Bariatric and metabolic endoscopy: impact on obesity and related comorbidities

Long term outcomes of metabolic/bariatric surgery in adults

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

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.

A phenotypic approach to obesity treatment

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

Endoscopic Sleeve Gastroplasty Assisted by Postgraduate Medical Trainees: An Early Safety Analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an emerging bariatric intervention with comparable safety and efficacy to surgical sleeve gastrectomy (SG). As ESG is utilized more commonly, postgraduate medical training in bariatric endoscopy has expanded to train physicians in this technically complex procedure. Prior studies have analyzed procedural outcomes of bariatric surgery assisted by medical trainees, but no such analysis has been performed with ESG.

AIMS

This study aims to evaluate the short-term safety of ESG in cases assisted by postgraduate medical trainees.

METHODS

We retrospectively analyzed over 2000 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2016 to 2020. Cases of ESG performed with the assistance of postgraduate medical trainees (residents and/or fellows) were propensity matched (1:1) to cases of ESG performed without trainee involvement. We compared the occurrences of adverse events (AE), readmissions, re-interventions, and re-operations between these matched cohorts of ESG. Secondary outcomes included procedure time, length of stay (LOS), and total body weight loss (TBWL).

RESULTS

A total of 1204 cases of ESG assisted by postgraduate medical trainees were compared to 1204 matched cases without trainee involvement. Procedures performed by attending physicians alone had fewer AE (0.7% vs 2.0%, p = 0.014) and rates of re-operations (0.8% vs 2.4%, p = 0.004) compared to procedures assisted by trainees. There were no significant differences in readmissions (4.0% vs 4.4%, p = 0.684) or reinterventions (3.8% vs. 4.6%, p = 0.416) at 30 days. Cases involving trainees had longer duration (71 vs 51 min, p < 0.001) and LOS (1.11 vs. 0.5 days, p < 0.001). TBWL at 30 days was greater in procedures performed with trainees (4.1% vs 3.4%, p = 0.033).

CONCLUSION

ESG is a technically complex procedure that can be safely performed with trainee assistance. Academic medical centers may continue supporting the expansion of training in bariatric endoscopy as an advanced endoscopic skill.

Endoscopic Sleeve Gastroplasty: A Safe Bariatric Intervention for Class III Obesity (BMI > 40)

PURPOSE

Endoscopic sleeve gastroplasty (ESG) is primarily offered to patients with class I and II obesity (BMI 30-40), although there are no guidelines specifying applicability. There is little data comparing ESG to bariatric surgery in patients with class III obesity (BMI > 40). This study evaluates the short-term safety of ESG compared to sleeve gastrectomy (SG) and gastric bypass (RYGB) in patients with class III obesity.

METHODS

We retrospectively analyzed over 500,000 patients who underwent ESG, SG, and RNYGB from 2016 to 2020 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. ESG patients were stratified by BMI to compare outcomes between class I and II versus class III obese patients. Class III obese patients who underwent ESG were also propensity matched to SG and RNYGB patients for matched comparisons. Primary outcomes included adverse events (AE), readmissions, re-operations, and re-interventions within 30 days. Secondary outcomes included procedure time, length of stay (LOS), and total body weight loss (%TBWL) at 30 days.

RESULTS

Among ESG patients, those with BMI > 40 had no difference in AE, readmissions, or re-interventions versus patients with BMI 30-40 (p > 0.05), while achieving greater %TBWL at 30 days (p < 0.05). In comparison to surgery, ESG had similar AE to SG and less than RNYGB, while producing comparable %TBWL to SG and RNYGB at 30 days.

CONCLUSIONS

The feasibility and safety of ESG in patients with class III obesity are comparable to patients with class I and II obesity. Additionally, the safety of ESG in patients with class III obesity is comparable to SG and safer than RYGB. Endoscopic sleeve gastroplasty: a safe bariatric intervention for class III obesity (BMI > 40).

Comparison of endoscopic sleeve gastroplasty versus surgical sleeve gastrectomy: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database analysis

BACKGROUND AND AIMS

Endoscopic sleeve gastroplasty (ESG) is an incisionless, transoral, restrictive bariatric procedure designed to imitate sleeve gastrectomy (SG). Comparative studies and large-scale population-based data are limited. Additionally, no studies have examined the impact of race on outcomes after ESG. This study aims to compare short-term outcomes of ESG with SG and evaluate racial effects on short-term outcomes after ESG.

METHODS

We retrospectively analyzed over 600,000 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database from 2016 to 2020. We compared occurrences of adverse events (AEs), readmissions, reoperations, and reinterventions within 30 days after procedures. Multivariate regression evaluated the impact of patient factors, including race, on AEs.

RESULTS

A total of 6054 patients underwent ESG and 597,463 underwent SG. AEs were low after both procedures with no significant difference in major AEs (SG vs ESG: 1.1% vs 1.4%; P > .05). However, patients undergoing ESG had more readmissions (3.8% vs 2.6%), reoperations (1.4% vs .8%), and reinterventions (2.8% vs .7%) within 30 days (P < .05). Race was not significantly associated with AEs after ESG, with black race associated with a higher risk of AEs in SG.

CONCLUSIONS

ESG demonstrates a comparable major AE rate with SG. Race did not impact short-term AEs after ESG. Further prospective studies long-term studies are needed to compare ESG with SG.

Examining the evidence for weight management in individuals with type 2 diabetes

The obesity epidemic has been linked to the worsening diabetes epidemic. Despite this, weight reduction for individuals with obesity is seen as a secondary, or even tertiary, consideration in the treatment of type 2 diabetes (T2D). The aim of this review is to examine the benefits of weight management in individuals with T2D. A literature review of current available published data on the benefits of weight reduction in individuals with T2D was conducted. In individuals with T2D who have obesity or overweight, modest and sustained weight reduction results in improvement in glycaemic control and decreased utilization of glucose-lowering medication. A total body weight loss of 5% or higher reduces HbA1c levels and contributes to mitigating risk factors of cardiovascular disease, such as hyperlipidaemia and hypertension, as well as other disease-related complications of obesity. Progressive improvements in glycaemic control and cardiometabolic risk factors can occur when the total body weight loss increases to 10% or more. In the approach to treating patients with T2D and obesity, prioritizing weight management and the use of therapeutics that offer glycaemic control as well as the additional weight loss should be emphasized given their potential to attenuate the progression and severity of T2D.