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

Endoscopic management of obesity and metabolic diseases

Obesity has become a global pandemic that is associated with a range of metabolic disorders. Traditional treatment options, such as lifestyle modification and anti-obesity medications, often exhibit limited efficacy and can lead to long-term weight gain, especially upon discontinuation of the medication. Although bariatric surgery is effective, its accessibility is constrained, and only a small percentage of eligible patients receive this intervention. Over the past two decades, endoscopic bariatric and metabolic therapies (EBMTs) have emerged as minimally invasive and effective alternatives for managing obesity and its related comorbidities. This article reviews primary gastric and small bowel EBMTs, their mechanisms of action, key supporting literature, and the metabolic outcomes associated with each device and procedure.

Endoscopic Weight Loss Options

Endoscopic therapies for obesity have emerged as safe, effective, and minimally-invasive alternatives to traditional approaches, including lifestyle modification, anti-obesity medications, and bariatric surgery. Currently, in the United States, 2 types of endoscopic weight loss therapies are Food and Drug Administration (FDA)-approved and are commercially available-intragastric balloons and endoscopic gastric remodeling. These devices and procedures are associated with approximately 10% to 20% total weight loss at 1 year and have distinct technical features, benefits, and risks that providers should be familiar with. This article will focus on the primary FDA-approved endoscopic treatments for obesity and also cover those in development.

Endoscopic bariatric and metabolic therapies and its effect on metabolic dysfunction-associated steatotic liver disease: a review of the current literature

Endoscopic bariatric and metabolic therapies (EBMTs) are minimally invasive endoscopic procedures that have shown to demonstrate significant weight loss in people with obesity. While abundant data support their positive effect on weight loss, there remains a notable dearth of information regarding their effects on metabolic dysfunction-associated steatotic liver disease (MASLD). As rates of type 2 diabetes and obesity have grown worldwide, so has the rate of MASLD. Therefore, addressing these knowledge gaps is crucial in improving liver health worldwide. In this review, we aim to provide the existing evidence delineating the effects of primary and secondary endoscopic bariatric therapies on MASLD and determine knowledge gaps requiring future study. Utilizing PubMed search with relevant keywords such as "endoscopic bariatric therapies," "NAFLD" (nonalcoholic fatty liver disease), "MAFLD" (metabolic dysfunction-associated fatty liver disease), "MASLD" (metabolic dysfunction-associated steatotic liver disease), we gathered case reports, reviews, and retrospective analyses, evaluating their data and limitations. In our manuscript, we detail many primary and secondary endoscopic therapies and the literature available exploring their impact on liver health. This review demonstrates that primary EBMTs improve noninvasive liver markers, weight loss, and overall metabolic syndrome suggesting significant benefit in MASLD. There is, however, a significant lack of literature studying how primary endoscopic therapies compare amongst each other and how revisional therapies affect MASLD. We additionally offer suggestions for future research to deepen our understanding of EBMTs and their effects on MASLD.

Endoscopic bariatric surgery for adults with overweight and obesity: a systematic review and network meta-analysis

BACKGROUND

Endoscopic bariatric surgery (EBS) is a new treatment for obesity. We compared the efficacy, safety, and probability of metabolic complications of different EBSs with laparoscopic sleeve gastrectomy (LSG).

METHODS

This systematic review and network meta-analysis (NMA) included searches of PubMed, Web of Science, and the Cochrane Library from January 1, 2017, to December 27, 2022, to find comparative trials of EBS procedures and EBS with LSG. We performed a frequentist model NMA to summarize the evidence and ranked the interventions according to SUCRA scores.

RESULTS

The search for this NMA yielded 14,160 articles, of which 18 eligible trials recruited 766,135 participants for procedures including LSG, endoscopic sleeve gastroplasty (ESG), nonadjustable intragastric balloon (NIB), BioEnterics Intragastric Balloon (BIB), and adjustable intragastric balloon (AIB). Definitive evidence suggests that LSG is most effective for weight reduction. Compared with LSG, NIB, SMD = -0.49 [95% CI -0.79, -0.18]; AIB, SMD = -0.41 [95% CI -0.76, -0.06] and ESG, SMD = -0.31 [95% CI -0.33, -0.29] in the index of percentage total weight loss under six months. In terms of safety outcomes, ESG had the lowest incidence of adverse events; the order of the observed incidence of adverse events from small to large was ESG, NIB, AIB, LSG, and BIB.

CONCLUSIONS

ESG is an effective and safe minimally invasive surgical method for people with overweight and obesity. Its 12-month effect is better than that of NIB, and its influence on lipid metabolism makes it more protective of the cardiovascular system and liver.

PROSPERO

CRD42022375343.

Improvement in obesity-related comorbidities 5 years after endoscopic sleeve gastroplasty: a prospective cohort study

BACKGROUND AND AIMS

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive bariatric procedure of the gastric cavity to facilitate weight loss. We aimed to evaluate the long-term effects of ESG as a monotherapy on obesity-related comorbidities over 5 years.

METHODS

This prospective study analyzed data from 404 consecutive patients (aged 45 ± 11.9 years, 76% women) who underwent ESG from August 2013 through June 2024. All patients had body mass indices ≥30 or ≥27 kg/m2 with comorbidities. Patients receiving adjuvant therapy were excluded to assess ESG as a monotherapy. All procedures were performed with a flexible endoscopic suturing system to facilitate restriction of the stomach. Patients were evaluated after 12 months (n = 336), 36 months (n = 210), and 60 months (n = 196) for anthropometric features, clinical parameters, metabolic panels, and liver function tests. Primary outcomes were the effects of ESG on obesity-related comorbidities and metabolic biomarkers. Secondary outcomes were total body weight loss (TBWL) and safety.

RESULTS

At 5 years after ESG, patients had significant reductions in levels of hemoglobin A1c (Δ .42%, P = .0007), systolic blood pressure (Δ 4.1 mm Hg, P = .0071), and alanine aminotransferase (Δ 7.4 U/L, P = .002). Body mass indices before the procedure were 37.5 ± 5.8 and 33.8 ± 6.7 kg/m2 at 60 months (P < .001). TBWL was 13.4% at 12 months (84.5% follow-up), 9.9% at 36 months (63.3% follow-up), and 11.8% at 60 months (74.8% follow-up), with 3 moderate adverse events (.7%).

CONCLUSIONS

ESG is an effective, noninvasive monotherapy that improved markers of hypertension, diabetes, and metabolic dysfunction-associated steatotic liver disease and led to a TBWL of 11.8% at 5 years after the procedure. (Clinical trial registration number: NCT04494048.).

Endoscopic Sleeve Gastroplasty Plus Lifestyle Intervention in Patients With Metabolic Dysfunction-associated Steatohepatitis: A Multicentre, Sham-controlled, Randomized Trial

BACKGROUND & AIMS

Metabolic dysfunction-associated steatohepatitis (MASH) is commonly seen in biopsy-proven steatotic liver disease. Lifestyle intervention reaching a weight loss higher than 10% promotes MASH resolution, but this goal is only achieved by a small number of patients. Endoscopic sleeve gastroplasty (ESG) has recently emerged as a safe and effective option to promote weight loss in the obese population. We report the results of a multicenter, randomized, controlled, and double-blind study to evaluate the effectiveness and safety of ESG in patients with MASH.

METHODS

Forty patients were randomized 1:1 to ESG plus lifestyle modification vs sham endoscopy (SE) plus lifestyle intervention. Inclusion criteria included biopsy-proven MASH with nonalcoholic fatty liver disease activity score (NAS) ≥3 and fibrosis stage F0 to F3. Eighteen patients from the ESG group and 19 from the endoscopic simulated intervention (ESI) group completed follow-up over 72 weeks. Baseline to end of follow-up changes in body weight, liver tests, liver stiffness (vibration-controlled transient elastography), and liver histology were recorded RESULTS: Total body weight loss (TBWL) was 9.47% (±9.38%) in the ESG group vs 3.91% (±5.43%) in the ESI group (P < .05). Liver stiffness decreased 5.63 (±7.17) KPa in the ESG group vs 0.2 (±5.38) KPa in the ESI group (P < .05). Steatosis was significantly reduced in the ESG group (-0.94 ± 0.87) vs the ESI group (-0.26 ± 0.99) (P = .033). No differences on NAS (-1.89 ± 2.11 vs -1.47 ± 2.01) score or fibrosis (-0.1 ± 0.91 vs -0.84 ± 1.21) was seen. In patients achieving weight loss >10%, we found a significant improvement on NAS score (-4 ± 0.94 vs -0.81 ± 1.62; P < .01), but not in fibrosis stage (-0.3 ± 1.06 vs -0.59 ± 1.25). Only 2 patients from the ESG group had adverse events that required admission; these resolved conservatively in 72 hours.

CONCLUSION

ESG is an effective and safe method to promote weight reduction associated with significant improvement in patients with MASH and obesity.

CLINICALTRIALS

gov, Number: NCT03426111.

Effect of bariatric endoscopy on liver fibrosis and steatosis and the course of NAFLD - a prospective interventional study

INTRODUCTION AND OBJECTIVES

With increases in obesity and metabolic syndrome because of lifestyle-related factors, the prevalence of non-alcoholic fatty liver disease (NAFLD) also is increasing worldwide. In a subset of patients with NAFLD, an inflammatory process arises in the steatotic liver, known as non-alcoholic steatohepatitis, that leads to liver fibrosis and liver cirrhosis. In selected patients with obesity, bariatric surgery, and bariatric endoscopy are important therapeutic options.

MATERIALS AND METHODS

This prospective interventional pilot study was conducted to investigate two types of intragastric balloons (IGB). The IGBs were the Orbera and the Spatz3. Liver fibrosis changes were monitored non-invasively using point and 2D shear wave ultrasound elastography (SWE) and transient elastography that allowed for quantification of liver steatosis using the controlled attenuation parameter (CAP). Patients were followed for 12 months.

RESULTS

Of 34 patients implanted with an IGB, 30 completed follow-up at month 12; results for one patient were excluded because of initiation of obesity pharmacotherapy. Fifteen patients received the Orbera IGB, and nineteen patients received the Spatz3 type. In month 12, total and excess weight loss was 7.88 % and 30.13 %. Elastography values decreased from baseline (3.88 kPa) to 3.61 kPa at month 12 (p 0.024). 2D SWE values decreased from baseline (5.42 kPa) to a value of 4.91 kPa at month twelve (p 0.135). Transient elastography values decreased from baseline (5.62 kPa) to a value of 4.17 kPa at month twelve (p 0.009).

CONCLUSIONS

Bariatric endoscopy in the form of IGB implantation leads to weight reduction and improvement of liver fibrosis and steatosis.

CLINICALTRIALS

GOV REGISTRATION

NCT04895943.

IFSO Bariatric Endoscopy Committee Evidence-Based Review and Position Statement on Endoscopic Sleeve Gastroplasty for Obesity Management

BACKGROUND

Obesity is a significant global health issue. Metabolic and bariatric surgery (MBS) is the gold standard in the treatment of obesity due to its proven effectiveness and safety in the short and long term. However, MBS is not suitable for all patients. Some individuals are at high surgical risk or refuse surgical treatment, while others do not meet the criteria for MBS despite having obesity-related comorbidities. This gap has driven the development of endoscopic solutions like endoscopic sleeve gastroplasty (ESG), which offers a less invasive alternative that preserves organ function and reduces risks. A recent IFSO International Delphi consensus study highlighted that multidisciplinary experts agree on the utility of ESG for managing obesity in patients with class I and II obesity and for those with class III obesity who do not wish to pursue or qualify for MBS. This IFSO Bariatric Endoscopy Committee position statement aims to augment these consensus statements by providing a comprehensive systematic review of the evidence and delivering an evidence-based position on the value of ESG within the spectrum of obesity management.

METHODS

A comprehensive systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Cochrane guidelines.

RESULTS

Systematic Review: The systematic review included 44 articles encompassing 15,714 patients receiving ESG. The studies varied from large case series to cohort studies and a randomized controlled trial (RCT). The mean baseline BMI was 37.56 kg/m2. The review focused on weight loss outcomes and safety data.

META-ANALYSIS

Time point Mean %EWL Mean %TBWL 6 months 48.04 15.66 12 months 53.09 17.56 18 months 57.98 16.25 24 months 46.57 15.2 36 months 53.18 14.07 60 months 45.3 15.9 These results demonstrate significant weight loss following ESG.

SAFETY

The pooled serious adverse event (SAE) rate was 1.25%. This low rate of SAEs indicates that ESG is a relatively safe procedure.

QUALITY OF EVIDENCE

The quality of evidence from the included observational studies was assessed as very low, primarily due to the inherent limitations associated with observational study designs, such as potential biases and lack of randomization. In contrast, the quality of evidence from the single randomized controlled trial was rated as MODERATE, reflecting a more robust study design that provides a higher level of evidence despite some limitations.

CONCLUSIONS

The IFSO Bariatric Endoscopy Committee, after conducting a comprehensive systematic review and meta-analysis, endorses endoscopic sleeve gastroplasty (ESG) as an effective and valuable treatment for obesity. ESG is particularly beneficial for patients with class I and II obesity, as well as for those with class III obesity who are not suitable candidates for metabolic bariatric surgery. ESG provides significant weight loss outcomes and demonstrates a favorable safety profile with a low rate of serious adverse events. Despite the limitations of the included observational studies, the randomized controlled trial included in the analysis reinforces the efficacy and safety of ESG and provides an evidence-based foundation for the position statement. Thus, the IFSO position statement supports and provides an evidence base for the role of ESG within the broader spectrum of obesity management.

Blood-based MASH diagnostic in candidates for bariatric surgery using mid-infrared spectroscopy: a European multicenter prospective study

Metabolic dysfunction-associated steatotic liver disease (MASLD) is common in individuals with obesity. Sexual dimorphism is present in MASLD. A noninvasive test to diagnose the severity of the disease, in particular the presence of Metabolic dysfunction-associated steatohepatitis (MASH), is lacking. This European multicenter prospective study uses a blood test based on mid-infrared (MIR) metabolic fingerprinting of individuals with severe or morbid obesity to diagnose MASH. Three hundred eighty-two individuals with severe or morbid obesity undergoing bariatric surgery were enrolled prospectively. Liver biopsies were obtained during surgery and assessed centrally. An algorithm was defined to calculate a score from the recorded MIR spectrum and to establish a diagnostic threshold to classify patients with MASH. Among the women (n = 217), MASH was diagnosed in 14.3% of cases. For women, the performance in terms of AUC were 0.83 and 0.82 in the calibration and validation groups, respectively. For a threshold of 0.1817, sensitivities were 86% and 70%, specificities were 81% and 75%, PPV were 43% and 32%, NPV were 97% and 94% and ACC were 82% and 74% for the calibration and validation groups, respectively. For men (n = 78; MASH: 33.3%), the performance of the spectral model was poor. The metabolic fingerprint obtained by MIR spectroscopy can rule out MASH in women with severe or morbid obesity. Its value in men needs new studies.Trial registration: ClinicalTrials.gov identifier: ClinicalTrials.gov identifier: NCT03978247 (04/06/2019).

Role of MASLD in CVD: A review of emerging treatment options

Metabolic dysfunction-associated steatotic liver disease (MASLD), represents a growing health concern due to its strong association with metabolic syndrome, obesity, and type 2 diabetes mellitus (T2DM). This condition, characterized by excessive fat accumulation in the liver not attributed to alcohol consumption, has emerged as a leading cause of chronic liver disease globally. MASLD significantly elevates the risk of major adverse cardiovascular events (MACE) through mechanisms like increased oxidative stress, insulin resistance, and chronic inflammation, all of which contribute to the development of atherosclerosis and endothelial dysfunction. Effective management of MASLD is crucial not only for liver health but also for cardiovascular disease (CVD) prevention. Lifestyle modifications, particularly weight loss achieved through dietary changes and increased physical activity, are the cornerstone of MASLD treatment. Additionally, pharmacological interventions, especially antihyperglycemic agents, play a pivotal role in treating MASLD in patients with T2DM. Novel therapeutic agents targeting various pathways of metabolic and liver dysfunction are under investigation, offering hope for more effective management strategies. This review explores the interconnectedness of MASLD and CVD, highlighting current and emerging therapeutic approaches.

Endoscopic Sleeve Gastroplasty: Practical Considerations, Current Techniques, and Troubleshooting

Endoscopic sleeve gastroplasty (ESG) has emerged as a safe and effective treatment for obesity over the past decade. This procedure, however, is technically challenging and requires frequent troubleshooting, even among experts. In this article the authors discuss current techniques, common pitfalls and adverse outcomes associated with ESG, how to avoid them, and how to address them if they occur.

The Future of Endobariatrics: Bridging the Gap

With the growing global burden of obesity, the field of endobariatrics has emerged as a promising alternative, filling the void between lifestyle interventions with modest efficacy and more invasive surgical procedures. This article explores the latest advancements in endobariatric therapies, encompassing endoscopic sleeve gastroplasty (ESG), intragastric balloons (IGB), endoscopic metabolic therapies, and promising pharmacologic and surgical combination approaches that integrate multiple therapeutic modalities. It also outlines the critical factors and strategic considerations necessary for the successful integration of endobariatric interventions into clinical practice.

Endoscopic sleeve gastroplasty for metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD, formerly nonalcoholic fatty liver disease - NAFLD) is a chronic liver condition linked to obesity and metabolic syndrome. It affects one-third of people globally and, in some cases, can lead to metabolic dysfunction-associated steatohepatitis (MASH, formerly nonalcoholic steatohepatitis, NASH) and fibrosis. Weight loss is crucial for the treatment of MASLD, but diet and lifestyle modifications often fail.

AREAS COVERED

In recent years, endoscopic sleeve gastroplasty (ESG) has gained popularity as an effective and minimally invasive option for obesity treatment, with widespread use worldwide. We present a current overview of the most significant studies conducted on ESG for the management of obesity and MASLD. Our report includes data from published studies that have evaluated the impact of ESG on noninvasive hepatic parameters used to estimate steatosis and fibrosis. However, at present, there are no data available on liver histology.

EXPERT OPINION

ESG has shown promising results in treating MASLD evaluated by noninvasive tests, but current data is limited to small, nonrandomized studies. More research is needed, particularly on the effects of ESG on histologically proven MASH. If future research confirms its efficacy, ESG may be incorporated into treatment guidelines in the future.

Mechanism of Action of Dihydroquercetin in the Prevention and Therapy of Experimental Liver Injury

Liver disease is a global health problem that affects the well-being of tens of thousands of people. Dihydroquercetin (DHQ) is a flavonoid compound derived from various plants. Furthermore, DHQ has shown excellent activity in the prevention and treatment of liver injury, such as the inhibition of hepatocellular carcinoma cell proliferation after administration, the normalization of oxidative indices (like SOD, GSH) in this tissue, and the down-regulation of pro-inflammatory molecules (such as IL-6 and TNF-α). DHQ also exerts its therapeutic effects by affecting molecular pathways such as NF-κB and Nrf2. This paper discusses the latest research progress of DHQ in the treatment of various liver diseases (including viral liver injury, drug liver injury, alcoholic liver injury, non-alcoholic liver injury, fatty liver injury, and immune liver injury). It explores how to optimize the application of DHQ to improve its effectiveness in treating liver diseases, which is valuable for preparing potential therapeutic drugs for human liver diseases in conjunction with DHQ.

The correlation between hepatic controlled attenuation parameter (CAP) value and insulin resistance (IR) was stronger than that between body mass index, visceral fat area and IR

BACKGROUND

Hepatic controlled attenuation parameter (CAP) is a novel marker for quantifying hepatic fat accumulation. Insulin resistance (IR) plays a major role in the pathogenesis and natural history of hepatic steatosis. This study aimed to investigate the possible relationship between CAP value and IR.

METHODS

This study included a total of 420 patients with overweight or obesity who came to the obesity clinic at Tianjin Union Medical Center. Vibration-controlled transient elastography examination was conducted to detect CAP and liver stiffness measurement (LSM) values. Body composition, including visceral fat area (VFA), and body fat mass (BFM), was evaluated by the direct segmental multi-frequency bioelectrical impedance analysis (BIA). The associations between CAP value, body mass index (BMI), VFA, BFM and homeostasis model assessment of insulin resistance (HOMA-IR) were analyzed.

RESULTS

CAP value was positively associated with HOMA-IR (r = 0.568, P < 0.001), the strength of which was much stronger than BMI, VFA, and BFM. In multivariate linear regression, CAP value and HOMA-IR showed a significant positive association (adjusted β = 0.015, 95% CI 0.007-0.022, P < 0.001). Subgroup analysis suggested no significant interaction between CAP value and HOMA-IR across age, BMI, LSM, hypertension, and sex groups (all P for interaction > 0.05).

CONCLUSIONS

Hepatic CAP value is more remarkably than other obesity markers associated with HOMA-IR in individuals with overweight or obesity, regardless of age, BMI, LSM, hypertension, and sex.

Meta-analysis: Impact of intragastric balloon therapy on NAFLD-related parameters in patients with obesity

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease affecting approximately 25% of adults in the western world. Intragastric balloon (IGB) is an endoscopic bariatric therapy -a therapeutic endoscopic tool that has shown promise in inducing weight loss. Its role in the treatment of NAFLD is yet to be established.

AIM

To evaluate the effect of IGB as a treatment option in NAFLD.

METHODS

We searched MEDLINE (PubMed) and EMBASE from inception to September 2022. We included studies evaluating the impact of IGB on obesity with the assessment of one or more liver-related outcomes and studies primarily evaluating the impact of IGB on NAFLD. We included comparative and non-comparative studies; primary outcomes were liver-related NAFLD surrogates.

RESULTS

We included 19 studies with 911 patients. IGB demonstrated an effect on NAFLD parameters including NAFLD activity score (NAS): mean difference (MD): -3.0 [95% CI: -2.41 to -3.59], ALT: MD: -10.40 U/L [95% CI: -7.31 to -13.49], liver volume: MD -397.9 [95% CI: -212.78 to 1008.58] and liver steatosis: MD: -37.76 dB/m [95% CI: -21.59 to -53.92]. There were significant reductions in non-liver-related outcomes of body weight, BMI, glycated haemoglobin and HOMA-IR.

CONCLUSION

Intragastric balloons may play an important role in addressing the treatment gap in NAFLD management.

Applicability of individualized metabolic surgery score for prediction of diabetes remission after endoscopic sleeve gastroplasty

Background

Endoscopic sleeve gastroplasty (ESG) is a safe and effective obesity treatment. The individualized metabolic score (IMS) is a validated score that uses preoperative variables predicting T2D remission (DR) in bariatric surgery.

Objectives

We evaluated the applicability of using the IMS score to predict DR in patients after ESG.

Design/Methods

We performed a retrospective review of patients with obesity and T2D who underwent ESG. We calculated DR, IMS score, and severity, and divided patients based on IMS category.

Results

The cohort comprised 20 patients: 25% (5) mild, 55% (11) moderate, and 20% (4) severe IMS stages. DR was achieved in 60%, 45.5%, and 0% of patients with mild, moderate, and severe IMS scores (p = 0.08), respectively. IMS score was significantly associated with DR (p = 0.03), with the area under the curve of the receiver operating characteristic for predicting DR 0.85.

Conclusion

These pilot data demonstrate that the IMS score appears to be useful in predicting DR after ESG.

MASLD treatment-a shift in the paradigm is imminent

MASLD prevalence is growing towards the leading cause of end-stage liver disease. Up to today, the most effective treatment is weight loss. Weight loss interventions are moving from lifestyle changes to bariatric surgery or endoscopy, and, more recently, to a new wave of anti-obesity drugs that can compete with bariatric surgery. Liver-targeted therapy is a necessity for those patients who already present liver fibrosis. The field is moving fast, and in the near future, we will testify to a disruptive change in MASLD treatment, similar to the paradigm-shift that occurred for hepatitis C almost one decade ago with direct antiviral agents.

From Scalpel to Scope: How Surgical Techniques Made Way for State-of-The-Art Endoscopic Procedures

The continuous evolution of endoscopic tools over the years has paved the way for minimally invasive alternatives to surgical procedures for multiple gastrointestinal conditions. While few endoscopic techniques have supplanted their surgical counterparts like percutaneous gastrostomy tubes, many have emerged as noninferior, less morbid alternatives for such diverse conditions as achalasia (peroral endoscopic myotomy), obesity (endoscopic sleeve gastroplasty), drainage of pancreatic walled off necrosis (EUS-guided cystogastrostomy), and gastric outlet obstruction (EUS-guided gastrojejunostomy). These techniques were based on surgical concepts and would not have been feasible without collaboration between surgeons and endoscopists. Such collaboration is exemplified by the antireflux fundoplication, which features combined hiatal hernia repair with transoral and incisionless fundoplication. The burgeoning armamentarium of endoscopic alternatives to traditional surgical procedures requires a multidisciplinary discussion and individually tailored treatment plans that consider patient preferences as well as the relative risks and benefits of surgical and endoscopic approaches. As technological advances give rise to ever more innovative endoscopic techniques, studies to evaluate clinical outcomes and define their role in treatment algorithms will be required.

Improvements in hepatic steatosis, obesity, and insulin resistance in adults with nonalcoholic fatty liver disease after the primary obesity surgery endoluminal 2.0 procedure

BACKGROUND

The primary obesity surgery endoluminal 2.0 (POSE 2.0) procedure involves full-thickness gastric body plications to narrow the stomach using durable suture anchor pairs. We evaluated POSE 2.0 as a treatment strategy for nonalcoholic fatty liver disease (NAFLD) in patients with obesity.

METHODS

Adults with obesity and NAFLD were prospectively allocated based on their preference to undergo POSE 2.0 with lifestyle modification or lifestyle modification alone (control). Primary end points were improvement in controlled attenuation parameter (CAP) and resolution of hepatic steatosis at 12 months. Secondary end points included %total body weight loss (%TBWL), change in serum measures of hepatic steatosis and insulin resistance, and procedure safety.

RESULTS

42 adult patients were included (20 in the POSE 2.0 arm and 22 in the control arm). At 12 months, POSE 2.0 significantly improved CAP, whereas lifestyle modification alone did not (P < 0.001 for POSE 2.0; P = 0.24 for control). Similarly, both resolution of steatosis and %TBWL were significantly higher with POSE 2.0 than with control at 12 months. Compared with controls, POSE 2.0 significantly improved liver enzymes, hepatic steatosis index, and aspartate aminotransferase to platelet ratio at 12 months. There were no serious adverse events. CONCLUSION : POSE 2.0 was effective for NAFLD in patients with obesity, with good durability and safety profile.

Clinical Classification of Obesity and Implications for Metabolic Dysfunction-Associated Fatty Liver Disease and Treatment

Obesity,and metabolic dysfunction-associated fatty liver disease (MAFLD) have reached epidemic proportions globally. Obesity and MAFLD frequently coexist and act synergistically to increase the risk of adverse clinical outcomes (both hepatic and extrahepatic). Type 2 diabetes mellitus (T2DM) is the most important risk factor for rapid progression of steatohepatitis and advanced fibrosis. Conversely, the later stages of MAFLD are associated with an increased risk of T2DM incident. According to the proposed criteria, MAFLD is diagnosed in patients with liver steatosis and in at least one in three: overweight or obese, T2DM, or signs of metabolic dysregulation if they are of normal weight. However, the clinical classification and correlation between obesity and MAFLD is more complex than expected. In addition, treatment for obesity and MAFLD are associated with a reduced risk of T2DM, suggesting that liver-based treatments could reduce the risk of developing T2DM. This review describes the clinical classification of obesity and MAFLD, discusses the clinical features of various types of obesity and MAFLD, emphasizes the role of visceral obesity and insulin resistance (IR) in the development of MAFLD,and summarizes the existing treatments for obesity and MAFLD that reduce the risk of developing T2DM.

The metabolic influence of duodenal mucosal resurfacing for nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) is a leading cause of chronic liver disease worldwide with decreased life expectancy. Duodenal mucosal resurfacing (DMR) has been associated with metabolic improvement in glycemic and hepatic parameters of type 2 diabetes, but the metabolic impact of DMR for NAFLD/NASH remains inconclusive. We conducted a meta-analysis to investigate metabolic effects of DMR in patients with NAFLD/NASH.

METHODS

Three major bibliographic databases were reviewed for enrollment of trials prior to January 28, 2022. We included adults with biopsy-proven NAFLD/NASH or liver magnetic resonance imaging proton density fat fraction (MRI-PDFF) >5% at baseline and focused on the metabolic difference of MRI-PDFF at 12 weeks, and HbA1c or homeostatic model assessment index for insulin resistance (HOMA-IR) at 24 weeks.

RESULTS

Two studies involved a total of 67 participants for analysis. When compared with pre-intervention status, mean difference of MRI-PDFF, HbA1c, and HOMA-IR after DMR were -2.22 (95% CI: -12.79~8.34), -0.32% (95% CI: -0.80~0.16), and 0.15 (95% CI: -5.11~5.41) without statistical significance.

CONCLUSIONS

For patients with NAFLD/NASH, DMR has the trend to improve liver fat at 12 weeks, and glycemic control in terms of HbA1c level at 24 weeks based on a very low quality of evidence.

Review of paediatric obesity and non-alcoholic fatty liver disease-A focus on emerging non-pharmacologic treatment strategies

Obesity in paediatrics has become one of the most serious public health concerns worldwide. Paediatric obesity leads to increased adult obesity and is associated with several comorbidities, both physical and psychological. Within gastroenterology, non-alcoholic fatty liver disease (NAFLD) is now the most common cause of paediatric liver disease and the most common cause of liver transplantation in young adults. Treatment for NAFLD largely focuses on treatment of obesity with weight loss strategies. Unfortunately, the traditional method of weight loss using multicomponent lifestyle modification (dietary changes, increased exercise and behavioural modification) has often led to disappointing results. In adult patients with obesity, treatment strategies have evolved to include bariatric surgery and, more recently, bariatric endoscopy. In paediatrics, the obesity and NAFLD epidemics will likely require this variety of treatment to address children in a personalized manner. Here, we present a review of paediatric obesity, paediatric NAFLD and the various treatment strategies to date. We focus on non-pharmacologic and emerging therapies, including bariatric surgery and bariatric endoscopy-based treatments. With such a large population of children and adolescents with obesity, further development of these treatments, including paediatric-focused clinical trials, is essential for these emerging modalities.

Metabolic and Bariatric Endoscopy: A Mini-Review

We are currently in a worldwide obesity pandemic, which is one of the most significant health problems of the 21st century. As the prevalence of obesity continues to rise, new and innovate treatments are becoming available. Metabolic and bariatric endoscopic procedures are exciting new areas of gastroenterology that have been developed as a direct response to the obesity crisis. These novel interventions offer a potentially reversible, less invasive, safer, and more cost-effective method of tackling obesity compared to traditional bariatric surgery. Minimally invasive endoscopic treatments are not entirely novel, but as technology has rapidly improved, many of the procedures have been proven to be extremely effective for weight loss and metabolic health, based on high-quality clinical trial data. This mini-review examines the existing evidence for the most prominent metabolic and bariatric procedures, followed by a discussion on the future trajectory of this emerging subspecialty.

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: 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.

Regression of Hepatic Fibrosis After Endoscopic Gastric Plication in Nonalcoholic Fatty Liver Disease

INTRODUCTION

Fibrosis stage is the strongest predictor of mortality in patients with nonalcoholic fatty liver disease (NAFLD). There is currently no approved therapy that specifically targets fibrosis. This study aims to assess the effect of endoscopic gastric plication on hepatic fibrosis in patients with underlying NAFLD.

METHODS

This is a retrospective analysis of prospectively collected registry of patients with obesity and NAFLD with clinically significant hepatic fibrosis (≥F2) who underwent endoscopic gastric plication. Full-thickness plications were placed in the gastric body using a commercially available platform to reduce the gastric volume. The primary outcome included various noninvasive tests (NITs) of hepatic fibrosis based on clinical chemistry and/or imaging. The secondary outcomes included NITs of hepatic steatosis, other metabolic outcomes, including hemoglobin A1c, insulin resistance, and total weight loss (TWL), and adverse events.

RESULTS

Forty-five patients (age 51 ± 13 years and body mass index 40.7 ± 6.9 kg/m 2 ) were included. All patients underwent endoscopic gastric plication successfully. At 6-12 months, there were significant reductions in biochemistries (alanine aminotransferase: 49.7 ± 36.8 U/L to 24.2 ± 12.0 U/L [ P < 0.0001], aspartate aminotransferase: 39.1 ± 24.1 U/L to 24.1 ± 10.0 U/L [ P < 0.0001]), composite fibrosis score (NAFLD fibrosis score: 0.48 ± 1.51 to -1.18 ± 1.56 [ P < 0.0001], fibrosis-4 index: 1.4 ± 1.2 to 1.2 ± 0.7 [ P = 0.03]), and imaging-based markers of fibrosis (vibration-controlled transient elastography: 13.9 ± 7.5 kPa to 8.9 ± 4.8 kPa ( P < 0.0001) and Agile 3+: 0.53 ± 0.28 to 0.37 ± 0.28 [ P = 0.001]). There were significant reductions in controlled attenuation parameter, Homeostatic Model Assessment for Insulin Resistance, and hemoglobin A1c ( P < 0.05 for all). At 12 months, patients experienced 15.5% ± 7.9% TWL, with 63% reaching at least 10% TWL.

DISCUSSION

Endoscopic gastric plication seems effective at treating NAFLD, with significant reduction in NITs of hepatic fibrosis even in patients with cirrhosis.

Comparable Short-Term Weight Loss and Safety of Endoscopic Sleeve Gastroplasty in Diabetic and Non-diabetic Patients

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a highly effective endo bariatric procedure. Data on outcomes of ESG in patients with diabetes mellitus (DM) compared to non-diabetics are limited.

AIMS

We aim to assess differences in clinical outcomes of ESG in DM patients in North America.

METHODS

We used the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database from 2016 to 2021 to identify all DM patients who underwent ESG as the primary procedure for weight loss. A 1:1 propensity score matched cohort of non-DM patients served as controls. Patient characteristics, clinical outcomes, and complications were compared and analyzed. Adult patients with Class I obesity and above were included.

RESULTS

After matching, 310 DM and non-DM patients that underwent ESG were compared. The median % BMI decrease (3.3% vs. 3.1%, P = 0.62) and median total body weight loss (%TBWL) (4.3% vs. 4%, P = 0.75) in 30 days were similar in the DM compared to non-DM cohorts. A similar proportion of patients with major adverse events (AEs) were present after ESG in the DM (1.6% vs. 1.3%, P = 0.74) compared to the non-DM cohort. The DM cohort had more patients with 30-day readmissions (3.2% vs. 1.9%, P = 0.08) than the non-DM cohort. %TBWL was similar in patients with HbA1c < 9% compared to ≥ 9%, (4.3% each, P = 0.33) with comparable AEs.

CONCLUSION

ESG is a safe procedure in DM patients, without an increase in AEs, and it shows similar short-term weight loss compared to non-DM patients.

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.

The Role Bariatric Surgery and Endobariatric Therapies in Nonalcoholic Steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Disease spectrum varies from steatosis, steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Currently, there are no approved medical therapies, and weight loss through lifestyle modifications remains a mainstay of therapy. Bariatric surgery is the most effective therapy for weight loss and has been shown to improve liver histology. Recently, endoscopic bariatric metabolic therapies have also emerged as effective treatments for patients with obesity and NAFLD. This review summarizes the role of bariatric surgery and endoscopic therapies in the management of patients with NAFLD.

Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.

Updates in Endoscopic Bariatric and Metabolic Therapies

The rising prevalence of obesity, and related morbidity and mortality, has necessitated the development of therapeutic weight loss strategies. Lifestyle modifications alone have only yielded modest benefit, and while bariatric surgery has shown significant short- and long-term results, only a minority of eligible patients end up receiving this treatment. Endoscopic bariatric and metabolic therapies (EBMTs) are a rapidly evolving field, which provides a less invasive middle ground treatment option for weight loss. Here we discuss the efficacy, as well as short- and long-term outcomes with restrictive, malabsorptive/metabolic and aspiration endoscopic techniques, and their effects on metabolic parameters.

Pathogenesis and treatment of non-alcoholic steatohepatitis and its fibrosis

The initial presentation of non-alcoholic steatohepatitis (NASH) is hepatic steatosis. The dysfunction of lipid metabolism within hepatocytes caused by genetic factors, diet, and insulin resistance causes lipid accumulation. Lipotoxicity, oxidative stress, mitochondrial dysfunction, and endoplasmic reticulum stress would further contribute to hepatocyte injury and death, leading to inflammation and immune dysfunction in the liver. During the healing process, the accumulation of an excessive amount of fibrosis might occur while healing. During the development of NASH and liver fibrosis, the gut-liver axis, adipose-liver axis, and renin-angiotensin system (RAS) may be dysregulated and impaired. Translocation of bacteria or its end-products entering the liver could activate hepatocytes, Kupffer cells, and hepatic stellate cells, exacerbating hepatic steatosis, inflammation, and fibrosis. Bile acids regulate glucose and lipid metabolism through Farnesoid X receptors in the liver and intestine. Increased adipose tissue-derived non-esterified fatty acids would aggravate hepatic steatosis. Increased leptin also plays a role in hepatic fibrogenesis, and decreased adiponectin may contribute to hepatic insulin resistance. Moreover, dysregulation of peroxisome proliferator-activated receptors in the liver, adipose, and muscle tissues may impair lipid metabolism. In addition, the RAS may contribute to hepatic fatty acid metabolism, inflammation, and fibrosis. The treatment includes lifestyle modification, pharmacological therapy, and non-pharmacological therapy. Currently, weight reduction by lifestyle modification or surgery is the most effective therapy. However, vitamin E, pioglitazone, and obeticholic acid have also been suggested. In this review, we will introduce some new clinical trials and experimental therapies for the treatment of NASH and related fibrosis.

Novel Endoscopic Bariatric Therapies for the Management of Nonalcoholic Steatohepatitis

Obesity is strongly associated with nonalcoholic fatty liver disease as well as advanced forms of the disease such as nonalcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma. While lifestyle and diet modifications have been the cornerstone of treatment for NASH thus far, they are only effective for less than half of the patients. New endoscopic bariatric therapies (EBTs) have already proved to be safe and effective for the treatment of obesity and type 2 diabetes mellitus, and may provide an intermediate, less invasive, cost-effective option for patients with NASH. In this review, we aim to describe the data and evidence as well as outline future areas of development for endobariatric therapies for the treatment of NASH. In conclusion, EBTs present an effective and safe therapeutic modality for use in the growing pandemic of obesity-related liver disease and should be investigated further with large-scale trials in this patient population.

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.

Endoscopic Bariatric and Metabolic Therapies for Liver Disease: Mechanisms, Benefits, and Associated Risks

Nonalcoholic fatty liver disease (NAFLD), including advanced-stage nonalcoholic steatohepatitis (NASH), is currently the most common chronic liver disease worldwide and is projected to become the leading indication for liver transplantation (LT). However, there are no effective pharmacological therapies for NAFLD. Endoscopic bariatric and metabolic therapies (EBMTs) are less invasive procedures for the treatment of obesity and its metabolic comorbidities. Several recent studies have demonstrated the beneficial effects of EBMTs on NAFLD/NASH. In this review, we summarize the major EBMTs and their mechanisms of action. We further discuss the current evidence on the efficacy and safety of EBMTs in people with NAFLD/NASH and obese cirrhotic LT candidates. The potential utility of EBMTs in reducing liver volume and perioperative complications in bariatric surgery candidates is also discussed. Moreover, we review the development of liver abscesses as a common serious adverse event in duodenal-jejunal bypass liner implantation.

Nonalcoholic Fatty Liver Disease: Review of Management for Primary Care Providers

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease in the United States and worldwide. The progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), is a leading indication for liver transplant. Comorbidities associated with NAFLD development and NASH include type 2 diabetes, obesity, metabolic syndrome, and dyslipidemia. Extrahepatic morbidity and mortality are considerable as NAFLD is associated with an increased risk of cardiovascular disease and chronic kidney disease. Once NAFLD is diagnosed, the presence of liver fibrosis is the central determinant of hepatic prognosis. Severe liver fibrosis requires aggressive clinical management. No pharmacologic agents have regulatory approval in the United States for the treatment of NAFLD or NASH. Management is centered on efforts to reduce underlying obesity (lifestyle, medications, surgical or endoscopic interventions) and metabolic derangements (prediabetes, type 2 diabetes, hypertension, hyperlipidemia, and others). Current pharmacologic therapy for NAFLD is limited mainly to the use of vitamin E and pioglitazone, although other agents are being investigated in clinical trials. Cardiovascular and metabolic risk factors must also be assessed and managed. Here, NAFLD evaluation, diagnosis, and management are considered in the primary care setting and endocrinology clinics.

Future of Metabolic Endoscopy

Obesity has been escalating as one of the worst public health epidemics. Conservative therapies including lifestyle modifications and weight loss medications have limited efficacy and long-term sustainability. Bariatric surgeries, although effective, remain underutilized due to their cost, safety concerns, and patient acceptance. In the past two decades, endoscopic bariatric and metabolic therapies (EBMTs) have emerged as safe, effective, and less invasive options for the treatment of obesity and its comorbidities, with recent studies reporting favorable outcomes in terms of weight loss and metabolic parameters. This article reviews the major and newly developed EBMTs, with emphasis on their metabolic effects and potential use in the management of metabolic conditions.

Body weight loss and glycemic control on the outcomes of patients with NAFLD. The role of new antidiabetic agents

Nonalcoholic fatty liver disease (NAFLD) is currently the most common cause of chronic liver disease worldwide affecting a third of adults and 12% of children in Western countries. In around 50-60%% of cases, NAFLD and type 2 diabetes mellitus (T2DM) coexist and act synergistically to increase the risk of adverse hepatic and extra-hepatic outcomes. T2DM is a strong risk factor for rapid progression of NAFLD to nonalcoholic steatohepatitis (NASH), cirrhosis or hepatocellular carcinoma (HCC), which have become frequent indications of liver transplantation. The pathophysiology of NAFLD is complex and its relationship with T2DM is bidirectional, where lipotoxicity and insulin resistance (IR), act as the strongest pillars. To date, no pharmacological treatment has been approved for NAFLD. However, there is an intense research with numerous drugs focused on reversing inflammation and liver fibrosis through modulation of molecular targets without good results. It has been known for some time that weight reduction >10% is associated to histological improvement of NAFLD. Recently, glycemic control has been shown to induce similar results. Diet and physical exercise for weight reduction have limitations, so alternative methods (pharmacologic, endoscopic or surgical) may be required. Currently, new antidiabetic drugs inducing weight loss, have been recently approved for the treatment of obesity. Nevertheless, their therapeutic effects on NAFLD have not been extensively studied. We will review here, recently published data on the effects of weight loss and glycemic control on the histological and metabolic parameters of NAFLD and recent published data on therapeutic studies of NAFLD with new antidiabetic drugs.

Endoscopic Bariatric and Metabolic Therapies and Their Effects on Metabolic Syndrome and Non-alcoholic Fatty Liver Disease - A Systematic Review and Meta-Analysis

Background

Endoscopic bariatric and metabolic therapies (EBMTs) are procedures that utilize instruments that require flexible endoscopy or placement of devices for inducing weight loss. We perform a systematic review and meta-analysis to evaluate four modalities – intragastric balloon (IGB), endoscopic sleeve gastroplasty (ESG), duodeno-jejunal bypass liner (DJBL), and duodenal mucosa resurfacing (DMR), for their efficacy and safety on weight loss, non-alcoholic fatty liver disease, and metabolic syndrome.

Methods

Databases MEDLINE via PubMed, and EMBASE are searched and relevant publications up to January 26, 2022 are assessed. Studies are included if they involved human participants diagnosed with obesity and obesity-related comorbid conditions who are treated with any of the 4 EBMTs. IGB and DJBL were chosen as the interventions for the meta-analysis with weight loss (percentage total body weight loss or body mass index) and glycemic control (fasting plasma glucose or HbA1c) as the two main outcomes analyzed.

Results

Six hundred and forty-eight records are reviewed, of which 15 studies are found to be duplicates. Of the 633 records screened, 442 studies are excluded. One hundred and ninety-one articles are assessed for eligibility, for which 171 are excluded. A total of 21 publications are included. Twelve studies are on IGB, two studies on ESG, five studies on DJBL, and two studies on DMR. In these studies with appropriate control, IGB, ESG, and DJBL showed promising benefits on weight loss reduction compared to standard medical therapy (SMT), while DMR appeared to have the least weight reduction benefit. However, the impact on glycemic control featured more prominently in DMR as compared to the rest of the modalities. Different EBMTs have different adverse effect profiles, although device-related adverse events are featured more prominently in DJBL. In the IGB group, there was a significant reduction in 6-month %TBWL [weighted mean difference (WMD) 5.45 (3.88, 7.05)] and FPG WMD −4.89 mg/dL (−7.74, −2.04) compared to the SMT group. There was no significant reduction in BMI between the DJBL and SMT group WMD −2.73 (−5.52, 0.07) kg/m2.

Conclusion

EBMTs have demonstrated a significant impact on weight loss and metabolic comorbidities, and reasonable safety profiles in the studies reviewed. Some data is available to demonstrate reduction of hepatic steatosis, but there is no high-quality data supporting benefits on hepatic lobular inflammation or fibrosis.

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.

Endoscopic Bariatric Interventions in Patients with Chronic Liver Disease

Obesity and its associated comorbidities are rapidly increasing in the US population. Therefore, metabolic associated fatty liver disease (MAFLD), previously known as nonalcoholic fatty liver disease (NAFLD), has become a leading indication for liver transplantation. Lifestyle modifications as a sole therapy have been insufficient to reduce the burden of chronic liver disease secondary to MAFLD. Endoscopic bariatric interventions (EBI) appear to be safe and effective therapies for obesity and chronic liver disease secondary to MAFLD. Gastric EBI include endoscopic sleeve gastroplasty (ESG) and intragastric balloons (IGB). Small bowel EBI are also evolving in the field of bariatric endoscopy.

Effects of Bariatric Endoscopy on Non-Alcoholic Fatty Liver Disease: A Comprehensive Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Endoscopic bariatric and metabolic therapies (EBMTs) are emerging minimally invasive therapeutic options for obesity and its related complications, including non-alcoholic fatty liver disease (NAFLD). This study aimed to evaluate the effects of EBMTs on NALFD in patients with obesity.

METHODS

Four databases were searched until Nov 2021. Randomized controlled trials (RCTs) and observational studies reporting liver-related outcomes following Food and Drug Administration (FDA)-approved and non-FDA-approved EBMTs were included. Liver parameters, metabolic parameters, and weight loss were evaluated. Risk of bias was assessed using the "risk of bias" tool in the Cochrane Collaboration for RCTs and the Methodological Index for Non-Randomized Studies criteria for observational studies.

RESULTS

Thirty-three studies with 1710 individuals were included. Regarding the effects of EBMTs on liver fibrosis, a significant decline of NAFLD Fibrosis Score, but not transient elastography-detected liver stiffness or Fibrosis-4 Index, was observed. EBMTs significantly improved liver steatosis (control attenuation parameter and Hepatic Steatosis Index), NAFLD Activity Score, and Homeostasis Model Assessment of Insulin Resistance. EBMTs reduced serum levels of alanine transaminase, aspartate aminotransferase, and gamma-glutamyl transpeptidase considerably. Moreover, EBMTs had reducing effects on the serum levels of triglycerides and total cholesterol as well as body weight.

CONCLUSIONS

Our meta-analysis suggested that EBMTs could ameliorate NAFLD based on the evidence of improved liver steatosis, liver function, and insulin resistance. Large-scale, prospective, long-term studies are warranted to clarify the role of EBMTs in patients with different stages of NAFLD.

Preoperative circulating peroxiredoxin 1 levels as a predictor of non-alcoholic fatty liver disease remission after laparoscopic bariatric surgery

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is associated with obesity and insulin resistance and can be improved after bariatric surgery. Circulating Peroxiredoxin 1 (Prdx1) protein was reported to regulate energy metabolism and inflammation. This study aimed to investigate the roles of serum prdx1 in NAFLD patients with obesity undergoing LSG and to develop a prognostic model to predict the remission of severe NAFLD.

METHODS

The data of 93 participants from a tertiary hospital were assessed. Before laparoscopic sleeve gastrectomy (LSG) and three months after LSG, anthropometric parameters, laboratory biochemical data, and abdominal B-ultrasound results were collected, and their hepatic steatosis index (HSI) and triglyceride-glucose index (TyG) were calculated. A NAFLD improvement (NAFLD-I) nomogram prediction model was constructed using the least absolute shrinkage and selection operator (LASSO) regression and multiple regression, and its predictive ability was verified in a validation cohort.

RESULTS

The baseline Prdx1 (OR: 0.887, 95% CI: 0.816-0.963, p=0.004), preoperative TyG (OR: 8.207, 95% CI: 1.903-35.394, p=0.005) and HSI (OR: 0.861, 95% CI: 0.765-0.969, p=0.013) levels were independently associated with NAFLD-I at three months after LSG in NAFLD patients with obesity. In the primary and validation cohorts, the area under the receiver operating characteristic (AUC) of the developed nomogram model was 0.891 and 0.878, respectively. The preoperative circulating Prdx1 levels of NAFLD patients with obesity were significantly reduced after LSG (25.32 [18.99-30.88] vs. 23.34 [15.86-26.42], p=0.001). Prdx1 was related to obesity and hepatic steatosis based on correlation analysis.

CONCLUSION

The nomogram based on preoperative serum prdx1, HSI and TyG could be an effective tool for predicting remission of severe NAFLD after LSG.