Efficacy and Safety of Endoscopic Sleeve Gastroplasty at Mid Term in the Management of Overweight and Obese Patients: a Systematic Review and Meta-Analysis

Recommendations on the management of severe obesity in patients with inflammatory bowel disease of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU), Spanish Society of Obesity (SEEDO), Spanish Association of Surgery (AEC) and Spanish Society of Digestive Endoscopy (SEED)

Obesity is a multifactorial, chronic, progressive and recurrent disease considered a public health issue worldwide and an important determinant of disability and death. In Spain, its current prevalence in the adult population is about 24% and an estimated prevalence in 2035 of 37%. Obesity increases the probability of several diseases linked to higher mortality such as diabetes, cardiovascular disease, hyperlipidemia, arterial hypertension, non-alcoholic fatty liver disease, several types of cancer, or obstructive sleep apnea. On the other hand, although the incidence of inflammatory bowel disease (IBD) is stabilizing in Western countries, its prevalence already exceeds 0.3%. Paralleling to general population, the current prevalence of obesity in adult patients with IBD is estimated at 15-40%. Obesity in patients with IBD could entail, in addition to its already known impact on disability and mortality, a worse evolution of the IBD itself and a worse response to treatments. The aim of this document, performed in collaboration by four scientific societies involved in the clinical care of severe obesity and IBD, is to establish clear and concise recommendations on the therapeutic possibilities of severe or typeIII obesity in patients with IBD. The document establishes general recommendations on dietary, pharmacological, endoscopic, and surgical treatment of severe obesity in patients with IBD, as well as pre- and post-treatment evaluation.

Randomized Controlled Trial Based US Commercial Payor Cost-Effectiveness Analysis of Endoscopic Sleeve Gastroplasty Versus Lifestyle Modification Alone for Adults With Class I/II Obesity

PURPOSE

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive day procedure that the MERIT randomized controlled trial (RCT) has demonstrated to be an effective and safe method of weight loss versus lifestyle modification alone. We sought to evaluate the cost-effectiveness of ESG from the perspective of a US commercial payer in a cohort of adults with class II and class I obesity with diabetes based on this RCT.

MATERIALS

We used a Markov modelling approach with BMI group health states and an absorbing death state. Baseline characteristics, utilities, BMI group transition probabilities, and adverse events (AEs) were informed by patient-level data from the MERIT RCT. Mortality was estimated by applying BMI-specific hazard ratios to US general population mortality rates. We used BMI-based health state utilities to reflect the impact of obesity comorbidities and applied disutilities due to ESG AEs. Costs included intervention costs, AE costs, and BMI-based annual direct healthcare costs to account for costs associated with obesity comorbidities. A willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was assumed.

RESULTS

In our base-case analysis over a 5-year time horizon, ESG was cost-effective versus lifestyle modification alone with an incremental cost-effectiveness ratio of $23,432/QALY. ESG remained cost-effective in all sensitivity analyses we conducted and was dominant in analyses with longer time horizons.

CONCLUSION

ESG is a cost-effective treatment option for people living with obesity and should be considered in commercial health plans as an additional treatment option for clinically eligible patients.

Role of endoscopic duodenojejunal bypass liner in obesity management and glycemic control

The treatment of obesity and its comorbidities ranges from clinical management involving lifestyle changes and medications to bariat-ric and metabolic surgery. Various endoscopic bariatric and metabolic therapies recently emerged to address an important therapeutic gap by offering a less invasive alternative to surgery that is more effective than conservative therapies. This article compre-hensively reviews the technical aspects, mechanism of action, outcomes, and future perspectives of one of the most promising endoscopic bariatric and metabolic therapies, named duodenojejunal bypass liner. The duodenojejunal bypass liner mimics the mechanism of Roux-en-Y gastric bypass by preventing food contact with the duodenum and proximal jejunum, thereby initiating a series of hormonal changes that lead to delayed gastric emptying and malabsorptive effects. These physiological changes result in significant weight loss and improved metabolic control, leading to better glycemic levels, preventing dyslipidemia and non-alcoholic fatty liver disease, and mitigating cardiovascular risk. However, concern ex-ists regarding the safety profile of this device due to the reported high rates of severe adverse events, particularly liver abscesses. Ongo-ing technical changes aiming to reduce adverse events are being evaluated in clinical trials and may provide more reliable data to sup-port its routine use in clinical practice.

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.

UK cost-effectiveness analysis of endoscopic sleeve gastroplasty versus lifestyle modification alone for adults with class II obesity

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that has been demonstrated in the MERIT randomised, controlled trial to result in substantial and durable additional weight loss in adults with obesity compared with lifestyle modification (LM) alone. We sought to conduct the first cost-effectiveness analysis of ESG versus LM alone in adults with class II obesity (BMI 35.0-39.9 kg/m2) from a national healthcare system perspective in England based on results from this study.

METHODS

A 6-state Markov model was developed comprising 5 BMI-based health states and an absorbing death state. Baseline characteristics, utilities, and transition probabilities were informed by patient-level data from the subset of patients with class II obesity in MERIT. Adverse events (AEs) were based on the MERIT safety population. Mortality was estimated by applying BMI-specific hazard ratios from the published literature to UK general population mortality rates. Utilities for the healthy weight and overweight health states were informed from the literature; disutility associated with increasing BMI in the class I-III obesity health states was estimated using MERIT utility data. Disutility due to AEs and the prevalence of obesity-related comorbidities were based on the literature. Costs included intervention costs, AE costs, and comorbidity costs.

RESULTS

ESG resulted in higher overall costs than LM alone but led to an increase in quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) for ESG vs LM alone was £2453/QALY gained. ESG was consistently cost effective across a wide range of sensitivity analyses, with no ICER estimate exceeding £10,000/QALY gained. In probabilistic sensitivity analysis, the mean ICER was £2502/QALY gained and ESG remained cost effective in 98.25% of iterations at a willingness-to-pay threshold of £20,000/QALY.

CONCLUSION

Our study indicates that ESG is highly cost effective versus LM alone for the treatment of adults with class II obesity in England.

What About My Weight? Insufficient Weight Loss or Weight Regain After Bariatric Metabolic Surgery

Context

This review study aimed to investigate the definition, etiology, risk factors (RFs), management strategy, and prevention of insufficient weight loss (IWL) and weight regain (WR) following bariatric metabolic surgery (BMS).

Evidence Acquisition

Electronic databases were searched to retrieve relevant articles. The inclusion criteria were English articles with adult participants assessing the definition, prevalence, etiology, RFs, management strategy, and prevention of IWL/WR.

Results

Definition: The preferred definition for post-BMS IWL/WR are the terms "Lack of maintenance of total weight loss (TWL)>20%" and "weight change in percentage compared to nadir weight or weight loss". Prevalence: The exact prevalence of IWL/WR is still being determined due to the type of BMS and various definitions. Etiology: Several mechanisms, including hormonal/metabolic, dietary non-adherence, physical inactivity, mental health, and anatomic surgical failure, are possible etiologies of post-BMS IWL/WR. Risk factors: Preoperative body mass index (BMI), male gender, psychiatric conditions, comorbidities, age, poor diet, eating disorders, poor follow-ups, insufficient physical activity, micronutrients, and genetic-epigenetic factors are the most important RFs. Management Strategy: The basis of treatment is lifestyle interventions, including dietary, physical activity, psychological, and behavioral therapy. Pharmacotherapy can be added. In the last treatment line, different techniques of endoscopic surgery and revisional surgery can be used. Prevention: Behavioral and psychotherapeutic interventions, dietary therapy, and physical activity therapy are the essential components of prevention.

Conclusions

Many definitions exist for WR, less so for IWL. Etiologies and RFs are complex and multifactorial; therefore, the management and prevention strategy is multidisciplinary. Some knowledge gaps, especially for IWL, exist, and these gaps must be filled to strengthen the evidence used to guide patient counseling, selection, and improved outcomes.

Endoscopic Sleeve Gastroplasty in Those With a Body Mass Index of 27-30

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) is safe and effective in patients with a body mass index (BMI) more than 30, with few cases reported in patients with overweight (BMI 27-30). However, evidence is lacking in the overweight group because the procedure is not currently performed routinely for such patients. In this study, we aim to evaluate the safety and efficacy of ESG in patients with a BMI between 27 and 30 who failed other weight loss modalities and/or had weight-related comorbidities.

METHODS

This was a subgroup analysis of data pertaining to adults with a BMI between 27 and 30 who underwent ESG as a primary weight loss intervention. Data were abstracted from our longitudinal, prospective single-center registry. We analyzed weight loss, comorbidity resolution, adverse events, revisions, and quality of life using the Bariatric Analysis and Reporting Outcome System.

RESULTS

Of 3,797 ESG procedures, 656 patients (17%) had a BMI of 27-30. The mean age was 33 ± 9 years and women comprised 94% (n = 616) of the sample. The mean % total weight loss at 6, 12, 24, and 36 months after ESG was 11.0 ± 7.2, 15.5 ± 6.3, 15.1 ± 8.3%, and 13.3 ± 9.9%, respectively. Eight of 22 patients with diabetes (36%) and 9 of 51 patients (18%) with hypertension experienced complete remission. Two patients were hospitalized with bleeding. Twenty-three patients (3.5%) underwent revision to laparoscopic sleeve gastrectomy or repeat ESG. Six more patients underwent suture removal. A total of 214 of 261 patients (82%) rated quality of life after ESG as good or better.

DISCUSSION

ESG seems to be well tolerated, safe, and effective in patients with a BMI of 27-30.

Impact of Endoscopic Sleeve Gastroplasty in Non-alcoholic Fatty Liver Disease: a Systematic Review and Meta-analysis

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. Endoscopic sleeve gastroplasty (ESG) has proven to be feasible, safe, and effective in the management of obesity. We performed the first systematic review and meta-analysis evaluating NAFLD and other metabolic parameters 12 months post-ESG. Four observational studies with a total of 175 patients were included. The results showed a significant (p < 0.05) reduction of 4.85 in hepatic steatosis index (95% CI - 6.02, - 3.67), 0.5 in NAFLD fibrosis score (95% CI - 0.80, - 0.19), 6.32 U/l in ALT (95% CI - 9.52, - 3.11), 17.28% in TWL (95% CI - 18.24, - 16.31), 6.31 kg/m2 in BMI (95% CI - 8.11, - 4.52), 47.97% in EWL (95% CI - 49.10, - 46.84), and 0.51% in HbA1c (95% CI - 0.90, - 0.12). ESG improves liver parameters, provides weight loss, and reduces HbA1c levels in patients suffering from NAFLD.

Endoscopic sleeve gastroplasty in class III obesity: Efficacy, safety, and durability outcomes in 404 consecutive patients

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an effective therapy for class I-II obesity, but there are knowledge gaps in the published literature about its implementation in patients with class III obesity [body mass index (BMI) ≥ 40 kg/m²].

AIM

To evaluate the safety, clinical efficacy, and durability of ESG in adults with class III obesity.

METHODS

This was a retrospective cohort study that used prospectively collected data on adults with BMI ≥ 40 kg/m² who underwent ESG and longitudinal lifestyle counseling at two centers with expertise in endobariatric therapies from May 2018-March 2022. The primary outcome was total body weight loss (TBWL) at 12 mo. Secondary outcomes included changes in TBWL, excess weight loss (EWL) and BMI at various time points up to 36 mo, clinical responder rates at 12 and 24 mo, and comorbidity improvement. Safety outcomes were reported through the study duration. One-way ANOVA test was performed with multiple Tukey pairwise comparisons for TBWL, EWL, and BMI over the study duration.

RESULTS

404 consecutive patients (78.5% female, mean age 42.9 years, mean BMI 44.8 ± 4.7 kg/m²) were enrolled. ESGs were performed using an average of 7 sutures, over 42 ± 9 min, and with 100% technical success. TBWL was 20.9 ± 6.2% at 12 mo, 20.5 ± 6.9% at 24 mo, and 20.3 ± 9.5% at 36 mo. EWL was 49.6 ± 15.1% at 12 mo, 49.4 ± 16.7% at 24 mo, and 47.1 ± 23.5% at 36 mo. There was no difference in TBWL at 12, 15, 24, and 36 mo from ESG. TBWL exceeding 10%, 15%, and 20% was achieved by 96.7%, 87.4%, and 55.6% of the cohort at 12 mo, respectively. Of the cohort with the relevant comorbidity at time of ESG, 66.1% had improvement in hypertension, 61.7% had improvement in type II diabetes, and 45.1% had improvement in hyperlipidemia over study duration. There was one instance of dehydration requiring hospitalization (0.2% serious adverse event rate).

CONCLUSION

When combined with longitudinal nutritional support, ESG induces effective and durable weight loss in adults with class III obesity, with improvement in comorbidities and an acceptable safety profile.

Effect of endoscopic sleeve gastroplasty on gastric emptying, motility and hormones: a comparative prospective study

OBJECTIVE

Endoscopic sleeve gastroplasty (ESG) has gained global adoption but our understanding of its mechanism(s) of action and durability of efficacy is limited. We sought to determine changes in gastric emptying (GE), gastric motility (GM), hormones and eating behaviours after ESG.

DESIGN

A priori-designed single-centre substudy of a large US randomised clinical trial, adults with obesity were randomised to ESG or lifestyle interventions (LS) alone. We measured GE, hormones and weight loss and assessed eating behaviours. In a subset of ESG patients, we assessed GM. The primary outcome was the change in T1/2 (min) at 3 months, and secondary outcomes were changes in weight, GE, GM, hormones and eating behaviours. We used t-test analyses and regression to determine the association between GE and weight loss.

RESULTS

36 (ESG=18; LS=18) participated in this substudy. Baseline characteristics were similar between the two groups. At 3 months, T1/2 was delayed in the ESG group (n=17) compared with the LS group (n=17) (152.3±47.3 vs 89.1±27.9; p<0.001). At 12 months, T1/2 remained delayed in the ESG group (n=16) vs control group (n=14) (137±37.4 vs 90.1±23.4; p<0.001). Greater delays in GE at 3 months were associated with greater weight loss. GM was preserved and fasting ghrelin, glucagon-like peptide 1 and polypeptide YY significantly increased 18 months after ESG.

CONCLUSION

ESG promotes weight loss through several key mechanistic pathways involving GE and hormones while preserving GM. These findings further support clinical adoption of this technique for the management of obesity.

TRIAL REGISTRATION NUMBER

NCT03406975.

Endobariatrics: a Still Underutilized Weight Loss Tool

Purpose of review

Bariatric and metabolic endoscopic therapies provide an option for patients seeking clinically significant weight loss with fewer adverse events than conventional bariatric surgery. Our aims are to provide an overview of the current state of primary endoscopic treatment options for weight loss and to emphasize the importance of including these therapies when presenting weight loss options to qualified patients.

Recent findings

Bariatric endoscopy procedures are associated with a lower adverse event rate when compared to bariatric surgery and result in more weight loss than most existing pharmacotherapies approved by the Food and Drug Administration.

Summary

Sufficient evidence exists to implement bariatric endoscopic therapies-namely, the intragastric balloon and endoscopic sleeve gastroplasty-as safe and effective treatment options for weight loss when used in combination with lifestyle changes. However, bariatric endoscopy remains an underutilized option by weight management providers. Future studies are needed to identify patient and provider-level barriers to adopting endoscopic bariatric therapies as an option for the treatment of obesity.

Endoscopic Gastric Sleeve: A Review of Literature

For morbid obesity, one of the treatment options that have been deemed the most effective is bariatric surgery. Specifically, endoscopic sleeve gastrectomy (ESG) has emerged as one of the minimally invasive procedures for weight loss to be developed recently. In this procedure, there is the endoscopic placement of sutures in a quest to ensure reductions in the stomach volume. In this review, the main aim was to review the literature concerning ESG's efficacy and safety. Secondary sources of data were used and electronic databases were searched to identify articles focused on assessing the safety or efficacy of ESG. They included several databases such as Clinicaltrials.gov, Embase (Excerpta Medica Database), and MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online) to select relevant articles. Both the titles and abstracts of the articles were used to determine their inclusion or exclusion from the current review. Additionally, some keywords were used to search and obtain relevant articles such as: ESG, obesity, bariatric surgery, and total body weight loss. This review relied on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework for the identification of articles, screening, determination of eligibility, and inclusion and exclusion as deemed appropriate. From the findings, the review established that ESG is effective when used as an alternative intervention for obesity. The beneficial effects are felt particularly in terms of the procedure's capacity to ensure that the total body weight loss mean percentage is significant. Apart from the benefit of ensuring weight loss, ESG was also found to impair gastric emptying, pose metabolic effects that are key to controlling obesity-associated metabolic dysregulation, and the ability to increase satiety. However, the procedure was documented to yield a few adverse events in some studies. Some of the notable adverse events include pulmonary embolism, potential pneumoperitoneum, and possible post-procedure leak in the posterior aspect of the gastric fundus as sutures exert tension and also cause thin walls. Emerging as a minimally-invasive procedure, ESG is a cost-effective alternative through which weight loss can be achieved significantly in obese populations. It leads to a slowdown of gastric emptying, causes an increase in satiety, and leads to an improvement in the metabolic profile. Therefore, for obese individuals not undergoing bariatric surgery, ESG can be an ideal treatment option, including individuals in need of a bridge to surgery and also those diagnosed with moderate obesity. Overall, when it comes to the management of obesity, this review established that ESG provides a paradigm shift targeting existing therapeutic gaps.

Evolving Technique of Laparoscopic Vertical Gastric Clip Placement

INTRODUCTION

Laparoscopic BariClip gastroplasty (LBCG) will address a similar tubular restriction than the one achieved with the laparoscopic sleeve gastrectomy (LSG) at the level of the gastric fundus, while maintaining the advantage of simplicity and anatomic preservation. The purpose of the current study was to analyze the risk of slippage and to present the evolving technique by adding gastro-gastric plication of the gastric wall covering the BariClip at those areas where the gastric wall "slips" between the limbs of the clip.

METHODS

All patients undergoing LBCG with the evolving technique of gastric plication around the device associated with antral gastroplasty from January 2021 to May 2022 were included in the study group (group A). A control group (group B) was designed with patients who underwent previous LBCG technique between May 2017 and June 2019. This is a case-controlled group with patients matched by gender and BMI. We have analyzed the postoperative complications and more notably the slippage.

RESULTS

One hundred seventy-six patients (44 male and 132 female) with a mean age of 33 years (± 11) underwent evolving technique of LBCG. A control group of 67 patients who underwent previous technique of LBCG was included. All procedures were completed by laparoscopy with no intraoperative complication. For the study group, we have recorded a number of 5 slippages (2.8%). The diagnosis occurred during the first 6 months after the operation. The management consisted of repositioning-3 cases-and BariClip removal-2 cases. For the control group, we have recorded a number of 3 slippages (4.3%). All three patients underwent BariClip removal, with no repositioning.

CONCLUSIONS

We reported a new technique of placement of the BariClip with additional gastric plication anterior, posterior, and volume reduction in the antrum to potentially reduce the rate of slippage and improve weight loss outcomes.

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.

Gastric Emptying and Its Correlation With Weight Loss and Body Mass Index in Patients With an Intragastric Balloon: A Prospective Study With Six Years of Follow-Up

Background Obesity is the most well-established and prolonged pandemic in modern society. Having a better understanding of the available tools is important to improve weight loss and make the strategies more productive. This study aims to evaluate the effect of intragastric balloon (IGB) on gastric emptying time, its relationship with weight loss after IGB removal, and weight maintenance after six years. Methodology This prospective study analyzed data from patients undergoing IGB placement. A six-years follow-up was performed and data about weight maintenance were collected. We analyzed the impact of the IGB on gastrointestinal motility and its correlation with weight loss. Results Of the 20 patients included in the study, 52.4% were diagnosed with class I obesity and 47.6% with class II obesity. The mean weight of the patients was 96.5 ± 11.9 kg at baseline, 79.6 ± 11.4 kg at the time of IGB removal, 81.8 ± 9.1 kg at six months, and 93.2 ± 14.3 kg six years after IGB removal. The mean difference between the initial weight and that measured immediately after IGB removal was 16.68 ± 5.71 kg. Regarding gastric emptying time, there was a difference in retention on comparing the measurement before balloon placement to that after the balloon was in place (72.9% vs. 86.8%) after one hour of food intake. Comparing two hours after food intake, patients before IGB placement had a 30.6% food retention, while patients with IGB in place had a 69.2% retention. Conclusions In patients with class I or II obesity, the use of an IGB delayed gastric emptying of foods but showed no direct correlation with weight loss. Weight loss achieved after IGB placement was maintained in half of the patients at a six-year follow-up.

Endobariatrics: well past infancy and maturing rapidly

PURPOSE OF REVIEW

This review summarizes the key developments with regard to FDA-approved endoscopic bariatric metabolic therapies (EBMTs) in the last 2 years.

RECENT FINDINGS

The prevalence of obesity has increased during the coronavirus disease 2019 (COVID-19) pandemic, and obesity worsens COVID-19 related outcomes. Several studies have confirmed the safety and short-term efficacy of intragastric balloons (IGBs). In the short-term IGBs may improve steatosis and fibrosis in nonalcoholic fatty liver disease and improve quality of life and mental health. Unfortunately weight loss from these temporarily placed devices is not sustained long-term. Endoscopic sleeve gastroplasty (ESG) may be more effective and durable than IGBs, and result in fewer adverse events compared to bariatric surgery. The recently completed MERIT trial may catapult ESG as a first-line EBMT. Aspiration therapy meets safety and effectiveness thresholds for incorporation into routine practice, but overall acceptance has been lower than other FDA-approved EBMTs.

SUMMARY

The field of endobariatrics is rapidly maturing. Significant knowledge gaps remain with regards to combining EBMTs with pharmacologic therapy to improve durability of weight loss. The rapid expansion in the literature supporting safety and long-term efficacy ESG may prompt revision of existing guidelines.

From surgery to endoscopy: the evolution of the bariatric discipline

ABSTRACT

Obesity, with its increasing morbidity and prevalence, is now a worldwide public health problem. Obesity and its related comorbidities impose a heavy burden on societal health and the economy. The practice of bariatric surgery has evolved from its early surgical procedures, many of which are no longer routine operations. With clinical practice, research, and experience, bariatric surgery has gradually become an important last resort for the control of weight and obesity-related metabolic diseases in moderately and severely obese patients. However, there is still room for further improvements in bariatric surgical procedures, especially with regard to long-term issues and complications. Endoscopic weight loss technology has developed rapidly in recent years. The advantages of this technology include minimal invasiveness, an obvious weight loss effect, and few complications, thus filling the gap between medications and lifestyle adjustments and surgical treatment of obesity. Endoscopic weight loss technology may even replace surgical bariatric procedures. This review summarized the current status of bariatric metabolic surgery and newly developed bariatric endoscopic procedures.

The Attitude of Practitioners Towards Endoscopic Sleeve Gastroplasty

BACKGROUND AND AIM

Despite widespread adoption and encouraging results seen over the last 5 years, no consensus exists regarding the endoscopic sleeve gastroplasty (ESG) technique, training, or preprocedure and postprocedure management of the patient. The aim of our survey was to assess practice trends and preferences of bariatric endoscopists with respect to ESG.

METHODS

Using a digital platform, we conducted a worldwide survey by emailing a link with an electronic questionnaire to 1200 bariatric endoscopists trained to perform endoscopic suturing using the Apollo Overstitch suturing device (Apollo Endosurgery).

RESULTS

We received 221 responses that were included in the analysis. Fifty-one responders (36.4%) required 1 to 10 procedures, and 37 (26.4%) needed 11 to 20 procedures to become proficient at ESG. Ninety-six (68.6%) stated that lower body mass index thresholds should be adopted for Asian and Arab patients. There was no consensus on the ideal number of sutures, with 45 (32.1%), 42 (30%), 36 (25.7%), 13 (9.3%), and 4 (2.9%) recommending 4 to 6, 5 to 7, 6 to 8, 7 to 9, and 8 to 12 sutures, respectively. The primary barriers to establishing an endobariatric program were the inability to establish a cash pay model, 77 (95.1%); lack of institutional support, 61 (75.3%); and difficulty in establishing an ambulatory surgical center/hospital to perform ESG, 73 (90.1%).

CONCLUSIONS

ESG practice trends remain heterogenous among practitioners in regard to indication, technique, and preprocedure and postprocedure management. Specific ESG guidelines are warranted, and this survey will assist in providing the framework for these guidelines to be written.

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.

Does endoscopic mean safer? A comparison of the short-term safety of endoscopic versus laparoscopic bariatric therapies

Background and study aims  There is minimal research on real-world, large-volume data comparing endoscopic bariatric therapy (EBT) to laparoscopic bariatric therapy (LBT). This study aimed to compare 30-day postoperative morbidity and mortality outcomes of primary EBT vs LBT using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Patients and methods  Patients aged 18 to 80 with body mass index (BMI) 35 to 40 kg/m ² undergoing primary procedures were included. Propensity score matching 1:50 was performed for EBT versus LBT based on age, sex, and BMI. Results  We matched 211 EBTs with 9,059 LBTs. Operative length (63.9, 95 % confidence interval [CI]: 57.9, 69.8 versus 81.1, 95 % CI: 80.1, 82.1) and length of stay (0.49 days, 95 % CI: 0.29, 0.69 versus 1.43 days, 95 % CI: 1.41, 1.45) were significantly lower in the EBT group than the LBT group. There was no difference between EBT and LBT in the odds of readmission (odds ratio [OR] = 0.31, 95 % CI: 0.08, 1.25), reoperation (OR = 0.39, 95 % CI: 0.05, 2.84), or reintervention (OR = 0.98, 95 % CI: 0.24, 3.99). After controlling for chronic obstructive pulmonary disease, sleep apnea, history of myocardial infarction, hypertension requiring medications, and diabetes, EBT continued to be associated with lower odds of having any adverse event (AE) than LBT, with an OR of 0.34 (95 % CI: 0.16, 0.69). Subgroup analysis comparing EBT to laparoscopic sleeve gastrectomy (LSG) showed that EBT was associated with a lower risk having any AE than LSG, with an OR of 0.39 (95 % CI: 0.19, 0.79). Conclusions  EBT is associated with a lower 30-day AE rate and shorter procedural length and length of stay than LBT, with similar rates of readmission, reintervention, and reoperation.

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.

Status of bariatric endoscopy–what does the surgeon need to know? A review

BACKGROUND

Obesity is a chronic and multifactorial disease with a variety of potential treatment options available. Currently, there are several multidisciplinary therapeutic options for its management, including conservative, endoscopic, and surgical treatment.

AIM

To clarify indications, technical aspects, and outcomes of bariatric endoscopy.

METHODS

Narrative review of current literature based on electronic databases including MEDLINE (PubMed), Cochrane Library, and SciELO.

RESULTS

Bariatric endoscopy is in constant development and comprises primary and revisional treatment options as well as management of surgical complications. Various devices act upon different mechanisms of action, which may be individualized to each patient. Despite favorable results for the endoscopic treatment of obesity, prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies. Regarding the management of bariatric surgery complications, endoscopic therapy may be considered the procedure of choice in a variety of situations. Still, as there is no standardized algorithm, local experience should be considered in decision-making.

CONCLUSION

The treatment of patients with obesity is complex, and a multidisciplinary approach is essential. Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications, and therefore, must be part of the armamentarium in the fight against this disease.

Primary obesity surgery endoluminal (POSE) for the treatment of obesity: a systematic review and meta-analysis

BACKGROUND

Primary obesity surgery endoluminal (POSE) utilizes an incision-less operating platform system to create full-thickness plications in the gastric fundus and body (original POSE). Many studies have demonstrated the safety and efficacy of original POSE for the treatment of obesity.

OBJECTIVE

We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to evaluate the outcomes of original POSE per the ASGE task force thresholds.

METHODS

Bibliographic databases were systematically searched for studies assessing the outcomes of POSE for the treatment of obesity. All randomized controlled trials (RCTs) and observational studies that assessed outcomes of POSE were included. Studies were included if they reported percent total weight loss (%TWL) or percent excess weight loss (%EWL) and the incidence of serious adverse events (SAE).

RESULTS

A total of seven studies with 613 patients were included. Two included studies were RCTs, while the remaining were observational studies. Pooled mean %EWL at 3-6 months and 12-15 months were 42.62 (95% CI 37.56-47.68) and 48.86 (95% CI 42.31-55.41), respectively. Pooled mean %TWL at 3-6 months and 12-15 months was 13.45 (95% CI 8.93-17.97) and 12.68 (95% CI 8.13-17.23), respectively. Subgroup analysis of two RCTs showed that weight loss at 1 year was significantly higher in POSE patients (%EWL difference in means 19.45 (95% CI 4.65-34.24, p value = 0.01). The overall incidence of serious adverse events was only 2.84% and included GI bleeding, extra-gastric bleeding, hepatic abscess, severe pain, severe nausea, and severe vomiting. The mean number of total anchors placed in the fundus and body was 13.18 (95% CI 11.77-14.58), and the mean procedure time was 44.55 min (95% CI 36.44-52.65).

CONCLUSION

POSE, a minimally invasive endoscopic bariatric therapy, is a safe and effective modality for the treatment of obesity. The outcomes of POSE meet and surpass the ASGE joint task force thresholds. Future studies should evaluate newer versions of this procedure that emphasize gastric body plication sparing the fundus.

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.

Endoscopic sleeve gastroplasty - minimally invasive treatment for non-alcoholic fatty liver disease and obesity

INTRODUCTION

Adequate weight loss can lead to reduction in steatosis, inflammation, and fibrosis in patients with obesity and non-alcoholic fatty liver disease (NAFLD). We evaluated the role of endoscopic sleeve gastroplasty (ESG) in patients with obesity and NAFLD.

METHODS

In this single-center prospective study, consecutive adult patients with NAFLD who underwent ESG between November 2018 and May 2019 were included. The primary outcome was the impact of ESG on hepatic parameters: change in alanine aminotransferase (ALT), hepatic steatosis index (HSI), NAFLD fibrosis score (NFS), fibrosis-4 index (FIB-4), and aspartate aminotransferase (AST)-to-platelet ratio index (APRI) from baseline to 6 and 12 months. Secondary outcomes included change in glycated hemoglobin (HbA1c), percentage weight loss, and safety. Analysis of variance with repeated measures was used for statistical analysis.

RESULTS

A total of 26 patients (mean age [SD] 41.5 [9.58] years; 16 females) with mean (SD) weight of 99.43 (21.89) kg at baseline were included. There was significant improvement in ALT (mean ± SD) from baseline of 59.54 ± 17.02 IU/L to 49.50 ± 11.72 IU/L and 48.42 ± 13.22 IU/L at 6 and 12 months (p = 0.001). Mean (SD) NFS was significantly improved from 0.228 (1.00) at baseline to -0.202 (1.16) and -0.552 (1.08) at 6 and 12 months (p 0.001). Mean (SD) HSI, FIB-4, and APRI scores significantly reduced from baseline to 6 and 12 months (p = 0.001). There was 18.07% total body weight loss at 12 months, with significant improvement in HbA1c. There were no major adverse events.

CONCLUSION

ESG is a safe and effective treatment option for patients with NAFLD and obesity causing significant weight loss. Rigorous randomized trials are required to incorporate ESG in NAFLD treatment algorithm.

GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.

Bariatric and Metabolic Endoscopy: A New Paradigm

The prevalence of obesity, type 2 diabetes mellitus, and metabolic syndromes is increasing globally. Minimally invasive metabobariatric (MB) endoscopic therapies are adjunct treatments that can potentially bridge the gap between surgical interventions and medical therapy. A growing number of MB techniques are becoming available, allowing for more personalized and patient-targeted treatment options for specific disease states. MB techniques are less invasive than surgery and can precisely target different parts of the gastrointestinal tract that may be responsible for the pathophysiology of obesity and metabolic syndromes such as type 2 diabetes mellitus. These alternatives should be selected on an individualized patient basis to balance the expected clinical outcomes and desired anatomical targets with the level of invasiveness and degree of acceptable risk. Each MB intervention presents great flexibility allowing for a tailored intervention and different levels of patient engagement. Patient awareness and motivation are essential to avoid therapy withdrawal and failure. Differences between MB procedures in terms of weight loss and metabolic benefit will be discussed in this review, along with the insights on clinical decision-making processes to evaluate the potential of further evolution and growth of bariatric and metabolic endoscopy.

Efficacy of Intragastric Balloons for Weight Loss in Overweight and Obese Adults: a Systematic Review and Meta-analysis of Randomized Controlled Trials

Intragastric balloons (IGB) are the most widely used endoscopic bariatric and metabolic therapies. We aimed to evaluate the efficacy of IGB in comparison with sham or lifestyle interventions for weight loss in overweight and obese patients. This systematic review and meta-analysis was performed following the PRISMA guidelines. Electronic searches were performed to identify randomized controlled trials, which compared IGB with sham or lifestyle intervention. Thirteen RCTs with 1523 patients were included. The difference in mean %EWL and %TWL at follow-up was 17.98%, and 4.40%, respectively, which was significantly higher in the IGB group. Similarly, the difference in mean AWL and BMIL was 6.12 kg, and 2.13 kg/m², respectively. IGB therapy is more effective than lifestyle intervention alone for weight loss in overweight and obese adults.

Intragastric Balloon Versus Endoscopic Sleeve Gastroplasty for the Treatment of Obesity: a Systematic Review and Meta-analysis

BACKGROUND

We aimed to individually evaluate IGB and ESG procedures and compare the efficacy, durability, and safety of these procedures.

METHODS

Bibliographic databases were systematically searched for studies investigating the use of IGB and ESG for the treatment of obesity. Studies reporting percent total weight loss (%TWL) or percent excess weight loss (%EWL) with at least 12 months of follow-up were included.

RESULTS

A total of 28 studies were included in the final analysis. Only 1 study directly compared ESG to IGB, 9 studies evaluated ESG alone, while 18 studies evaluated IGB. At 12-month follow-up after ESG, mean %TWL was 17.51 (95% CI 16.44-18.58), and %EWL was 60.51 (95% CI 54.39-66.64). Mean %TWL and %EWL after IGB at 12 months was 10.35 (95% CI 8.38-12.32) and 29.65 (95% CI 25.40-33.91), respectively. Mean %TWL and %EWL after IGB were significantly decreased at 18 or 24 months compared to 6 months indicating weight regain after IGB removal. ESG achieved significantly superior weight loss compared to IGB, the difference in mean %TWL was 7.33 (95% CI 5.22-9.44, p value = 0.0001) at 12 months. Serious adverse events were observed in < 5% for both procedures.

CONCLUSION

Although ESG and IGB are safe and effective for weight loss, our study suggests that ESG results in more significant and sustained weight loss. Nevertheless, a variety of approaches are essential to care for this underserved population, and there are several factors other than weight loss that should be considered in selecting the ideal therapy for individual patients.

Endoscopic assessment of morphological and histopathological upper gastrointestinal changes after endoscopic sleeve gastroplasty

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a promising bariatric endoluminal procedure. Restriction and shortening of the stomach are obtained by means of non-resorbable full-thickness sutures, thus inducing the formation of several endoluminal pouches in which food can stagnate. The effect of ESG on the upper gastrointestinal tract has never been investigated.

OBJECTIVES

This study objectively evaluates endoscopic macroscopic and histopathologic changes within 12-month follow-up (FU) in patients who underwent ESG.

SETTING

Retrospective study on a prospective database of patients who underwent ESG at our tertiary referral center between October 2016 and March 2019.

METHODS

All consecutive patients undergoing upper endoscopy (EGD) preoperatively and 6 and 12 months after ESG were included. The upper gastrointestinal tract was evaluated for mucosal abnormalities and biopsies were systematically taken.

RESULTS

Eighty-six patients were included. EGD results were as follows: esophagitis decreased from 14% preoperatively to 3.6% and 1.2% at 6- and 12-month FU, respectively (P = .001); 19.8% of patients presented preoperatively a type I hiatal hernia <4 cm and showed no size increment or de novo hiatal hernia at 6- and 12-months. The rate of preoperative hyperemic (23.2%) and erosive (3.5%) gastropathy decreased to 9.5% and 1.2% at 6 months and 17.4% and 1.2% at 12 months, respectively. Gastric ulcer (4.7%), duodenal hyperemic mucosa (1.2%) and duodenal micro-ulcerations (2.3%) detected preoperatively were not present at 6- and 12-month EGD. The rate of histopathological disease, which was 68.1% preoperatively, dropped to 29.2% at 12 months, chronic gastritis decreased from 40.3% to 26.4%, acute gastritis from 9.7% to 0%, and acute inflammation on chronic gastritis from 18% to 2.8% (P < .001).

CONCLUSION

ESG is a safe procedure that does not promote the new onset of macroscopic and histopathologic abnormalities within 1-year follow-up.

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 Efficacy and Safety of Endoscopic Sleeve Gastroplasty as an Alternative to Laparoscopic Sleeve Gastrectomy

Endoscopic sleeve gastroplasty (ESG) is a therapeutic endoscopic technique for reducing the size of the gastric reservoir in obese patients, using a full-thickness endoscopic suturing device. The effectiveness of ESG in weight loss is significantly greater than that of high-intensity diet and lifestyle therapy and lower than that of laparoscopic sleeve gastrectomy (LSG). The efficacy at 12 months after ESG in terms of percentage of total body weight loss and excess body weight loss was approximately 16% and 60%, respectively. The well-known predictive factors for increased weight loss by ESG are good compliance with regular monitoring and post-procedure care involving a multidisciplinary team approach. Although the underlying mechanism of weight loss induced by ESG is debatable, delayed gastric emptying and early satiation are some of the proposed mechanisms. The pooled rate of adverse events after ESG reported in several meta-analysis studies ranged from 1.5% to 2.3% and the incidence of new-onset gastroesophageal reflux disease after ESG was negligible, indicating that ESG has a superior safety profile to LSG. Moreover, ESG reduced the risk of obesity-related metabolic comorbidities, evidenced by the reduction in HbA1c level, systolic blood pressure, triglyceride level, and risk of hepatic steatosis and fibrosis; it even improved the quality of life. ESG could be considered safe and qualify as an alternative treatment to LSG.

Metabolic Effects of Endoscopic Duodenal Mucosal Resurfacing: a Systematic Review and Meta-analysis

Duodenal mucosal resurfacing (DMR) is an innovative endoscopic bariatric and metabolic therapy (EBMT) emerging in recent years. It uses the duodenum to achieve better glycemic and weight control. This study aimed to evaluate in a critical and systematic way the metabolic effects of this procedure. Electronic searches were performed evaluating the DMR procedure based on predefined inclusion and exclusion criteria. Changes in measured outcomes were evaluated using random-effects models by computing weighted mean differences (MD) and corresponding 95% CIs between pre-and post-procedure metabolic characteristics. Four studies were selected for qualitative and quantitative analysis. DMR demonstrated beneficial glycemic and hepatic metabolic effects among patients with non-insulin dependent type 2 diabetes (T2D) at 3 and 6 months post-procedure.

Multidisciplinary Approach for Weight Regain-how to Manage this Challenging Condition: an Expert Review

Weight regain is a multifactorial condition that affects many patients following bariatric surgery. The purpose of the paper is to review the multidisciplinary approach for the management of weight regain. We performed a search in current clinical evidence regarding the causes, consequences, and treatments of weight regain. The multidisciplinary approach with periodic monitoring is of fundamental importance to prevent or treat weight regain. Several therapeutic options are ranging from nutritional to surgical options, which should be tailored according to patients' anatomy, lifestyle behavior, and compliance. Specialized multidisciplinary care is the key to achieve optimal long-term weight loss and maintenance goals following bariatric surgery.

Metabolic bariatric surgery as a treatment for obstructive sleep apnea hypopnea syndrome: review of the literature and potential mechanisms

Obstructive sleep apnea hypopnea syndrome (OSAHS) is closely related to obesity and can cause multiple organs and systems damage. Metabolic bariatric surgery (MBS) is presently the only long-term effective treatment and an important strategy for severely obese population, which also provides a novel therapeutic for obese patients with OSAHS, especially in patients with poor continuous positive air pressure (CPAP) adherence. To date, the resolution mechanism of OSAHS in obese patients after MBS has not been fully clarified. In addition, there is no specific metabolic bariatric surgical treatment of OSAHS guidelines. Therefore, this review provides an update on the relationship between OSAHS and MBS for highlighting the importance of weight loss strategies for obese patients with OSAHS.

Brazilian Consensus on Endoscopic Sleeve Gastroplasty

PURPOSE

Bariatric endoscopy is a less invasive approach for obesity management, with better efficacy than pharmacological treatment and low morbidity. Endoscopic sleeve gastroplasty (ESG) is the remodeling of the stomach using a suturing device showing technical feasibility, safety, and sustained weight loss. With growing numbers of procedures worldwide, there is a need to standardize the procedure.

MATERIALS AND METHODS

A consensus meeting was held in São Caetano do Sul-SP, Brazil, in June 2019, bringing together 47 Brazilian endoscopists with experience in ESG from all regions of the country. Topics on indications and contraindications of the procedure, pre-procedure evaluation and multidisciplinary follow-up, technique and post-procedure follow-up, and training requirements were discussed. An electronic voting was carried, and a consensus was defined as ≥ 70% agreement.

RESULTS

The panel's experience consisted of 1828 procedures, with a mean percentage total body weight loss (TBWL) of 18.2% in 1 year. Adverse events happened in 0.8% of the cases, the most common being hematemesis. The selected experts discussed and reached a consensus on several questions concerning patient selection, contraindications for the procedure, technical details such as patient preparation, procedure technique, and patient follow-up.

CONCLUSIONS

This consensus establishes practical guidelines for performance of ESG. The experience of 1828 procedures shows the expertise of the selected specialists participating in this consensus statement. The group's experience has a satisfactory weight loss with low adverse events rate. The main points discussed in this paper may serve as a guide for endoscopists performing ESG. Practical recommendations and technique standardization are described.