Aspiration Therapy for Obesity

Mechanism of action and selection of endoscopic bariatric therapies for treatment of obesity

Endoscopic bariatric therapies (EBTs) are minimally invasive and safe procedures with favorable weight loss outcomes in obesity treatment. We aimed to present the weight loss mechanism of action of EBTs and an individualized selection method for patients with obesity. We searched PubMed, Medline, Scopus, Embase, and Google Scholar databases for studies on the topic from databases inception to July 1, 2023, written in English. We focused on EBTs potential mechanism of action to induce weight loss. We also present an expert opinion on a novel selection of EBTs based on their mechanism of action. EBTs can result in weight loss through variable mechanisms of action. They can induce earlier satiation, delay gastric emptying, restrict the accommodative response of the stomach, decrease caloric absorption, and alter the secretion of gastrointestinal hormones. Selecting EBTs may be guided through their mechanism of action by which patients with abnormal satiation may benefit more from tissue apposition devices and aspiration therapy while patients with fast gastric emptying may be better candidates for intragastric devices, endoscopic anastomosis devices, and duodenal mucosal resurfacing. Consequently, the selection of EBTs should be guided by the mechanism of action which is specific to each type of therapy.

The evolution and current state of bariatric endoscopy in Western countries

With the alarmingly increasing prevalence of obesity in the Western world, it has become necessary to provide more acceptable treatment options for patients with obesity. Minimally invasive endoscopic techniques are continuously evolving. Currently, metabolic and bariatric endoscopies encompass several different techniques that can offer significant weight loss and improvement in comorbidities with a favorable safety profile. Restrictive bariatric procedures include the use of intragastric balloons and gastric remodeling techniques with different suturing devices. Several studies have demonstrated the efficacy and safety of these techniques that are widely used in clinical practice. Small intestine-targeted metabolic endoscopy is an intriguing and rapidly evolving field of research, although it is not widespread in routine practice. These techniques include duodenal-jejunal bypass liners, duodenal mucosal resurfacing, and incisionless anastomoses. The aim of this review article is to provide a detailed update on the currently available bariatric endoscopy techniques in Western countries.

Overview on the endoscopic treatment for obesity: A review

Obesity rates have increased, and so has the need for more specific treatments. This trend has raised interest in non-surgical weight loss techniques that are novel, safe, and straightforward. Thus, the present review describes the endoscopic bariatric treatment for obesity, its most recent supporting data, the questions it raises, and its future directions. Various endoscopic bariatric therapies for weight reduction, such as intragastric balloons (IGBs), aspiration therapy (AT), small bowel endoscopy, endoscopic sleeve gastroplasty, endoluminal procedures, malabsorption endoscopic procedures, and methods of regulating gastric emptying, were explored through literature sourced from different databases. IGBs, AT, and small bowel endoscopy have short-term effects with a possibility of weight regain. Minor adverse events have occurred; however, all procedures reduce weight. Vomiting and nausea are common side effects, although serious complications have also been observed.

Association for Bariatric Endoscopy systematic review and meta-analysis assessing the American Society for Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for aspiration therapy

A subcommittee of the Association for Bariatric Endoscopy, a division of the American Society for Gastrointestinal Endoscopy (ASGE) comprising experts in the subject area, performed this systematic review and meta-analysis. The systematic review and meta-analysis was reviewed by the ASGE Technology Committee and was ultimately submitted to the ASGE Governing Board for approval. The systematic review and meta-analysis underwent peer review by outside experts in statistics and meta-analysis before receiving final ASGE Governing Board approval. The Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) initiative is an ASGE program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice, presuming the appropriate training in that endoscopic technology has been achieved. ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds.

Bariatric endoscopy: current primary therapies and endoscopic management of complications and other related conditions

The steady increase in bariatric surgery has led to room for innovation. Endoscopy has become an important tool for evaluation, diagnosis, management of complications, and even for primary bariatric interventions. Leaks are the most feared complication and new endoscopic therapies have been developed such as septotomy, double-pigtail stents, and endoscopic vacuum therapy. Additionally, primary bariatric endoscopic procedures are gaining popularity and the new procedures include intragastric balloons, stoma reduction, aspiration therapy, among others. The altered anatomy and reoperation increase the risk of complications after bariatric surgery, especially when managing conditions like achalasia, gastroparesis, and cholelithiasis. Per-oral endoscopic myotomy, per-oral pyloromyotomy, and endoscopic ultrasound-guided transgastric endoscopic retrograde cholangiopancreatography provide a less invasive approach to address these conditions. This narrative review article intends to expose current endoscopic therapies for the management of primary bariatric procedures, complications and related conditions.

New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review

Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.

Procedures and devices for bariatric and metabolic endoscopy

Obesity is a leading cause of preventable death in developed countries, with a rising incidence over time. Lifestyle modification, pharmacotherapy, and bariatric surgery are the mainstays of bariatric therapy, even though burdened by several limitations in terms of efficacy or safety. Bariatric endoscopy has been developed in the last decades as a minimally invasive alternative, aimed to bridge the gap between conservative and interventional conventional therapies. This review aims to provide an updated overview of the bariatric and metabolic available endoscopic procedures and to drive the choice of the right procedure for the right patient.

An Approach to Obesity Management for Gastroenterologists and Hepatologists

PURPOSE OF REVIEW

Obesity is associated with multiple gastrointestinal and liver diseases such as gastroesophageal reflux disease, Barrett's esophagus, esophageal adenocarcinoma, cholelithiasis, colon polyps, and fatty liver disease. To effectively manage obesity, it is imperative to understand current and emerging therapies and procedures.

FINDINGS

Obesity is becoming increasingly prevalent and is associated with a growing monetary health care burden. Cardiac disease, cerebrovascular disease, and diabetes are among the leading causes of preventable and premature death of Americans related to obesity. In addition to behavioral modification (diet and exercise) and bariatric surgery, multiple pharmacotherapies and endoscopic procedures are newly approved and available for the management of obesity. This paper reviews the current literature on the treatments available for the management of obesity including behavior modification, pharmacotherapy, endoscopic weight loss procedures (endobariatrics), and bariatric surgery.

Conversion of AspireAssist System® to Sleeve Gastrectomy: Technical Video Description

PURPOSE

The AspireAssist System® (Aspire Bariatrics, Inc. King of Prussia, PA) is a new endoscopic procedure used to treat obese patients. The aim of this dedicated video is to present a case that required revision surgery due to failure of the AspireAssist System®, and to show how the cannula was removed from the abdomen, and why sleeve gastrectomy (SG) was a good option for revisional surgery in that patient. We aim to discuss technical aspects.

PATIENT AND METHODS

A 43-year-old female patient who underwent a placement in 2016. Her initial BMI (body mass index) was 38 kg/m², with a follow-up period of 26 months. A revisional surgery was performed including dissection of the previous gastric fistula and adhesiolysis from the previous AspireAssist System® placement. A complete dissection of the gastrostomy, including removal of all the system, was done. A decision was made, once the incisura angularis and the placement of a 40 Fch bougie showed that the transection could be performed. SG was done. Patients showed an uneventful postoperative course and 4 months follow-up with 45% EWL.

CONCLUSION

In case of having the device in place, the surgeon must be aware to remove intraoperatively or endoscopically, the device. Surgeons should consider endoscopic removal of the AspireAssist System® before conversion to another procedure (SG or GBP) at least 6 months of the removal. Removal of the AspireAssist System® should be performed endoscopically but direct conversion to another bariatric procedure can be considered, either to SG or GBP depending on the technical intraoperative aspects.

Endoscopic bariatric and metabolic therapies: Another tool for the management of diabetes and obesity

Endoscopic bariatric and metabolic therapies (EBMTs) have sparked significant interest as minimally invasive therapeutic options for weight loss. Although bariatric surgery remains an effective option for sustained weight loss and improvement in the metabolic syndrome, access and utilization are limited. Various EBMTs have been designed to emulate the physiologic effects of established surgical interventions, including space-occupying and non-space-occupying gastric therapies, gastric remodeling procedures, and small bowel therapies. This review discusses the safety and efficacy of available US Food and Drug Administration-approved minimally invasive endoscopic bariatric interventions, as well as those currently under investigation. In addition, the role of endoscopic revision after failed surgical intervention is discussed.

Abdominal Abscess Related to Endoscopically Placed AspireAssist® Device

We report a 55-year-old diabetic woman with abdominal pain, pyrexia, and leukocytosis 3 months after aspiration tube placement. Abdominal computed tomography revealed a hypodense mass (10.8 × 7.2 cm) extending into the right anterior abdominal wall. Aspiration of the abscess revealed purulent fluid that grew Streptococcus intermedius. The aspiration tube was removed and 4 endoclips were deployed to close the intragastric stoma. The patient recovered well with 21 days of antibiotics, with resolution of the abscess and full wound healing.