 6 and 12 months were 15.2, 15.8, 26.5, and 28.7 kg, respectively. There was no significant difference in the mean %TBWL in patients undergoing IGB placement for 6 or for 12 months (15.3% vs. 14.7%, P = 0.7). ESG patients showed a significantly higher mean %TBWL than IGB patients after 6 months (15.3 vs. 19.8, P = 0.005) and 12 months (14.7 vs. 22.5, P < 0.001).

CONCLUSION

All three studied methods were effective for achieving weight loss. However, there was no significant difference between 6-month and 12-month IGB therapies outcomes. ESG appeared to be a more effective obesity treatment modality than IGB.

Comparison of distal primary obesity surgery endolumenal techniques for the treatment of obesity (with videos)

BACKGROUND AND AIMS

Distal primary obesity surgery endolumenal (POSE) procedures involve plication of the gastric body, sparing the fundus. We aim to assess the efficacy of distal POSE procedures and to compare plication techniques (single-helix vs double-helix approaches).

METHODS

This is a prospective registry study of patients who underwent distal POSE procedures using 2 techniques: the single-helix plication technique, in which a single plication with serosa-to-serosa approximation is obtained with each device activation, and the double-helix plication technique, where 2 serosa-to-serosa plications with an internal mucosa-to-mucosa approximation are obtained with each device activation.

RESULTS

One hundred ten patients (90 women; mean age, 43 ± 13 years) underwent distal POSE procedures. Baseline body mass index was 38.2 ± 6.1 kg/m². Technical success was 100%. An average of 21 ± 5 plications were placed per case. The gastric body was shortened by 74%. At 12 months, patients experienced 15.8% ± 8.9% total weight loss (TWL) (P < .0001), with 93% and 61% achieving at least 5% and 10% TWL, respectively. Blood pressure, insulin resistance, and liver enzymes improved. The serious adverse event rate was .9%, including a case of gastric perforation. Of 110 patients, 42 and 68 underwent distal POSE procedures using a single- or double-helix technique, respectively. The double-helix technique resulted in greater reduction in gastric volume (length reduction by 78% vs 65%, P < .0001), weight loss (20.3% ± 8.3% vs 13.4% ± 8.3% TWL, P = .005), and proportion of patients achieving 10% TWL (94.7% vs 58.3%, P = .03) than the single-helix technique.

CONCLUSIONS

Distal POSE techniques appear to be effective at treating obesity and its related comorbidities. The double-helix technique is associated with greater gastric volume reduction, weight loss, and response rate.

Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an endolumenal, organ-sparing therapy for obesity, with wide global adoption. We aimed to explore the efficacy and safety of ESG with lifestyle modifications compared with lifestyle modifications alone.

METHODS

We conducted a randomised clinical trial at nine US centres, enrolling individuals aged 21-65 years with class 1 or class 2 obesity and who agreed to comply with lifelong dietary restrictions. Participants were randomly assigned (1:1·5; with stratified permuted blocks) to ESG with lifestyle modifications (ESG group) or lifestyle modifications alone (control group), with potential retightening or crossover to ESG, respectively, at 52 weeks. Lifestyle modifications included a low-calorie diet and physical activity. Participants in the primary ESG group were followed up for 104 weeks. The primary endpoint at 52 weeks was the percentage of excess weight loss (EWL), with excess weight being that over the ideal weight for a BMI of 25 kg/m². Secondary endpoints included change in metabolic comorbidities between the groups. We used multiple imputed intention-to-treat analyses with mixed-effects models. Our analyses were done on a per-protocol basis and a modified intention-to-treat basis. The safety population was defined as all participants who underwent ESG (both primary and crossover ESG) up to 52 weeks.

FINDINGS

Between Dec 20, 2017, and June 14, 2019, 209 participants were randomly assigned to ESG (n=85) or to control (n=124). At 52 weeks, the primary endpoint of mean percentage of EWL was 49·2% (SD 32·0) for the ESG group and 3·2% (18·6) for the control group (p<0·0001). Mean percentage of total bodyweight loss was 13·6% (8·0) for the ESG group and 0·8% (5·0) for the control group (p<0·0001), and 59 (77%) of 77 participants in the ESG group reached 25% or more of EWL at 52 weeks compared with 13 (12%) of 110 in the control group (p<0·0001). At 52 weeks, 41 (80%) of 51 participants in the ESG group had an improvement in one or more metabolic comorbidities, whereas six (12%) worsened, compared with the control group in which 28 (45%) of 62 participants had similar improvement, whereas 31 (50%) worsened. At 104 weeks, 41 (68%) of 60 participants in the ESG group maintained 25% or more of EWL. ESG-related serious adverse events occurred in three (2%) of 131 participants, without mortality or need for intensive care or surgery.

INTERPRETATION

ESG is a safe intervention that resulted in significant weight loss, maintained at 104 weeks, with important improvements in metabolic comorbidities. ESG should be considered as a synergistic weight loss intervention for patients with class 1 or class 2 obesity. This trial is registered with ClinicalTrials.gov, NCT03406975.

FUNDING

Apollo Endosurgery, Mayo Clinic.

Outcomes of Endoscopic Sleeve Gastroplasty in the Elder Population

Purpose

With the aging of the population and the epidemic spread of obesity, the frequency of older individuals with obesity is steadily growing. To date, no data evaluating the use of endoscopic sleeve gastroplasty (ESG) in the elderly have been published. In this case series, we evaluate the short- and medium-term outcomes of ESG in patients with obesity aged 65 years and older.

Materials and Methods

A retrospective analysis was done on a prospective database; patients aged 65 years and older were included in our analysis. EWL%, TBWL%, the Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire, and the presence of comorbidities were assessed.

Results

Eighteen patients aged 65 years and older underwent ESG between November 2017 and July 2021. The median age was 67 years and the mean baseline BMI was 41.2 kg/m². After ESG, the median TBWL% was 15.1%, 15.5%, and 15.5% at 6, 12, and 24 months, while the median %EWL was 39%, 37%, and 41% at 6, 12, and 24 months, respectively. The median BAROS score was 3.0, 3.4, and 2.5 at 6, 12, and 24 months, respectively. Six out of twelve patients with hypertension and 3/4 diabetic patients reduced or removed their medications within 12 months following ESG. Two out of six patients with OSA stopped therapy with CPAP. No adverse events were recorded.

Conclusion

According to our experience, ESG is a promising therapeutic option for elder individuals with obesity who fail non-invasive methods, and who refuse or are deemed not suitable for bariatric surgery because of age and comorbidities.

Graphical abstract

Safety of Endoscopic Sleeve Gastroplasty with a Single-Channel Endoscope

PURPOSE

Less invasive endoscopic bariatric procedures are under development for the management of class I of obesity. The purpose of our study is to evaluate the safety of endoscopic sleeve gastroplasty (ESG) using the new suturing device OverStitch Sx™.

MATERIALS AND METHODS

This is a retrospective single-center study over 191 patients using the ESG under general anesthesia with overnight inpatient observation between January 2019 and December 2020. The analyzed variables were adverse effects and change in body weight at 6 and 12 months of follow-up.

RESULTS

A total of 191 patients underwent ESG for primary obesity. There were 173 female (90.6%) with a mean age of 36.9 years. The mean BMI was 33.7 kg/m² (range: 28.9-54). There were no major intra-procedure adverse events. There were two postprocedural complications (1.04%), a transparietal suturing of falciform ligament which needed laparoscopic exploration for severe abdominal pain and a perigastric collection with antibiotic treatment, both with favorable outcome. Considering the weight loss results, the %TWL recorded was 22.4% for 84 patients (43.9%, 6 months' follow-up) and 18.7% for 69 patients (36.1%, 12 months' follow-up) with the mean EWL of 41.6% and respectively 34.7%. A total of 59 patients (30.9%) were lost follow-up and 12 patients underwent revisional bariatric procedure. According to ASGE definition, 53.8% (n = 71) reached > 25% of EWL.

CONCLUSION

Endoscopic gastroplasty represents a safe minimal invasive approach with the new device OverStitch Sx™ that can be considered an effective and well-tolerated procedure especially for primary obesity treatment.

Hierarchical task analysis of endoscopic sleeve gastroplasty

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic weight loss procedure used to treat obesity. The long-term goal of this project is to develop a Virtual Bariatric Endoscopy (ViBE) simulator for training and assessment of the ESG procedure. The objectives of this current work are to: (a) perform a task analysis of ESG and (b) create metrics to be validated in the created simulator.

METHODS

We performed a hierarchical task analysis (HTA) by identifying the significant tasks of the ESG procedure. We created the HTA to show the breakdown and connection of the tasks of the procedure. Utilizing the HTA and input from ESG experts, performance metrics were derived for objective measurement of the ESG procedure. Three blinded video raters analyzed seven recorded ESG procedures according to the proposed performance metrics.

RESULTS

Based on the seven videos, there was a positive correlation between total task times and total performance scores (R = 0.886, P = 0.008). Endoscopists expert were found to be more skilled in reducing the area of the stomach compared to endoscopists novice (34.6% reduction versus 9.4% reduction, P = 0.01). The mean novice performance score was significantly lower than the mean expert performance score (34.7 vs. 23.8, P = 0.047). The inter-rater reliability test showed a perfect agreement among three raters for all tasks except for the suturing task. The suturing task had a significant agreement (Inter-rater Correlation = 0.84, Cronbach's alpha = 0.88). Suturing was determined to be a critical task that is positively correlated with the total score (R = 0.962, P = 0.0005).

CONCLUSION

The task analysis and metrics development are critical for the development of the ViBE simulator. This preliminary assessment demonstrates that the performance metrics provide an accurate assessment of the endoscopist's performance. Further validation testing and refinement of the performance metrics are anticipated.

Safety and efficacy of endoscopic sleeve gastroplasty for obesity management in new bariatric endoscopy programs: a multicenter international study

Background:

Endoscopic sleeve gastroplasty (ESG) is an incisionless procedure that reduces the size of the gastric cavity. In prior studies, it has been proven to be a safe and effective treatment for obesity. In this study, we performed a collaborative study to evaluate the effectiveness of ESG among new endobariatric programs.

Methods:

This was an international, multicenter study reviewing the outcomes of ESG in centers starting ESG programs. Total body weight loss, change of body mass index (BMI), excess body weight loss (EBWL), technical success, duration of hospitalization, and immediate and delayed adverse events and complications at 24 h, 1 week, and 1, 3, and 6 months post-procedure were evaluated.

Results:

A total of 91 patients (35 males) from six centers were included. The patients’ mean BMI before the procedure was 38.7 kg/m². BMI reduction at 3 months was 7.3 (p < 0.000), at 6 months 9.3 (p < 0.000), and at 12 months 8.6 (p < 0.000) from baseline. EBWL was 17.3% at 1 month (p < 0.000), 29.2% at 3 months (p < 0.000), and 35.6% at 6 months (p < 0.000). The mean procedure duration was 85.1 min. The mean length of hospital stay post-procedure was 27 h.

Conclusion:

ESG provides EBWL percentage sustained up to 12 months. These results are equivalent among the new ESG centers compared to previous studies by expert centers.

Lay title

Endoscopic sleeve gastroplasty in new bariatric endoscopy programs:

Plain Language Summary

This article is the result of a collaborative international study on new endoscopic programs offering endoscopic sleeve gastroplasty.

The minimally invasiveness and increasing accessibility of this technique makes it very attractive for patients with obesity while being poor candidate for surgery or refusing surgery.

This study will also provide valuable information regarding this rising technique of endobariatric treatment.

Primary Bariatric Procedures

Obesity is pandemic. It is estimated that by 2030, half of the U.S. population will have obesity. Current treatment options for obesity includes lifestyle modification, pharmacotherapy, endoscopic bariatric and metabolic therapy (EBMT) and bariatric surgery. Over the past decades, an increasing number of EBMTs have been developed and become available. As a gastroenterologist, it is therefore important to become familiar with the available EBMTs as well as their safety and efficacy profiles in order to educate and expeditiously refer patients for the appropriate therapy when eligible. This chapter will review currently available and upcoming EBMTs. Details on how the procedures are performed, their mechanisms of action as well as data from pivotal studies will be summarized.

Endoscopic bariatrics: current therapies and future directions

Endoscopic bariatric therapies (EBTs) are endoscopic procedures indicated for weight loss in the obese population. They are shown to be safe and effective for patients who do not quality for bariatric surgery. There are currently no randomized controlled studies comparing bariatric surgery with EBTs. However, EBTs are more cost effective and have fewer complications. This review will examine currently available EBTs with published data.

Persistence of Sutures and Gastric Reduction After Endoscopic Sleeve Gastroplasty: Radiological and Endoscopic Assessment

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an effective medium-term procedure for obesity treatment. There are no consistent studies confirming persistence of maintained gastric tubular configuration. We determined sleeve duration, gastric reduction degree, and suture persistence at 12-month follow-up.

PATIENTS AND METHODS

This is a prospective, single-center study, including patients with obesity undergoing ESG with at least 1-year follow-up, who underwent the following: (1) Barium X-ray study (BS) prior and at 6 months, assessing degree of gastric reduction (severe, moderate, or mild), and (2) gastroscopy at 12 months, accounting the number of persistent sutures (tense, lax, or absent). Secondary outcomes were weight loss data and procedure safety profile.

RESULTS

Thirty-eight patients (30 women), median age of 47.0 [40.0-51.0] years, and average baseline BMI of 37.6 [35.5-41.5] kg/m² were included. Median %TWL of 17.1% [16.1-22.3%] with TWL > 10% in 94.7% of patients was obtained at 1 year. No major AEs were observed. Six months BS was performed on 30 patients: 12 (40.0%), 14 (46.7%), and 4 (13.3%) patients showed severe, moderate, and mild gastric reduction, respectively. Twelve months gastroscopy was performed on 22 patients with 83.64% of sutures persisting (92 of 110, mean 4.2 of 5.0 sutures/patient) and 70.9% with adequate tension. We found intact sutures in 12 patients (54.5%), and 10 patients (45.5%) had some suture detached (average 1.8, r = 1-3). There were no differences in %TWL according to BS reduction (p = 0.662) or number of persistent sutures (p = 0.678).

CONCLUSIONS

ESG is an effective and safe weight loss strategy at 12-month follow-up with persistence of most sutures and maintenance of notable gastric reduction and remodeling.

Endoscopic sleeve gastroplasty

Since its first description in 2013, robust evidence supporting the efficacy and safety of the endoscopic sleeve gastroplasty (ESG) has been on the rise. A large case series and meta-analysis report supported results up to 24 months, while some other studies already described 5-year data. If associated with pharmacotherapy, the ESG may help one to achieve weight loss similar to that of surgical sleeve gastrectomy. Though the results of the ongoing randomized trials on ESG are awaited, currently available data support the clinical use of the ESG, especially for patients who are refusing or unfit for bariatric surgery.

Efficacy and safety of endoscopic sleeve gastroplasty and laparoscopic sleeve gastrectomy with 12+ months of adjuvant multidisciplinary support

Background

The laparoscopic sleeve gastrectomy (LSG) and the incisionless endoscopic sleeve gastroplasty (ESG) weight loss procedures require further investigation of their efficacy, safety and patient-centered outcomes in the Australian setting.

Methods

The aim was to examine the 6- and 12-month weight loss efficacy, safety, and weight-related quality of life (QoL) of adults with obesity who received the ESG or LSG bariatric procedure with 12+ months of adjuvant multidisciplinary pre- and postprocedural support. Data were from a two-arm prospective cohort study that followed patients from baseline to 12-months postprocedure from a medical center in Queensland. Percent excess weight loss (%EWL) was the primary outcome. Secondary outcomes were body composition (fat mass, fat-free mass, android:gynoid ratio, bone mineral content) via dual energy X-ray absorptiometry, weight-related QoL, lipid, glycemic, and hepatic biochemistry, and adverse events.

Results

16 ESG (19% attrition; 81.2% female; aged:41.4 (SD: 10.4) years; BMI: 35.5 (SD: 5.2) kg/m²) and 45 LSG (9% attrition; 84.4% female; aged:40.4 (SD: 9.0) years; BMI: 40.7 (SD: 5.6) kg/m²) participants were recruited. At 12-months postprocedure, ESG %EWL was 57% (SD: 32%; p < 0.01) and LSG %EWL was 79% (SD: 24%; p < 0.001). ESG and LSG cohorts improved QoL (19.8% in ESG [p > 0.05]; 48.1% in LSG [p < 0.05]), liver function (AST: − 4.4 U/L in ESG [p < 0.05]; − 2.7 U/L in LSG [p < 0.05]), HbA1c (− 0.5% in ESG [p < 0.05]; − 0.1% in LSG [p < 0.05]) and triglycerides (− 0.6 mmol/L in ESG [p > 0.05]; − 0.4 mmol/L in LSG [P < 0.05]) at 12-months. Both cohorts reduced fat mass (p < 0.05). The ESG maintained but LSG decreased fat-free mass at 6-months (p < 0.05); and both cohorts lost fat-free mass at 12-months (p < 0.05). There were no adverse events directly related to the procedure. The ESG reported 25% mild-moderate adverse events possibly related to the procedure, and the LSG reported 27% mild-severe adverse events possibly related to the procedure.

Conclusions

In this setting, the ESG and LSG were safe and effective weight loss treatments for obese adults alongside multidisciplinary support. Patients who elected the ESG maintained fat-free mass at 6-months but both cohorts lost fat-free mass at 12-months postprocedure. Patients who elected the LSG had large and significant improvements to weight-related quality of life. Further well-powered studies are required to confirm these findings.

Trial registration

This study was registered prospectively at the Australia New Zealand Clinical Trials Registry on 06/03/2018, Registration Number ACTRN12618000337279.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01629-7.

Review about Psychological Barriers to Lifestyle Modification, Changes in Diet Habits, and Health-Related Quality of Life in Bariatric Endoscopy

Obesity is an expanding disease responsible for significant deterioration in the Health-Related Quality of Life (HRQL) of those who suffer from it. Bariatric Endoscopy (BE) therapies have proven to be an effective treatment for this pathology. A multidisciplinary approach is essential for the successful therapeutic management of BE. This article addresses the multidisciplinary treatment of BE by considering the possible variables that can influence treatment. In particular, the variables that can facilitate or hinder changes in patients’ habits are discussed. These include the neuropsychological, emotional, and social implications that may influence the formation of healthy habits necessary for improvement in a patient’s quality of life; the individual and environmental psychological factors that influence the monitoring of nutritional and physical activity indications; and different psychological disorders such as depression, anxiety, or disorders related to eating. The main objective of BE treatment, except in certain special biological situations, must be to establish a long-term sustainable change in habits such that patients, once they reach a healthy weight, do not revert to the lifestyle that caused their obesity, as well as identifying and addressing major problems that may exist prior to, or arise during, treatment.

OverStitch Sx Endoscopic suturing system in minimally invasive endoscopic procedures: overview of its safety and efficacy and comparison to oversticthTM

INTRODUCTION

OverStitch endoscopic suturing enables advanced closure by tissue approximation via endoscopically placed sutures with the ability to customize suture patterns. Newer OverStitch generation also known as OverStitch Sx overcame the limitation of the previous generation and is compatible with 20 single channel scopes over four platforms with greater maneuverability and visibility.

AREAS COVERED

In this article we will focus on the differences between three generations of OverStitch. In addition, we will review existing literature on the efficacy of OverStitch in the management of full thickness defect closure, fistula and leaks repair, stent fixation, and bariatric surgeries along with its complications and limitations.

EXPERT OPINION

Assembling overstitch takes less than five minutes and the correct sequence of system assembly is the key for a successful procedure. Transition from the second-generation OverStitch to OverStitch Sx may require three to five cases for learning curve.

Personalized Approach for Obese Patients Undergoing Endoscopic Sleeve Gastroplasty

Obesity is a chronic, relapsing disease representing a major global health problem in the 21st century. Several etiologic factors are involved in its pathogenesis, including a Western hypercaloric diet, sedentariness, metabolic imbalances, genetics, and gut microbiota modification. Lifestyle modifications and drugs often fail to obtain an adequate and sustained weight loss. To date, bariatric surgery (BS) is the most effective treatment, but only about 1% of eligible patients undergo BS, partly because of its negligible morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, endoscopic, bariatric procedure, which proved to be safe and effective. In this review, we aim to examine evidence supporting the role of a personalized and multidisciplinary approach, guided by a multidisciplinary team (MDT), for obese patients undergoing ESG, from patient selection to long-term follow-up. The cooperation of different health professionals, including an endocrinologist and/or obesity medicine physician, a bariatric surgeon, an endoscopist experienced in bariatrics, a registered dietitian, an exercise specialist, a behaviour coach, a psychologist, and a nurse or physician extender, aims to induce radical and sustained lifestyle changes. We also discussed the relationship between gut microbiota and outcomes after bariatric procedures, speculating that the characterization of gut microbiota before and after ESG may help develop new tools, including probiotics, to optimize weight loss outcomes.

Advances in gastrointestinal surgical endoscopy

Surgeons have a role in observing, detect abnormalities, disease, and other deficiencies in function which could be treated. Diagnosing and treating back days were challenging for many reasons. However, technology's innovation enhances surgeons' ability to treat their patients. The term endoscopy refers to the Greek prefix endo- ("within") and the verb skopein ("to view or observe"). Endoscopy is practical both in the diagnosis and treatment of various pathologies. Technological advances, especially in endoscopy, gradually progress and discover many possibilities which allow rapid advancement. Endoscopy development aims to assess human orifice that has not been inspected, probed, and examined over the centuries. Endoscopy over these decades is improving, which led to new problem solving using advanced technological approaches. Thus, a surgeon can solve any issues from examination, diagnosis, and treatment using progressive endoscopy evolution. This review delivers a brief history of advances in surgical endoscopy and describes current endoscopy development.

Efficacy and Mechanisms of Gastric Volume-Restriction Bariatric Devices

Obesity is a chronic disease that affects over 795 million people worldwide. Bariatric surgery is an effective therapy to combat the epidemic of clinically severe obesity, but it is only performed in a very small proportion of patients because of the limited surgical indications, the irreversibility of the procedure, and the potential postoperative complications. As an alternative to bariatric surgery, numerous medical devices have been developed for the treatment of morbid obesity and obesity-related disorders. Most devices target restriction of the stomach, but the mechanism of action is likely more than just mechanical restriction. The objective of this review is to integrate the underlying mechanisms of gastric restrictive bariatric devices in obesity and comorbidities. We call attention to the need for future studies on potential mechanisms to shed light on how current gastric volume-restriction bariatric devices function and how future devices and treatments can be further improved to combat the epidemic of obesity.

Endoscopic Approaches to Obesity Management

The field of endoscopic bariatric and metabolic therapy has rapidly evolved from offering endoscopic treatment of weight regain following bariatric surgery to providing primary weight loss options as alternatives to pharmacologic and surgical interventions. Gastric devices and remodeling procedures were initially designed to work through a mechanism of volume restriction, leading to earlier satiety and reduced caloric intake. As the field continues to grow, small bowel interventions are evolving that may have some effect on weight loss but focus on the treatment of obesity-related comorbidities. Future implementation of combination therapy that utilizes both gastric and small bowel interventions offers an exciting option to further augment weight loss and alleviate metabolic disease. This review considers gastric devices and techniques including space-occupying intragastric balloons, aspiration therapy, endoscopic tissue suturing, and plication interventions, followed by a review of small bowel interventions including endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically delivered devices to create incisionless anastomoses. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Endoscopic bariatric therapies for obesity: a review

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two-thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15-20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.

Endoscopic sleeve gastroplasty requiring conversion to partial gastrectomy with paraesophageal hernia repair

Endoluminal bariatric surgery has lower costs and perceived risks compared to traditional surgery. Endoluminal procedures are a newer approach to weight loss but long-term outcomes and complications continue to emerge. This case report is an endoscopic sleeve gastroplasty that resulted in a paraesophageal hernia repair with removal of gastroplasty sutures and partial gastrectomy.

Five-Year Outcomes of Endoscopic Sleeve Gastroplasty for the Treatment of Obesity

BACKGROUND AND AIMS

The growing burden of obesity as a chronic disease necessitates a multifaceted approach to management. There has been an increase in the number of available endoscopic therapies for weight management with endoscopic sleeve gastroplasty (ESG) proving to be one of the best options. The long-term efficacy of ESG for management of obesity is not known. This study sought to assess the long-term safety and efficacy of ESG for treatment of obesity.

METHODS

This was a prospective cohort study. Participants underwent ESG in a single academic center, and were prospectively enrolled. All procedures were performed by the same therapeutic endoscopist. Patients with a body mass index of >30 kg/m2 (or >27 with comorbidities), who underwent ESG from August 2013 to August 2019 for treatment of obesity were enrolled. Patients were followed for up to 5 years after their procedure. The primary outcome was weight loss at 5 years after the procedure (% total body weight loss, TBWL) RESULTS: 216 patients (68% female) with a mean age of 46±13 years, and mean BMI of 39±6 kg/m² underwent ESG. Out of 216 patients, 203, 96, and 68 patients were eligible for a 1-, 3-, and 5-year follow up, with complete follow-up rates of 70%, 71%, and 82%, respectively. At 5 years, mean TBWL was 15.9% (95% CI, 11.7-20.5, p < .001) and 90 and 61% of patients maintained 5 and 10% TBWL, respectively. There was an overall rate of 1.3% moderate adverse events (AEs), without any severe or fatal AEs.

CONCLUSIONS

Our results suggest that ESG is safe and effective for treatment of obesity, with durable long-term results for at least up to 5 years after the procedure. This procedure should be considered as a reliable option for treatment of obesity.

Improvement in insulin resistance and estimated hepatic steatosis and fibrosis after endoscopic sleeve gastroplasty

BACKGROUND AND AIMS

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the United States and is closely associated with obesity and insulin resistance (IR). Weight loss is the best treatment for NAFLD. Endoscopic sleeve gastroplasty (ESG) is a promising endoscopic procedure for treatment of obesity. Our aim is to evaluate the change in IR and estimated hepatic steatosis and fibrosis after ESG.

METHODS

One hundred eighteen patients with obesity and NAFLD underwent ESG and were followed for 2 years. Weight loss was evaluated as % total body weight loss. IR was evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR). The previously validated hepatic steatosis index and NAFLD fibrosis score were used to estimate hepatic steatosis and risk of fibrosis.

RESULTS

Patients' mean body mass index was 40 ± 7 kg/m² at baseline. Eighty-four percent of patients completed 2 years of follow-up. At 2 years, the mean total body weight loss was 15.5% (95% confidence interval, 13.3%-17.8%). Patients' HOMA-IR improved significantly from 6.7 ± 11 to 3.0 ± 1.6 after only 1 week from ESG (P = .019) with continued improvement up to 2 years (P = .03). Patients' hepatic steatosis index score improved significantly, decreasing by 4 points per year (P for trend, <.001). Patients' NAFLD fibrosis score improved significantly, decreasing by 0.3 point per year (P for trend, .034). Twenty-four patients (20%) improved their risk of hepatic fibrosis from F3-F4 or indeterminate to F0-F2, whereas only 1 patient (1%) experienced an increase in the estimated risk of fibrosis (P = .02).

CONCLUSIONS

Our results suggest a significant and sustained improvement in estimated hepatic steatosis and fibrosis after ESG in patients with NAFLD. Importantly, we showed an early and weight-independent improvement in insulin resistance, which lasted for 2 years after the procedure.

Endoscopic Sleeve Gastroplasty (ESG) for High-Risk Patients, High Body Mass Index (> 50 kg/m2) Patients, and Contraindication to Abdominal Surgery

BACKGROUND

For high-risk classified patients, patients with superobesity and in cases of contraindication to abdominal surgery, traditional bariatric surgery might lead to potential morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a novel and effective bariatric therapy for morbidly obese patients. Our research group initially evaluated the safety, feasibility, and efficacy of ESG for high-risk, high body mass index (BMI) patients, and patients contraindicated to abdominal surgeries.

METHODS

Eligible patients characterized as high-risk for bariatric surgery due to high-BMI, severe comorbidities, or impenetrable abdomen were prospectively documented. ESG was performed by using Overstich® (Apollo Endosurgery, Austin, TX, USA). Primary outcomes included technical success, post-procedure adverse events and mortality, and the change of weight and BMI.

RESULTS

ESG was successfully performed for all patients (N = 24, mean age was 55.6 (± 9.2) years old, 75% male). Baseline weight and BMI were 157.9 (± 49.1) kg and 49.9 (± 14.4) kg/m². According to Edmonton Obesity Staging System (EOSS), 8 (33.3%), 14 (58.3%), and 2 (8.3%) patients were respectively classified as EOSS 2, 3, and 4. Mean operation time was 114.7 (± 26.0) min, without intraoperative complication. Weight loss, BMI reduction, %total weight loss (%TWL), and %excess weight loss (%EWL) were 17.5 (± 14.6) kg, 5.6 (± 4.6) kg/m², 12.2% (± 8.9%), and 29.1% (± 17.9%) at post-ESG 12-month, respectively. One (4.2%) moderate post-procedure adverse event (gastric mucosal bleeding) was observed.

CONCLUSIONS

ESG can be used as a safe, feasible, and effective option for the therapy of patients with superobesity, high-risk patients, and patients contraindicated to abdominal surgery. Graphical Abstract.

The First Study Evaluating Effectiveness and Safety of the Endoscopic Sleeve Gastroplasty in HIV Patients

The authors evaluated, retrospectively, the endoscopic sleeve gastroplasty impact in seven HIV patients, regarding effectiveness and safety outcomes. The mean baseline body mass index (BMI) was 33.76 kg/m². The mean baseline CD4+ cell count was 690.43 cells/mm³, and the baseline viral load was undetectable. After 6 months, absolute weight loss, percentage of excess weight loss, percentage total weight loss, and BMI reduction were 20.2 ± 2.6 kg, 85.5 ± 11.1%, 21.3 ± 2.4%, and 7.1 ± 0.8 kg/m², respectively. No patients presented severe adverse events. After 6 months, the viral load remained undetectable and the mean CD4+ cell count was 710.57 cells/mm³. The endoscopic sleeve gastroplasty is an effective and safe procedure to perform in obese HIV patients.

AGA Technical Review on Intragastric Balloons in the Management of Obesity

Several strategies are available to address the obesity epidemic and range from noninvasive lifestyle interventions to medications and bariatric surgical procedures. Endoscopic bariatric techniques, such as intragastric balloons, have become an attractive alternative as a tool for weight loss that can augment the effect of lifestyle interventions. This technical review includes multiple systematic reviews performed to support a clinical practice guideline by the American Gastroenterological Association on the role of intragastric balloons as a tool for weight loss. The systematic reviews targeted a priori selected clinical questions about the effectiveness and periprocedural care of intragastric balloons and concomitant and subsequent weight-loss strategies.

Systematic Review of Innovation Reporting in Endoscopic Sleeve Gastroplasty

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic procedure used to treat obesity-related comorbidities. Whilst its use is increasing in clinical practice, there is comparatively little understanding about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of ESG in the context of guidelines for evaluating innovative surgical devices and procedures.

METHODS

Systematic searches were used to identify all published studies reporting ESG insertion. Data collected included patient selection, governance arrangements, proceduralist expertise, technique description and outcome reporting.

RESULTS

Searches identified 2289 abstracts; 37 full-text papers were included (one prospective comparative cohort study, 16 retrospective cohort studies, 17 prospective cohort studies and three case reports). No randomized trials were identified. Eighteen studies were conducted prospectively. The number of patients in the included studies ranged from 1 to 1000. The lower BMI limit ranged from 27 to 35 kg/m². Research approvals were reported in 26 studies. Two studies reported on the learning curve. All studies reported some aspect of technical implementation, but many variations were noted. Suturing device used and suture pattern were the most commonly reported aspects (32 studies). Follow-up ranged from 1 to 24 months, but was 12 months or less in 28 studies. Forty-eight different outcomes were reported across all studies.

CONCLUSION

The literature on ESG has demonstrated some progression in reporting and analysis and the next stage of assessment should be a randomized controlled trial to demonstrate efficacy.

The current state of bariatric endoscopy

A variety of endoscopic bariatric and metabolic treatments (EBMTs) have been developed in recent years to combat the growing prevalence of obesity in the United States (US) and worldwide. This manuscript reviews the current state of bariatric endoscopy, detailing all US Food and Drug Administration (FDA) approved EBMTs including space-occupying intragastric balloons (IGBs), aspiration therapy, and endoscopic tissue apposition devices. Additionally, this review describes non-FDA approved treatments including additional IGBs, endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically placed anastomosis devices.

Endoscopic sleeve gastroplasty, laparoscopic sleeve gastrectomy, and laparoscopic greater curve plication: do they differ at 2 years?

Endoscopic sleeve gastroplasty (ESG) is an effective treatment option for obesity. However, data comparing its efficacy to bariatric surgery are scarce. We aimed to compare the effectiveness and safety of ESG with laparoscopic sleeve gastrectomy (LSG) and laparoscopic greater curve plication (LGCP) at 2 years. METHODS : We reviewed 353 patient records and identified 296 patients who underwent ESG (n = 199), LSG (n = 61), and LGCP (n = 36) at four centers in Spain between 2014 and 2016. We compared their total body weight loss (%TBWL) and safety over 2 years. A linear mixed model (LMM) was used to analyze repeated measures of weight loss outcomes at 6, 12, 18, and 24 months to compare the three procedures. RESULTS : Among the 296 patients, 210 (ESG 135, LSG 43, LGCP 32) completed 1 year of follow-up and 102 (ESG 46, LSG 34, LGCP 22) reached 2 years. Their mean (standard deviation [SD]) body mass index (BMI) was 39.6 (4.8) kg/m². There were no differences in age, sex, or BMI between the groups. In LMM analysis, adjusting for age, sex, and initial BMI, we found ESG had a significantly lower TBWL, %TBWL, and BMI decline compared with LSG and LGCP at all time points (P = 0.001). The adjusted mean %TBWL at 2 years for ESG, LSG, and LGCP were 18.5 %, 28.3 %, and 26.9 %, respectively. However, ESG, when compared with LSG and LGCP, had a shorter inpatient stay (1 vs. 3 vs. 3 days; P < 0.001) and lower complication rate (0.5 % vs. 4.9 % vs. 8.3 %; P = 0.006). CONCLUSION : All three procedures induced significant weight loss in obese patients. Although the weight loss was lower with ESG compared with other techniques, it displayed a better safety profile and shorter hospital stay.

Endoscopic sleeve gastroplasty (ESG) for morbid obesity: how effective is it?

INTRODUCTION

ESG is an effective treatment for classes I and II obesity. However, the benefit of ESG in patients with morbid obesity (BMI ≥ 40 kg/m²) who decline surgery is not known. The study aims to compare the effectiveness and safety of ESG in all three obesity classes at 1 year.

METHODS

We reviewed 484 patient records and identified 435 patients (class I: 105, class II: 169, class III: 161) who underwent ESG at our unit between May 2013 and March 2020. We compared their total body weight loss (%TBWL) and safety over 1 year. We used a linear mixed model (LMM) to analyse repeated measures of weight loss outcomes at 3, 6, 9, and 12 months for comparison between the three BMI groups.

RESULTS

Among the 435 patients, 396 patients (class I: 99, class II: 151, class III: 146) completed 6 months, and 211 patients reached 1 year (class I: 50, class II: 77, class III: 84). There was no difference in age between the groups. In LMM analysis, adjusting for age and sex, we found ESG had a significantly higher TBWL, %TBWL, and BMI decline in class III compared to classes I and -II obesity at all time points (p < 0.001). The adjusted mean %TBWL at 1 year with classes I, -II, and -III obesity was 16.5%, 18.2%, and 20.5%, respectively. The overall complication rate and the hospital stay was identical in the three groups.

CONCLUSION

ESG induced significant weight loss in all classes of obesity. In class III obesity, the weight loss achieved was significantly higher at 1 year. In patients declining or unsuitable for surgery, ESG could be considered as an alternative treatment option.

Endoscopic gastroplasty: an effective solution in a high-risk patient with morbid obesity

A 61-year-old man was referred to the bariatric endoscopy unit for the management of morbid obesity (BMI 47 kg/m²). He had multiple obesity-related medical comorbidities. His weight gain started 8 years after suffering smoke inhalation syndrome following an industrial accident. He sustained permanent lung parenchymal injury resulting in impaired pulmonary function. His mobility was restricted to a wheelchair and was dependent on long term oxygen therapy. He tried diet and lifestyle intervention but could not achieve significant weight loss. He was referred for bariatric surgery but was declined because of substantial comorbidities, poor pulmonary function, anesthetic risk (ASA Class 4), and risk of complications. After depleting all of his options, he sought us for endoscopic therapy. Following a successful collaboration with the anesthetist, endocrinologist, and nutritionist, we performed an endoscopic gastroplasty using the modified primary obesity surgery endoluminal procedure (POSE-2) and reduced the gastric volume. He recovered immediately without complications and achieved significant weight loss at 10 months (41 kg). He is now able to walk, the oxygen requirements have decreased, and the comorbidities have significantly improved.

Endobariatric procedures for obesity: clinical indications and available options

Obesity remains a growing public health epidemic that has increased healthcare costs and related comorbidities. Current treatment guidelines encourage a multidisciplinary approach starting from patient selection, interventions, and long-term follow-up to maintain weight loss. However, these conservative interventions are largely ineffective at reducing body weight due to low adherence to the treatment regimen. Recently, endoscopic bariatric therapies have become an attractive alternative to traditional invasive bariatric surgeries due to their improved efficacy, safety, and cost-effectiveness. Endoscopic bariatric therapies include intragastric balloon placement, endoscopic sleeve gastroplasty, gastric bypass revision, and aspiration therapy. These procedures fall into two separate categories depending on the primary mechanism involved: restrictive or malabsorptive. Restrictive methods, such as the Orbera® and ReShape™ intragastric balloons, increase satiation and delay gastric emptying while decreasing the amount of food that can be ingested. In contrast, malabsorptive devices, such as the EndoBarrier®, interfere with the small intestine's ability to absorb food while restoring normal gastrointestinal hormone levels regulating satiation. Together, these techniques provide useful alternatives for patients in whom pharmacological or lifestyle modifications have proven ineffective. Despite these advantages, the long-term effects of these procedures on metabolic changes remain to be studied. Furthermore, the management of complications from these procedures continues to evolve. In this review, we aim to elaborate on the clinical indications and efficacy of the endobariatric procedures, together with various types of available endoscopic bariatric therapy procedures.

Laparoscopic sleeve gastrectomy versus endoscopic sleeve gastroplasty: a systematic review and meta-analysis

Background and study aims  Laparoscopic sleeve gastrectomy (LSG) is the current standard for bariatric surgery, but it is affected by several postoperative complications. Endoscopic sleeve gastroplasty (ESG) was created as a less invasive alternative to LSG. However, its efficacy and safety compared with LSG is unclear. Materials and methods  Relevant publications were identified in MEDLINE/Cochrane/EMBASE/OVID/ PROSPERO and NIH up to January 2020. Studies were selected that included obese patients with a baseline body mass index (BMI) between 30 and 40 kg/m² with a minimum of 12 months of follow-up and with reported incidence of complications. The mean difference in percentage of excess weight loss (%EWL) at 12 months between LSG and ESG represented the primary endpoint. We also assessed the difference in pooled rate of adverse events. The quality of the studies and heterogeneity among them was analyzed. Results  Sixteen studies were selected for a total of 2188 patients (LSG: 1429; ESG: 759) with a mean BMI 34.34 and 34.72 kg/m² for LSG and ESG, respectively. Mean %EWL was 80.32 % (± 12.20; 95 % CI; P  = 0.001; I² = 98.88) and 62.20 % (± 4.38; 95 % CI; P  = 0.005; I² = 65.52) for the LSG and ESG groups, respectively, corresponding to an absolute difference of 18.12 % (± 0.89; 95 % CI, P  = 0.0001). The difference in terms of mean rate of adverse events was 0.19 % (± 0.37; 95 %CI; χ ²  = 1.602; P  = 0.2056). Conclusions  Our analysis showed a moderate superiority of LSG versus ESG. No difference in terms of safety was shown between the two groups. ESG is a less-invasive, repeatable and reversable and acceptable option for mild-moderate obese patients.

Endobariatrics and Metabolic Endoscopy: Can We Solve the Obesity Epidemic with Our Scope?

PURPOSE OF REVIEW

Obesity is a chronic relapsing disease that results in cardiovascular disease, diabetes mellitus, and non-alcoholic fatty liver disease. Currently, surgery represents the most effective treatment. However, the advent of minimally invasive endoscopic bariatric therapy (EBT) has shifted the treatment paradigm to less invasive, cost-effective procedures with minimal complications and recovery time that are preferred by patients. In this review, we will describe current and future EBTs, focusing on outcomes and safety.

RECENT FINDINGS

The endoscope has provided an incisionless portal into the gastrointestinal tract for placement of space-occupying devices and intraluminal procedures. EBTs are no longer solely manipulating anatomic alterations; instead, they aim to improve metabolic parameters such as glycated hemoglobin, low-density lipoprotein, cholesterol, and hepatic indices by targeting the mucosal layer of the gastrointestinal tract. The endoscope has succeeded in facilitating clinically meaningful weight loss and improvement of metabolic parameters. Future, solutions to the obesity epidemic will likely entail genetic testing, evaluation of the microbiome, and delivery of personalized therapy, utilizing combination endoscopic modalities that change the anatomy and physiology of individual patients, with new targets such as the abnormal metabolic signal.