Advances in the Endoscopic Management of Obesity

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.

Early safety and efficacy comparison of endoscopic bariatric interventions

BACKGROUND

Intragastric balloon (IGB) placement and endoscopic sleeve gastroplasty (ESG) are the 2 primary endoscopic bariatric therapies currently performed in the United States. Procedural selection is often based primarily on patient preference. There is a paucity of comparative data between these interventions.

OBJECTIVES

The aim of this study is to compare the short-term safety and efficacy of IGB to ESG in the largest, direct comparative analysis to date.

SETTING

Accredited bariatric centers across the United States and Canada.

METHODS

We retrospectively analyzed patients who underwent IGB or ESG from 2016 to 2020 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. IGB patients were propensity matched (1:1) to ESG patients. We compared readmissions, reinterventions, serious adverse events (SAE), weight loss, procedure time, and length of stay between the 2 interventions. All outcomes were measured within 30 days of the initial procedure.

RESULTS

A total of 1998 pairs of patients who underwent IGB and ESG were propensity matched with no difference in baseline characteristics. Patients who underwent ESG had more readmissions within 30 days. Patients who underwent IGB had more outpatient treatments for dehydration and re-interventions, with 3.7% of patients undergoing early balloon removal less than 30 days from implantation. Both procedures had similarly low rates of SAE (P > .05). ESG led to greater total body weight loss at 30 days.

CONCLUSIONS

ESG and IGB are both safe procedures with comparably low rates of SAE. Higher rates of dehydration and re-interventions after IGB suggest that ESG is perhaps better tolerated.

Comparison of The Short-Term Effects of Intragastric Balloon and Botulinum Toxin Injection On Weight Loss

Aim: To compare the effects of endoscopic intragastric balloon (IGB) placement and intragastric botulinum toxin-A (BTX-A) injection in terms of weight loss among patients with non-morbid obesity. Methods: This retrospective single center study was conducted between 01.08.2020 and 01.01.2022. A total of 39 patients with a body mass index (BMI) of <40 without comorbidities were included in the study. Nineteen underwent intragastric BTX-A injection and 20 underwent IGB placement. Patients were evaluated 1 month and 6 months after the procedures. Results: Mean age was 39.4 ± 8.6 in the BTX-A group and 37.3 ± 10.4 in the IGB group (p = 0.496). 78.9% of the BTX-A group and 75.0% of the IGB group were female (p = 1.000). In both groups, the median weight 1 month after the procedure was significantly lower than before the procedure, and the median weight 6 months after the procedure was significantly lower than 1 month after the procedure (p<0.001 for both groups). The median weight loss in the IGB group at both the 1st and 6th months was significantly greater than the corresponding values of the BTX-A group (p < 0.001 for both). Conclusion: IGB insertion appears to be a more successful endoscopic bariatric procedure than intragastric BTX-A injection, as measured by weight loss at post-intervention 1 month and 6 months. IGB may be preferred in patients with a BMI below 40 without obesity-related comorbidity.

Real-World Experience of Intragastric Balloons for Obesity: Insights from the FDA Manufacturer and User Facility Device Experience (MAUDE) Database

Intragastric balloons have been used to bridge the obesity treatment gap. We aim to investigate the number and type of complications associated with intragastric balloons using public-access governmental databanks. We analyzed post-marketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from Jan 2017 through Nov 2020. During the study period, approximately 773 cases with 830 device issues and 1134 patient complications were identified. Most balloon complications were due to leaks (33.4%). The most reported adverse events were vomiting (26.6%), abdominal pain (25.3%), and nausea (15.8%). Findings from the MAUDE database highlight patient and device adverse outcomes that should be addressed to improve clinical success.

The Utility of EndoFLIP for Measuring Gastrojejunal Anastomosis Diameter and Distensibility in Patients Experiencing Weight Regain Post Roux-en-Y Gastric Bypass

A dilated gastrojejunal anastomosis (GJA) diameter is an independent predictor of weight regain following Roux-en-Y gastric bypass (RYGB). Despite this, there is no standardized method for GJA diameter measurement. We performed a retrospective analysis to compare endoscopic visual estimation and endoluminal functional impedance planimetry (EndoFLIP) for measuring GJA diameter in patients with weight regain post-RYGB. Visual estimation was found to overestimate GJA diameter by a mean of 4.2mm ± 4.6mm when compared with EndoFLIP. Furthermore, we identified symptomatic patients with normal GJA diameter but increased distensibility, which may represent a previously unrecognized subgroup. Our findings suggest the potential utility of EndoFLIP in the evaluation of post-RYGB weight regain and support the need for prospective studies to investigate the relationship between GJA distensibility and weight regain.

Do Endoscopic Bariatric Procedures Improve Postprocedural Quality of Life and Mental Health? A Systematic Review and Meta-analysis

Quality of life and mental health are important outcomes of bariatric therapy. This review aimed to determine endoscopic bariatric procedures' impact on postprocedural quality of life and mental health. Four electronic databases were systematically searched. Studies with adults > 18 years who underwent an endoscopic bariatric procedure and reported pre- and postprocedural quality of life and/or mental health using a validated tool were included. Meta-analyses were conducted using RevMan and study quality was assessed. Twenty studies evaluating five different endoscopic procedures were included (N = 876 total sample size). Intragastric balloon placement was associated with a large improvement in postprocedural quality of life and mental health. Endoscopic bariatric therapies may improve short-term quality of life and mental health alongside weight loss and comorbidity improvement.

Endoscopic bariatric therapies for treating obesity: a learning curve for gastroenterologists

Obesity represents a growing public health threat. Until recently, surgery was the primary means for treating pharmacotherapy resistant obese patients. However, therapeutic endoscopy has evolved as an effective and safe alternative strategy. Particularly, endoscopic bariatric therapy (EBT) can bridge the gap in patients who do not fit the BMI criteria for surgery and fail conservative or medical therapy. Today there are many tools within the realm of EBT available to endoscopists. While there are no formal guidelines for their use, training and use of these tools are limited by the type of institution, preferences of senior endoscopists, cost, and availability. We review different EBT tools available to trainees and gastroenterologist, and the learning curves associated with them.

Intragastric Balloon for Obesity Treatment: Safety, Tolerance, and Efficacy

Background

Obesity is an increasing worldwide problem associated with a vast number of comorbidities. Decreasing body weight by only 5-10% has been shown to slow and even prevent the onset of obesity-related comorbidities. Between pharmacological therapy and bariatric surgery a great variety of endoscopic techniques are available, the most common being intragastric balloon (IGB). The purpose of this study was to assess the safety, tolerance, and kinetics of IGBs in weight loss. The kinetics of weight loss were evaluated in 2 different contexts and phases: after the IGB's removal and after follow-up that varied between 6 and 12 months. Successful weight loss was defined as ≥10% weight loss after 6-12 months.

Methods

The study included 51 patients who had undergone Orbera® IGB placement between September 2014 and February 2016. Inclusion criteria were age between 18 and 65 years; body mass index (BMI) 28-35 with severe obesity-related disorders; or BMI 35-40. The IGB was removed 6 months later. All patients were followed for a minimum period of 6-12 months.

Results

Of 51 patients, 16 were excluded (7 due to intolerance) and 35 patients entered the study, of which 83% were followed for more than 6-12 months. The average weight loss (WL) and % excess WL (%EWL) after 6 months of treatment were 11.94 kg and 42.16%, respectively. At 6-12 months, after removal of the IGB, the mean WL was 8.25 kg and %EWL was 30.27%. Nineteen patients attained a WL of ≥10% the baseline value at IGB removal and 12 maintained their weight below this threshold during the 6-12 following months.

Conclusions

After temporary IGB implantation in overweight or obese individuals, a WL that was ≥10% of weight at baseline was achieved in 54.3% and sustained at 6-12 months in 41.4% of participants. IGBs are an attractive intermediate option between diet and exercise programs and bariatric surgery. In general, IGB placement is a safe and well-tolerated procedure.

Endoluminal weight loss and metabolic therapies: current and future techniques

Obesity is a public health epidemic associated with a number of comorbidities, most notably type 2 diabetes and hypertension, as well as elevated all-cause mortality. The treatment for obesity and its associated comorbidities has most recently expanded into the field of bariatric endoscopy. This field bridges a gap between lifestyle counseling with or without pharmaceutical treatment and the most effective treatment of obesity, bariatric surgery. Because of its minimally invasive nature, bariatric endoscopic therapy has the potential to appeal to the large sector of the obese population that resists surgery, as well as those early in the onset of obesity. To date, five endoscopic devices have been approved by the U.S. Food and Drug Administration for the treatment of obesity, and many more are in development, undergoing clinical trials, or being used around the world. Here, we present the current state of the field, highlight recent developments, and describe the clinical outcomes of these minimally invasive procedures in terms of weight loss, improvement in metabolic profile, and reduction in comorbidities.

Current and cutting-edge interventions for the treatment of obese patients

The number of people classified as obese, defined by the World Health Organization as having a body mass index ≥30, has been rising since the 1980s. Obesity is associated with comorbidities such as hypertension, diabetes mellitus, and nonalcoholic fatty liver disease. The current treatment paradigm emphasizes lifestyle modifications, including diet and exercise; however this approach produces only modest weight loss for many patients. When lifestyle modifications fail, the current "gold standard" therapy for obesity is bariatric surgery, including Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, and placement of an adjustable gastric band. Though effective, bariatric surgery can have severe short- and long-term complications. To fill the major gap in invasiveness between lifestyle modification and surgery, researchers have been developing pharmacotherapies and minimally invasive endoscopic techniques to treat obesity. Recently, interventional radiologists developed a percutaneous transarterial catheter-directed therapy targeting the hormonal function of the stomach. This review describes the current standard obesity treatments (including diet, exercise, and surgery), as well as newer endoscopic bariatric procedures and pharmacotherapies to help patients lose weight. We present data from two ongoing human trials of a new interventional radiology procedure for weight loss, bariatric embolization.

Aspiration therapy for obesity; a safe and effective treatment

Background

This study evaluated the efficacy and safety of the novel AspireAssist® Aspiration Therapy System for treatment of obesity, and its effect on patient’s quality of life.

Methods

A prospective observational study with 25 obese subjects, mean age 48 years (range 33–65), was performed. A custom gastrostomy tube (A-tube, Aspire Bariatrics) was percutaneously inserted during a gastroscopy performed under conscious sedation. Drainage and irrigation of the stomach were performed 3 times daily, 20 min after each meal, for 1–2 years. Efficient aspiration required thorough chewing of ingested food. Treatment included a cognitive behavioral weight loss program.

Results

Mean body mass index (BMI) at inclusion was 39.8 kg/m² (range 35–49). After 1 year mean (SD) BMI was 32.1 kg/m² (5.4), p < 0.01, and excess weight loss was 54.4% (28.8), p < 0.01. Quality of life, as measured with EQ-5D, improved from 0.73 (0.27) to 0.88 (0.13), p < 0.01. After 2 years BMI was 31.0 kg/m² (5.1), p < 0.01, and excess weight loss was 61.5% (28.5), p < 0.01. There were no serious adverse events or electrolyte disorders. Compliance was 80% after 1 year and 60% after 2 years.

Conclusions

Aspiration therapy is an efficient and safe treatment for obesity, and weight reduction improves quality of life. Excess weight was approximately halved in a year, with weight stability if treatment was continued.

Trial registration

Trial Register ISRCTN 49958132. Retrospectively registered 28/02/2014.