Endoscopic Bariatric and Metabolic Therapies: Surgical Analogues and Mechanisms of Action

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Bariatrics and endoscopic therapies for the treatment of metabolic disease: Past, present, and future

The burden of chronic metabolic diseases such as obesity, type 2 diabetes mellitus (T2DM), and metabolic dysfunction-associated steatotic liver disease (MASLD) and the urgency of the epidemiological situation necessitate the development of therapies that enhance metabolic health and alter the trajectory of metabolic disease in society. Certain bariatric-metabolic surgeries have proven to be effective approaches for treating metabolic dysfunction, showing remission or significant improvements in obesity, T2DM, and MASLD-related outcomes, suggesting that these interventions might be able to "reset" a pathologically calibrated metabolic setpoint. However, considering the challenges and invasiveness of surgery, endoscopic bariatric metabolic therapies (EBMTs) have emerged with a primary focus to reconstruct or mimic anatomical and/or functional changes observed with bariatric surgery in a more broadly accessible manner. These innovative approaches offer a potentially promising solution to address significant unmet medical need in the large segment of society, which remains at risk for the consequences of metabolic diseases. In this review, we discuss therapeutic options within the EBMT space in the context of the metabolic setpoint intellectual model and provide a brief overview of current knowledge surrounding their mechanisms of action and impact on metabolic health. Finally, we explore future perspectives and directions in this exciting field.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Semaglutide vs Endoscopic Sleeve Gastroplasty for Weight Loss

Importance

Obesity is a disease with a large socioeconomic burden. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric procedure with wide global adoption. More recently, new weight-loss medications, such as glucagon-like peptide-1 receptor agonists (eg, semaglutide), have attracted increased attention due to their efficacy. However, their cost-effectiveness over an extended period compared with ESG is a critical gap that needs to be better explored for informed health care decision-making.

Objective

To assess the cost-effectiveness of semaglutide compared with ESG over 5 years for individuals with class II obesity.

Design, Setting, and Participants

This economic evaluation study, conducted from September 1, 2022, to May 31, 2023, used a Markov cohort model to compare ESG and semaglutide, with a no-treatment baseline strategy. The study comprised adult patients in the US health care system with class II obesity (body mass index [BMI] of 35-39.9). The base case was a 45-year-old patient with class II obesity (BMI of 37). Patients undergoing ESG were subjected to risks of perioperative mortality and adverse events with resultant costs and decrement in quality of life.

Interventions

Strategies included treatment with semaglutide and ESG.

Main Outcomes and Measures

Costs (2022 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100 000/QALY. A 5-year time horizon with a cycle length of 1 month with a 3% discount rate was used. Probabilities, costs, and quality-of-life estimates of the model were derived from published literature. One-way, 2-way, and probabilistic sensitivity analyses were also performed.

Results

The model found that ESG was more cost-effective than semaglutide over a 5-year time horizon, with an ICER of -$595 532/QALY. Endoscopic sleeve gastroplasty added 0.06 QALYs and reduced total cost by $33 583 relative to semaglutide. The results remained robust on 1-way and probabilistic sensitivity analyses. Endoscopic sleeve gastroplasty sustained greater weight loss over 5 years vs semaglutide (BMI of 31.7 vs 33.0). To achieve nondominance, the annual price of semaglutide, currently $13 618, would need to be $3591.

Conclusions and Relevance

This study suggests that ESG is cost saving compared with semaglutide in the treatment of class II obesity. On price threshold analyses, a 3-fold decrease in the price of semaglutide is needed to achieve nondominance.

Characteristics of changes in plasma proteome profiling after sleeve gastrectomy

Bariatric surgery (BS), recognized as the most effective intervention for morbid obesity and associated metabolic comorbidities, encompasses both weight loss-dependent and weight loss-independent mechanisms to exert its metabolic benefits. In this study, we employed plasma proteomics technology, a recently developed mass spectrometric approach, to quantitatively assess 632 circulating proteins in a longitudinal cohort of 9 individuals who underwent sleeve gastrectomy (SG). Through time series clustering and Gene Ontology (GO) enrichment analysis, we observed that complement activation, proteolysis, and negative regulation of triglyceride catabolic process were the primary biological processes enriched in down-regulated proteins. Conversely, up-regulated differentially expressed proteins (DEPs) were significantly associated with negative regulation of peptidase activity, fibrinolysis, keratinocyte migration, and acute-phase response. Notably, we identified seven proteins (ApoD, BCHE, CNDP1, AFM, ITIH3, SERPINF1, FCN3) that demonstrated significant alterations at 1-, 3-, and 6-month intervals post SG, compared to baseline. These proteins play essential roles in metabolism, immune and inflammatory responses, as well as oxidative stress. Consequently, they hold promising potential as therapeutic targets for combating obesity and its associated comorbidities.

The effect of endoscopic gastric plication on portosystemic pressure gradient in patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease

BACKGROUND

 The goals of therapy for patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease include weight loss and reduction of the portosystemic pressure gradient (PPG) to decrease the risk of hepatic decompensation. Endoscopic gastric plication (EGP) is an effective endoscopic weight loss procedure. This study aimed to assess the effect of EGP on PPG.

METHODS

 In this prospective pilot study, patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease underwent endoscopic ultrasound-guided PPG measurement prior to and at 6 months following EGP. Primary outcomes were the change in PPG and proportion of patients experiencing ≥ 20 % reduction in PPG at 6 months. Secondary outcomes included percent total weight loss (TWL) and changes in noninvasive tests of fibrosis.

RESULTS

 20 patients were included. Baseline median body mass index and liver stiffness measurement were 40.2 kg/m2 (range 30.1-56.7) and 14.7 kPa (range 8.2-36), respectively. At 6 months, median PPG decreased from 5.4 mmHg (range 0.7-19.6) to 1.8 mmHg (range 0.4-17.6) (P = 0.002), with 79 % (11/14) experiencing ≥ 20 % reduction. Patients experienced 12.5 % (6.5 %-26.1 %) TWL (P < 0.001) at 6 months, with 89 % (17/19) achieving ≥ 7 % and 68 % (13/19) achieving ≥ 10 % TWL. There were significant improvements in noninvasive tests of fibrosis.

CONCLUSION

 EGP appeared to be effective at reducing PPG in patients with nonalcoholic fatty liver disease and compensated advanced chronic liver disease.

Performance of Endoscopic Sleeve Gastroplasty by Obesity Class in the United States Clinical Setting

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) has gained popularity over the past decade and has been adopted in both academic and private institutions globally. We present outcomes of the largest cohort of patients from the United States undergoing ESG and evaluate these according to obesity class.

METHODS

We performed a retrospective analysis of adult patients who underwent ESG. Medical information was abstracted from the electronic record with weight records up to 2 years after ESG. Percent total body weight loss (%TBWL) at 6, 12, 18, and 24 months was calculated based on baseline weight at the procedure. SPSS (version 29.0) was used for all statistical analyses.

RESULTS

A total of 1,506 patients from 7 sites were included (501 Class I obesity, 546 Class II, and 459 Class III). Baseline demographics differed according to obesity class due to differences in age, body mass index (BMI), height, sex distribution, and race. As early as 6 months post-ESG, mean BMI for each class dropped to the next lower class and remained there through 2 years. %TWBL achieved in the Class III group was significantly greater when compared with other classes at all time points. At 12 months, 83.2% and 60.9% of patients had ≥10% and ≥15% TBWL for all classes. There were no differences in adverse events between classes.

DISCUSSION

Real-world data from a large cohort of patients of all BMI classes across the United States shows significant and sustained weight loss with ESG. ESG is safe to perform in a higher obesity class with acceptable midterm efficacy.

Non-Pharmacological Approach to Diet and Exercise in Metabolic-Associated Fatty Liver Disease: Bridging the Gap between Research and Clinical Practice

This review provides a practical and comprehensive overview of non-pharmacological interventions for metabolic-associated fatty liver disease (MASLD), focusing on dietary and exercise strategies. It highlights the effectiveness of coffee consumption, intermittent fasting, and Mediterranean and ketogenic diets in improving metabolic and liver health. The review emphasizes the importance of combining aerobic and resistance training as a critical approach to reducing liver fat and increasing insulin sensitivity. Additionally, it discusses the synergy between diet and exercise in enhancing liver parameters and the role of gut microbiota in MASLD. The paper underscores the need for a holistic, individualized approach, integrating diet, exercise, gut health, and patient motivation. It also highlights the long-term benefits and minimal risks of lifestyle interventions compared to the side effects of pharmacological and surgical options. The review calls for personalized treatment strategies, continuous patient education, and further research to optimize therapeutic outcomes in MASLD management.

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.

Progress in the study of intragastric occupancy device for weight reduction

Obesity is a global public health problem that imposes a heavy economic burden on society. The current main strategies for treating obesity include lifestyle interventions, pharmacological treatments, endoscopic treatments and metabolic surgery. With the development of medical technology, weight reduction by intragastric occupancy devices represented by intragastric balloons and intragastric capsules are gradually emerging. Intragastric balloons are used to reduce weight by occupying the volume of the stomach with balloons filled with different volumes of gas or liquid, among which ReShape, Orbera, Obalon, Elipse and Spatz balloons are gradually used in patients with mild to moderate obesity due to their non-invasive, high safety and reusable advantages. Intragastric capsules are recommended in overweight and obese patients for weight loss through hydrogels with transient superabsorbent swelling properties and completely noninvasive. Both approaches achieve weight loss by limiting gastric volume, increasing satiety and reducing food intake. Despite the presence of adverse gastrointestinal events associated with nausea, vomiting, and abdominal distention, they offer new ideas for the non-invasive clinical treatment of obesity.

Endoscopic Gastric Sleeve: A Review of Literature

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

Current treatment landscape for obesity in Singapore

The rising prevalence of obesity in Singapore is a harbinger for a corresponding increase in obesity-related complications such as type 2 diabetes mellitus (T2DM) and coronary heart disease. Obesity is a complex disease driven by multiple factors, and hence, treatment cannot follow a 'one-size-fits-all' approach. Lifestyle modifications involving dietary interventions, physical activity and behavioural changes remain the cornerstone of obesity management. However, similar to other chronic diseases such as T2DM and hypertension, lifestyle modifications are often insufficient on their own, hence the importance of other treatment modalities including pharmacotherapy, endoscopic bariatric therapy and metabolic-bariatric surgery. Weight loss medications currently approved in Singapore include phentermine, orlistat, liraglutide and naltrexone-bupropion. In recent years, endoscopic bariatric therapies have evolved as an effective, minimally invasive and durable therapeutic option for obesity. Metabolic-bariatric surgery remains the most effective and durable treatment for patients with severe obesity, with an average weight loss of 25%-30% after one year.

Endoscopic management of obesity: Impact of endoscopic sleeve gastroplasty on weight loss and co-morbidities at six months and one year

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) is one of the new minimally invasive endoscopic treatments aimed at inducing weight loss. Its effectiveness in terms of weight loss is proven. Gastric volume reduction and delayed gastric emptying are the mechanisms that drive weight loss. However, potential benefits for co-morbidities in relation to weight loss after ESG are still being investigated. This study aims to evaluate the effect of ESG procedures on major obesity-associated co-morbidities, and on some biological parameters.

PATIENTS AND METHODS

This is a series of consecutive cases from a prospective observational study carried out in a specialized center that follows a standardized care pathway for the multimodal management of obesity. Patients who have undergone ESG with endoscopic and laboratory follow-up at six and twelve months after this intervention were included in the study. Prospectively recorded data on weight loss, co-morbidities and laboratory parameters at six and twelve months after surgery was analyzed retrospectively. Changes in body mass index (BMI), absolute weight loss (AWL), percent of excess weight loss (%EWL) and percent total weight loss (%TWL) were assessed at six and twelve months. Reduction in various obesity-related co-morbidities (arterial hypertension [AHT], type 2 diabetes mellitus [T2DM], gastroesophageal reflux disease [GERD], obstructive sleep apnea syndrome [OSAS] and dyslipidemia was also evaluated at six and twelve months. Changes in blood glucose, liver function tests and lipid blood tests were also analyzed at six and twelve months.

RESULTS

From October 2016 to July 2021, 99 of the 227 patients who underwent ESG in our unit (43.6%) subsequently underwent a complete endoscopic and laboratory follow-up at six and twelve months. The initial BMI was 42.7±7.8kg/m² and age was 45±12.7 years. Seventy-four patients (74.8%) were female. Total weight loss (%TWL) and excess weight loss (%EWL) were 16.6±7.4% and 43.3±21.2%, respectively, at six months, 16.6±9.6% and 42.9±25.6%, respectively, at one year. At six and twelve month follow-up, a statistically significant reduction was observed for the rates of T2DM (30.8 and 32.7%), hypertension (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). A statistically significant difference was found in the reduction in blood glucose between the pre-operative period and six months post-operatively (P<0.01) and between the pre-operative period and twelve months post-operatively (P<0.01). The reduction in triglycerides and total cholesterol between the pre-operative values and at six months was statistically significant (P<0.01) as was the reduction at twelve months (P<0.01) (P=0.017). For liver function tests, the reduction in AST was statistically significant at six and twelve months after ESG (P=0.048) (P=0.048) as was ALT (P<0.01) (P<0.01) respectively. From October 2016 to July 2021, of the 227 patients who underwent ESG, 99 (43.6%) had follow-up gastro-duodenoscopy at 6 and 12 months. %TWL and %EWL were respectively 16.6±7.4% and 43.3%±21.2 at 6 months, 16.6±9.6% and 42.9±25.6% at one year. Statistically significant reduction rates at 6 and 12 months were observed in T2DM (30.8 and 32.7%), AHT (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). Moreover, glycemic levels were statistically significantly reduced between the pre-operative period and 6 months post-operative (1.11±0.22mg/L vs. 1.01±0.17mg/L, P<0.01), and between the pre-operative period and 12 months post-operative (1.11±0.22mg/L vs. 1.06±0.32mg/L, P<0.01). A statistically significant reduction was also observed in triglycerides and total cholesterol levels at 6 months (1.52±0.74mmol/L vs. 1.14±0.52mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.85±0.36mmol/L, P<0.01) and at 12 months (1.52±0.74mmol/L vs. 1.18±0.67mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.82±0.39mmol/L, P=0.017) and in AST (27.2±11.7 IU/L vs. 23.7 IU/L; P=0.048) (27.2±11.7 IU/L vs. 24.7±14.65 IU/L, P=0.048) and ALAT levels (34±21.32 IU/L vs. 22.3±10.4 IU/L, P<0.01 and 34±21.32 IU/L vs. 27.07±25 IU/L, P<0.01) at 6 and 12 months after ESG, respectively.

CONCLUSION

ESG is a well-tolerated and safe surgical procedure that is effective in terms of weight loss and reduction of obesity-related co-morbidities at six months and one year. This procedure could thus be adopted on a broader clinical scale and be more widely promoted as an effective treatment for morbid obesity.

The Efficacy Comparison of Endoscopic Bariatric Therapies: 6-Month Versus 12-Month Intragastric Balloon Versus Endoscopic Sleeve Gastroplasty

INTRODUCTION

Intragastric balloon (IGB) insertion and endoscopic sleeve gastroplasty (ESG) are known to be effective and safe in achieving weight loss. The aim of this study was to compare the effects of a 6-month IGB therapy, a 12-month IGB therapy, and ESG.

METHODS

We retrospectively analyzed the weight loss at IGB (Orbera) removal after 6 months (124 patients), at IGB (Orbera365) removal after 12 months (61 patients) and at 6 and 12 months after ESG (42 and 34 patients, respectively). Postprocedural care, including medication and diet, was the same for all procedures.

RESULTS

Mean TBWL in patients undergoing IGB placement for 6 and 12 months and ESG after 6 and 12 months were 15.2, 15.8, 26.5, and 28.7 kg, respectively. There was no significant difference in the mean %TBWL in patients undergoing IGB placement for 6 or for 12 months (15.3% vs. 14.7%, P = 0.7). ESG patients showed a significantly higher mean %TBWL than IGB patients after 6 months (15.3 vs. 19.8, P = 0.005) and 12 months (14.7 vs. 22.5, P < 0.001).

CONCLUSION

All three studied methods were effective for achieving weight loss. However, there was no significant difference between 6-month and 12-month IGB therapies outcomes. ESG appeared to be a more effective obesity treatment modality than IGB.

Comparison of distal primary obesity surgery endolumenal techniques for the treatment of obesity (with videos)

BACKGROUND AND AIMS

Distal primary obesity surgery endolumenal (POSE) procedures involve plication of the gastric body, sparing the fundus. We aim to assess the efficacy of distal POSE procedures and to compare plication techniques (single-helix vs double-helix approaches).

METHODS

This is a prospective registry study of patients who underwent distal POSE procedures using 2 techniques: the single-helix plication technique, in which a single plication with serosa-to-serosa approximation is obtained with each device activation, and the double-helix plication technique, where 2 serosa-to-serosa plications with an internal mucosa-to-mucosa approximation are obtained with each device activation.

RESULTS

One hundred ten patients (90 women; mean age, 43 ± 13 years) underwent distal POSE procedures. Baseline body mass index was 38.2 ± 6.1 kg/m². Technical success was 100%. An average of 21 ± 5 plications were placed per case. The gastric body was shortened by 74%. At 12 months, patients experienced 15.8% ± 8.9% total weight loss (TWL) (P < .0001), with 93% and 61% achieving at least 5% and 10% TWL, respectively. Blood pressure, insulin resistance, and liver enzymes improved. The serious adverse event rate was .9%, including a case of gastric perforation. Of 110 patients, 42 and 68 underwent distal POSE procedures using a single- or double-helix technique, respectively. The double-helix technique resulted in greater reduction in gastric volume (length reduction by 78% vs 65%, P < .0001), weight loss (20.3% ± 8.3% vs 13.4% ± 8.3% TWL, P = .005), and proportion of patients achieving 10% TWL (94.7% vs 58.3%, P = .03) than the single-helix technique.

CONCLUSIONS

Distal POSE techniques appear to be effective at treating obesity and its related comorbidities. The double-helix technique is associated with greater gastric volume reduction, weight loss, and response rate.

Nutritional Management and Role of Multidisciplinary Follow-Up after Endoscopic Bariatric Treatment for Obesity

The prevalence of obesity has risen exponentially, and patients living with obesity suffer from its debilitating consequences. The treatment options for obesity have expanded significantly and include lifestyle changes, pharmacotherapy, endoscopic bariatric therapies (EBTs), and bariatric surgery. Endoscopic bariatric therapies comprise volume-reducing procedures such as endoscopic gastroplasty and gastric space-occupying devices such as intragastric balloons. Because of its minimally invasive nature and ease of delivery, EBTs are increasingly being adopted as a treatment option for obesity in several centers. These procedures mainly achieve weight loss by inducing early satiety and reducing meal volume. While the technical aspects of EBTs have been well explained, the nutritional management surrounding EBTs and the effectiveness of multidisciplinary team for maximizing weight loss is less described. There is considerable variation in post-EBT care between studies and centers. In this paper, we review the existing literature and share our experience on nutrition and the role of multidisciplinary management of obesity following EBT.

Effect of Novel Gastro-Duodenal Flow Restrictor on Relative Weight Loss and Glucose Levels in a Porcine Model: A Pilot Randomized Study

Endoscopic bariatric and metabolic therapies are promising for obesity. We developed a novel gastro-duodenal flow restrictor (G-DFR) device for relative weight loss and lowering of glucose level and evaluated its safety and efficacy in a porcine model. The G-DFR comprised self-expandable gastro-duodenal partially covered polytetrafluoroethylene (PTFE) metal stent distally attached to a PTFE skirt. Eleven juvenile pigs were randomized into the evaluation of migration (n = 3), mid-term efficacy (n = 5), and control (n = 3) groups. Five pigs showed G-DFR migration at 2, 4, 7, and 10 weeks after placement in the migration and mid-term efficacy group. Compared to the control group, the mid-term efficacy group showed up to 55.4% relative weight loss in 12 weeks. Compared to the case group, the control group showed higher mean ghrelin hormone level from 6 to 12 weeks. Glucose level was significantly lower in the efficacy group than in the control group after 6 weeks. Serum alanine transferase levels and histological collagen deposition were lower in the liver of the case group than in the control group. Although it did not demonstrate consistent performance with respect to migration, a well-positioned G-DFR in the pyloroduodenal portion may lead to relative weight loss, lowering of glucose levels, and improved hepatic parameters.

Effect of Endoscopic Bariatric and Metabolic Therapies on Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Weight loss via lifestyle intervention remains the mainstay of treatment for nonalcoholic fatty liver disease (NAFLD). Endoscopic bariatric and metabolic therapies (EBMTs) have recently been developed as an alternative treatment option for obesity. This study aimed to assess the effect of FDA-approved EBMTs on NAFLD.

METHODS

We searched MEDLINE, EMBASE, Web of Science and Cochrane Central through December 2020 for studies that assessed changes in liver outcomes following EBMT. Primary Outcomes: Liver fibrosis.

SECONDARY OUTCOMES

Liver biochemistry, steatosis, NAFLD histological changes and insulin sensitivity. The Grading of Recommendations, Assessment, Development, and Evidence (GRADE) approach was conducted to assess quality of evidence.

RESULTS

Of 4994 potential studies, 18 studies with 863 patients were included. Average weight loss was 14.5% of initial weight at a 6-month follow-up. Primary outcomes: Following EBMT, liver fibrosis significantly reduced by standardized mean difference (SMD) of 0.7 (95% CI, 0.1, 1.3; P = .02).

SECONDARY OUTCOMES

There were significant improvements in other NAFLD surrogates including alanine aminotransferase (-9.0 U/L; 95% CI, -11.6, -6.4; P < .0001), hepatic steatosis (SMD: -1.0; 95% CI, -1.2, -0.8; P < .0001) and histologic NAFLD activity score (-2.50; 95% CI, -3.5, -1.5; P < .0001). Other metabolic parameters including insulin resistance and waist circumference also significantly improved. The overall quality of the evidence for primary outcomes was low to very low.

CONCLUSIONS

EBMTs appear effective at treating NAFLD with significant improvement in liver fibrosis. Given the worsening NAFLD pandemic and limitations of currently available therapies, EBMTs should be further investigated as a potential treatment option for this patient population.

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.

Bariatric and metabolic endoscopy: impact on obesity and related comorbidities

The global obesity pandemic is among the most significant public health crises today. Furthermore, obesity remains a major risk factor for many weight-related comorbid conditions including cardiovascular disease, type 2 diabetes mellitus, liver disease, and cancer. Endoscopic bariatric therapies are currently on the rise as a new tool in the fight against the obesity epidemic, offering patients an alternative to more invasive surgery and a more effective option than diet and lifestyle modifications. The aim of this review article is to summarize the current literature regarding endoscopic bariatric therapies and their impact on obesity and its associated metabolic complications.

Obesity Primer for the Practicing Gastroenterologist

With worsening of the obesity pandemic, gastroenterologists will see more patients with this chronic disease. Given the association between obesity and several gastrointestinal conditions and the interplay between obesity pathophysiology and gut hormones, gastroenterologists can play an important role in the management of this disease. Furthermore, because more patients undergo bariatric surgery, an understanding of postsurgical anatomy and medical and endoscopic management of bariatric surgical complications is essential. This article provides clinical tools for the assessment and management of obesity for the general gastroenterologist. Tables containing high-yield practical information are also provided for quick reference.

Obesity: Overview of Weight Management

INTRODUCTION

Obesity is a chronic illness that requires a multifaceted personalized treatment approach.

METHODS & FINDINGS

Using current guidelines and recent studies in weight management, this article reviews the multiple components of weight management: lifestyle intervention (dietary intervention, physical activity, and behavioral interventions), pharmacotherapy, endoscopic procedures, and surgical procedures. This review briefly discusses specific diets and dietary strategies, compensatory mechanisms acting against weight loss, recent changes to Food and Drug Administration approved antiobesity medications, and technological advances in weight management delivery.

CONCLUSION

Current literature is lacking large studies on the safety and efficacy of combination therapies involving pharmacotherapy plus 1 or more procedures.

Is duodeno-jejunal bypass liner superior to pylorus preserving bariatric surgery in terms of complications and efficacy?

PURPOSE

Based on recent scientific evidence, bariatric surgery is more effective in the management of morbid obesity and related comorbidities than conservative therapy. Pylorus preserving surgical procedures (PPBS) such as laparoscopic single-anastomosis duodeno-jejunal or duodeno-ileal bypass with sleeve gastrectomy are modified duodenal switch (DS) surgical techniques. The duodeno-jejunal bypass liner (DJBL) is a novel surgical method in the inventory of metabolism focused manual interventions that excludes duodeno-jejunal mucosa from digestion, mimicking DS procedures without the risk of surgical intervention. The aim of this article is to summarize and compare differences between safety-related features and weight loss outcomes of DJBL and PPBS.

METHODS

A literature search was conducted in the PubMed database. Records of DJBL-related adverse events (AEs), occurrence of PPBS-related complications and reintervention rates were collected. Mean weight, mean body mass index (BMI), percent of excess of weight loss (EWL%), percent of total weight loss (TWL%) and BMI value alterations were recorded for weight loss outcomes.

RESULTS

A total of 11 publications on DJBL and 6 publications on PPBS were included, involving 800 and 1462 patients, respectively. The baseline characteristics of the patients were matched. Comparison of DJBL-related AEs and PPBS-related severe complications showed an almost equal risk (risk difference (RD): -0.03 and confidence interval (CI): -0.27 to 0.21), despite higher rates among patients having received endoscopic treatment. Overall AE and complication rates classified by Clavien-Dindo showed that PPBS was superior to DJBL due to an excess risk level of 25% (RD: 0.25, CI: 0.01-0.49). Reintervention rates were more favourable in the PPBS group, without significant differences in risk (RD: -0.03, CI: -0.27 to 0.20). However, PPBS seemed more efficient regarding weight loss outcomes at 1-year follow-up according to raw data, while meta-analysis did not reveal any significant difference (odds ratio (OR): 1.08, CI: 0.74-1.59 for BMI changes).

CONCLUSION

Only limited conclusions can be made based on our findings. PPBS was superior to DJBL with regard to safety outcomes (GRADE IIB), which failed to support the authors' hypothesis. Surgical procedures showed lower complication rates than the incidence of DJBL-related AEs, although it should be emphasized that the low number of PPBS-related mild to moderate complications reported could be the result of incomplete data recording from the analysed publications. Weight loss outcomes favoured bariatric surgery (GRADE IIB). As the DJBL is implanted into the upper gastrointestinal tract for 6 to 12 months, it seems a promising additional method in the inventory of metabolic interventions.

The current state of bariatric endoscopy

A variety of endoscopic bariatric and metabolic treatments (EBMTs) have been developed in recent years to combat the growing prevalence of obesity in the United States (US) and worldwide. This manuscript reviews the current state of bariatric endoscopy, detailing all US Food and Drug Administration (FDA) approved EBMTs including space-occupying intragastric balloons (IGBs), aspiration therapy, and endoscopic tissue apposition devices. Additionally, this review describes non-FDA approved treatments including additional IGBs, endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically placed anastomosis devices.

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

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

From Entero-Endocrine Cell Biology to Surgical Interventional Therapies for Type 2 Diabetes

The physiological roles of the enteroendocrine system in relation to energy and glucose homeostasis regulation have been extensively studied in the past few decades. Considerable advances were made that enabled to disclose the potential use of gastro-intestinal (GI) hormones to target obesity and type 2 diabetes (T2D). The recognition of the clinical relevance of these discoveries has led the pharmaceutical industry to design several hormone analogues to either to mitigate physiological defects or target pharmacologically T2D.Amongst several advances, a major breakthrough in the field was the unexpected observation that enteroendocrine system modulation to T2D target could be achieved by surgically induced anatomical rearrangement of the GI tract. These findings resulted from the widespread use of bariatric surgery procedures for obesity treatment, which despite initially devised to induce weight loss by limiting the systemic availably of nutrients, are now well recognized to influence GI hormone dynamics in a manner that is highly dependent on the type of anatomical rearrangement produced.This chapter will focus on enteroendocrine system related mechanisms leading to improved glycemic control in T2D after bariatric surgery interventions.

Endobariatric procedures for obesity: clinical indications and available options

Obesity remains a growing public health epidemic that has increased healthcare costs and related comorbidities. Current treatment guidelines encourage a multidisciplinary approach starting from patient selection, interventions, and long-term follow-up to maintain weight loss. However, these conservative interventions are largely ineffective at reducing body weight due to low adherence to the treatment regimen. Recently, endoscopic bariatric therapies have become an attractive alternative to traditional invasive bariatric surgeries due to their improved efficacy, safety, and cost-effectiveness. Endoscopic bariatric therapies include intragastric balloon placement, endoscopic sleeve gastroplasty, gastric bypass revision, and aspiration therapy. These procedures fall into two separate categories depending on the primary mechanism involved: restrictive or malabsorptive. Restrictive methods, such as the Orbera® and ReShape™ intragastric balloons, increase satiation and delay gastric emptying while decreasing the amount of food that can be ingested. In contrast, malabsorptive devices, such as the EndoBarrier®, interfere with the small intestine's ability to absorb food while restoring normal gastrointestinal hormone levels regulating satiation. Together, these techniques provide useful alternatives for patients in whom pharmacological or lifestyle modifications have proven ineffective. Despite these advantages, the long-term effects of these procedures on metabolic changes remain to be studied. Furthermore, the management of complications from these procedures continues to evolve. In this review, we aim to elaborate on the clinical indications and efficacy of the endobariatric procedures, together with various types of available endoscopic bariatric therapy procedures.

Effect of Aspiration Therapy on Obesity-Related Comorbidities: Systematic Review and Meta-Analysis

BACKGROUND/AIMS

Aspiration therapy (AT) involves endoscopic placement of a gastrostomy tube with an external device that allows patients to drain 30% of ingested calories after meals. Its efficacy for inducing weight loss has been shown. This study aimed to assess the effect of AT on obesity-related comorbidities.

METHODS

A meta-analysis of studies that assessed AT outcomes was conducted through December 2018. Primary outcomes were changes in comorbidities at 1 year following AT. Secondary outcomes were the amount of weight loss at up to 4 years and pooled serious adverse events (SAEs).

RESULTS

Five studies with 590 patients were included. At 1 year, there were improvements in metabolic conditions: mean difference (MD) in systolic blood pressure: -7.8 (-10.7 - -4.9) mm Hg; MD in diastolic blood pressure: -5.1 (-7.0 - 3.2) mm Hg; MD in triglycerides: -15.8 (-24.0 - -7.6) mg/dL; MD in high-density lipoprotein: 3.6 (0.7-6.6) mg/dL; MD in hemoglobin A1c (HbA1c): -1.3 (-1.8 - -0.8) %; MD in aspartate transaminase: -2.7 (-4.1 - -1.3) U/L; MD in alanine transaminase: -7.5 (-9.8 - -5.2) U/L. At 1 (n=218), 2 (n=125), 3 (n=46), and 4 (n=27) years, the patients experienced 17.8%, 18.3%, 19.1%, and 18.6% total weight loss (TWL), corresponding to 46.3%, 46.2%, 48.0%, and 48.7% excess weight loss (EWL) (p<0.0001 for all). Subgroup analysis of 2 randomized controlled trials (n=225) showed that AT patients lost more weight than did controls by 11.6 (6.5-16.7) %TWL and 25.6 (16.0-35.3) %EWL and experienced greater improvement in HbA1c and alanine transaminase by 1.3 (0.8-1.8) % and 9.0 (3.9-14.0) U/L. The pooled SAE rate was 4.1%.

CONCLUSION

Obesity-related comorbidities significantly improved at 1 year following AT. Additionally, a subgroup of patients who continued to use AT appeared to experience significant weight loss that persisted up to at least 4 years.

The effect of a duodenal-jejunal bypass liner on lipid profile and blood concentrations of long chain polyunsaturated fatty acids

BACKGROUND & AIMS

Duodenal-jejunal bypass liners (DJBLs) prevent absorption in the proximal small intestine, the site of fatty acid absorption. We sought to investigate the effects of a DJBL on blood concentrations of essential fatty acids (EFAs) and bioactive polyunsaturated fatty acids (PUFAs).

METHODS

Sub-study of a multicentre, randomised, controlled trial with two treatment groups. Patients aged 18-65 years with type-2 diabetes mellitus and body mass index 30-50 kg/m² were randomised to receive a DJBL for 12 months or best medical therapy, diet and exercise. Whole plasma PUFA concentrations were determined at baseline, 10 days, 6 and 11.5 months; data were available for n = 70 patients per group.

RESULTS

Weight loss was significantly greater in the DJBL group compared to controls after 11.5 months: total body weight loss 11.3 ± 5.3% versus 6.0 ± 5.7% (mean difference [95% CI] = 5.27% [3.75, 6.80], p < 0.001). Absolute concentrations of both EFAs, linoleic acid and α-linolenic acid, and their bioactive derivatives, arachidonic acid, eicosapentaenoic acid, docosapentaenoic acid and docosahexaenoic acid, were significantly lower in the DJBL group than in the control group at 6 and 11.5 months follow-up. Total serum cholesterol, LDL-cholesterol and HDL-cholesterol were also significantly lower in the DJBL group.

CONCLUSION

One year of DJBL therapy is associated with superior weight loss and greater reductions in total serum cholesterol and LDL-cholesterol, but also depletion of EFAs and their longer chain derivatives. DJBL therapy may need to be offset by maintaining an adequate dietary intake of PUFAs or by supplementation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02459561.

Overview of bariatric and metabolic endoscopy interventions

The rise of endoscopic techniques allowing weight loss offers an attractive alternative to surgical interventions in Western countries where the obesity epidemic has risen dramatically. Endoscopists are well positioned to manage obesity given their broad-based medical knowledge, understanding of gastrointestinal physiology, and training in endoscopic technique. The field of bariatric and metabolic endoscopy has permitted the development of several efficacious and safe technologies. This review focuses on techniques and devices used for endoscopic management of obesity, as well as the fundamental justifications to offer those therapies to obese patients.

Minireview: Current status of endoscopic duodenal mucosal resurfacing

Several strategies are being pursued to overcome the alarming pandemics of obesity and type 2 diabetes (T2D). In recent years, duodenal mucosal resurfacing (DMR) has shown its potential to improve glycemic indices. Following animal studies, which demonstrated feasibility and safety, the procedure has been applied in two human studies. The DMR procedure has been considered feasible and safe in humans with a limited occurrence of complications and adverse events. Reductions in glycated haemoglobin, weight, fasting plasma glucose, and alanine transaminase have been proven at different follow-up time-points. The length of the ablation may induce different outcomes, having the patients with long duodenal segment ablated showed greater beneficial effects. The current evidence does not still prove the apparent insulin-sensitizing mechanism explaining the impact of the DMR procedure on hepatic glucose production. However, the initial findings have demonstrated a positive risk-benefit ratio and an effect on the treatment of metabolic diseases, such as T2D. Future studies should clarify the mechanisms underlying the positive effects and durability of the treatment using controlled trial conditions on larger number of patients.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

Endoscopic gastric body plication for the treatment of obesity: technical success and safety of a novel technique (with video)

BACKGROUND AND AIMS

Primary obesity surgery endoluminal (POSE) is a primary endoscopic bariatric therapy focusing on gastric remodeling. The original POSE procedure involved placement of full-thickness plications in the fundus. Here we aim to assess the feasibility, safety, and efficacy of a novel POSE procedure that involves plications of only the gastric body to reduce the width and length of the stomach.

METHODS

This was a pilot study of patients who underwent a distal POSE procedure with gastric body plications for the treatment of obesity. Outcomes included technical success rate, serious adverse event (AE) rate, and efficacy of this novel POSE procedure at inducing weight loss and improving obesity-related comorbidities.

RESULTS

Ten patients (6 women, age 52 ± 20 years) underwent a distal POSE procedure. Baseline body mass index was 38.1 ± 6.2 kg/m². The technical success rate was 100%. An average of 21 ± 4 plications were placed per case (6 ± 2 for distal belt, 10 ± 3 for suspenders, 4 ± 2 for proximal belt, and 3 ± 1 for fillers). The gastroesophageal junction was pulled distally by 3.0 ± 1.6 cm. The gastric body was shortened by 11.0 ± 5.1 cm, representing a 59% reduction. The serious AE rate was 0%. At 6 months, patients experienced 15.0% ± 7.1% total weight loss (TWL). All patients achieved at least 5% TWL, and 8 patients (80%) achieved at least 25% excess weight loss. Hypertension, diabetes, GERD, and obstructive sleep apnea improved after the procedure.

CONCLUSIONS

This novel POSE procedure, focusing on gastric body plication and sparing the fundus, is technically feasible and appears to be safe and effective for the treatment of obesity.

Endoscopic Treatments for Obesity: The Good, the Bad, and the Ugly

In the current setting of an obesity pandemic, there is an urgent need for minimally invasive, safe, and effective interventions for weight loss. Endoscopic bariatric procedures have been developed as an alternative to more traditional medical and surgical therapies. Multiple options are undergoing evaluation or are already available for clinical use. This review aims to describe these treatments, including their mechanisms of action, efficacy, safety and the knowledge gaps regarding their use.

Efficacy and Safety of Novel, Disposable Endoscopic Scissors in Patients with Roux-en-Y Gastric Bypass: a Single-Center Feasibility Study

BACKGROUND

Retained suture material from primary Roux-en-Y gastric bypass or revisions may result in local inflammation, ulcer formation, and abdominal pain. The primary aim of this study was to evaluate the feasibility, efficacy, and safety of novel, disposable endoscopic scissors for suture removal.

METHODS

This was a single-center, retrospective analysis of prospectively collected data from December 2016 to January 2019. Patients with history of Roux-en-Y gastric bypass and upper endoscopy utilizing this novel, disposable endoscopic scissors device were reviewed. Measured outcomes included endoscopy indication, technical success (as determined by ability to achieve adequate cut and suture removal), improvement in abdominal pain if present prior to procedure, and adverse events.

RESULTS

Sixty-two patients were included in this analysis. Mean age was 54.69 ± 9.40 years. Eighty-eight percent of patients were female. Roux-en-Y gastric bypass occurred on average 142.43 ± 62.33 months prior to suture removal. Primary indications for endoscopy were evaluation of gastric pouch and gastrojejunal anastomosis for weight regain (37.10%) and abdominal pain (30.65%). Overall, technical success of these novel endoscopic scissors was 100% with a mean procedure duration of 23.00 ± 9.50 min. Symptom improvement post-suture removal occurred in approximately half of the patients (48.65%). Post-procedure bleeding was self-limited and occurred in 2 patients (3.23%). Two patients developed transient post-procedure abdominal pain.

CONCLUSIONS

Novel, disposable endoscopic scissors appear to be highly effective and safe for removal of suture material with high technical success and minimal adverse events.

The effect of weight loss and exercise on Health-Related Quality of Life (HRQOL) following Endoscopic Bariatric Therapies (EBT) for obesity

Introduction

Endoscopic bariatric therapies (EBT) have demonstrated to induce weight loss and improve comorbidities in obese patients. However, little is known about its impact on health-related quality of life (HRQOL) outcomes and physical activity status. This study aimed to evaluate the change in HRQOL and physical activity following EBT induced weight loss in obese patients.

Methods

We approached 181 patients who underwent EBT in a standardized multidisciplinary follow-up program to participate in the study. We provided them two questionnaires-a) Short Form-36 health survey with the physical (PSC) and mental (MSC) summary component scores to capture generic HRQOL, and b) international physical activity questionnaire (IPAQ) for physical activity (PA). We administered the survey at baseline and at 9 months post-procedure. We expressed the procedure outcome as percentage total body weight loss (%TBWL). We expressed continuous variables as mean (SD) or median and categorical variables as percentages. We used non-parametric tests for comparison and performed multivariable linear regression analysis to identify factors associated with improvement in HRQOL.

Results

The mean age was 42.2 (11.3) years, and the mean BMI was 38 (5.9)kg/m². A majority of them were female (n-132, 73%). The EBT included intragastric balloons (n-136, 75%) and endoscopic sleeve gastroplasty (n-24, 25%). The mean %TBWL achieved after the intervention was 16.9 (9.7)%. We noticed a significant improvement in the median PSC (77.8 vs. 90.4, p < 0.001) and MSC (67 vs. 80.2, p < 0.001) scores after EBT. Similarly, we observed a significant positive change in physical activity compared to baseline (1606.2 vs. 2749 MET-minutes/week, p = < 0.001). Linear regression analysis showed an increase in %TBWL was associated with significant improvement in PSC (β = 0.193, p = 0.003) and MSC (β = 0.166, p = 0.02) scores of HRQOL, and likewise, increase in PA was independently associated with improvement in MSC (β = 0.192, p = 0.01). We did not find any difference in outcome based on gender or the type of intervention.

Conclusion

EBT improves HRQOL in obese patients regardless of the type of intervention. The weight loss induced by EBT and the improvement in PA positively influence the health outcomes and quality of life.

Safety and Feasibility of a Novel Endoscopic Suturing Device (EndoZip TM) for Treatment of Obesity: First-in-Human Study

INTRODUCTION

Endoscopic gastroplasty and gastric volume reduction techniques have been shown to achieve significant weight loss and improvement in comorbid conditions. The objective of this study is to assess the feasibility and safety of a novel fully automated, operator-independent endoscopic suturing system (EndoZip™) for minimally invasive treatment of obesity.

DESIGN

Single-center pilot feasibility study.

PATIENTS

Eleven patients with a body mass index (BMI) of 30 to 40 kg/m² with or without obesity-associated comorbidity.

INTERVENTIONS

Gastric volume reduction with EndoZip™ system.

MAIN OUTCOME MEASUREMENTS

Primary outcome was to assess the technical feasibility and safety. The secondary outcome was to determine %total body weight loss (TBWL) and %excess weight loss (EWL) at 6 months.

RESULTS

The mean ± SD age was 42.7 ± 5.6 years, and the mean ± SD BMI was 36.9 ± 2.8 kg/m². A majority (64%) were men. The procedure was technically successful (100%) in all patients. A median of 3 (range, 2-4) full-thickness sutures were placed, and the mean procedure time was 54.6 ± 23.9 (23-100) min. No immediate complications occurred, and all were discharged in 24 h. One patient developed respiratory infection 3 days after the procedure and required hospitalization. The infection was mild and resolved with antibiotic treatment. At 6-month follow-up, the mean ± SD TBWL, %TBWL, and %EWL were 17.8 ± 6.7 kg, 16.2 ± 6.0%, and 54.3 ± 28.4%, respectively (p < 0.001).

LIMITATIONS

Limited number of patients.

CONCLUSION

Our first-in-human study showed that the Endozip™ device could be safely used for the treatment of obesity. The early weight loss results are promising. An extended feasibility study on a larger sample size is being planned (Clinicaltrials.gov. NCT03472196).

Changes in Time of Gastric Emptying After Surgical and Endoscopic Bariatrics and Weight Loss: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Gastric emptying (GE) is involved in the regulation of appetite. We compared times of GE after different bariatric endoscopic and surgical interventions and associations with weight loss.

METHODS

We performed a comprehensive search of publication databases, through September 14, 2018, for randomized and nonrandomized studies reporting outcomes of weight-loss surgeries. Two independent reviewers selected and appraised studies. The outcome of interest was GE T1/2 (min), measured before and after the procedure. A random-effects model was used to pool the mean change in T1/2 (min) after the intervention. We performed a meta-regression analysis to find associations between GE and weight loss. Heterogeneity was calculated using the I2 statistic. Methodologic quality was assessed.

RESULTS

From 762 citations, the following studies were included in our analysis: 9 sleeve gastrectomies, 5 intragastric balloons, and 5 antral botulinum toxins. After sleeve gastrectomy, the pooled mean reduction in GE T1/2 at 3 months was 29.2 minutes (95% CI, 40.9-17.5 min; I2 = 91%). Fluid-filled balloons increased GE T1/2 by 116 minutes (95% CI, 29.4-203.4 min; I2 = 58.6%). Air-filled balloons did not produce a statistically significant difference in GE T1/2. Antral botulinum injections increased GE T1/2 by 9.6 minutes (95% CI, 2.8-16.4 min; I2 = 13.3%). Placebo interventions reduced GE T1/2 by 6.3 minutes (95% CI, 10-2.6 min). Changes in GE were associated with weight loss after sleeve gastrectomy and intragastric balloons, but not botulinum toxin injections.

CONCLUSIONS

In a systematic review and meta-analysis, we found that sleeve gastrectomy reduced GE T1/2 whereas fluid-filled balloons significantly increased GE T1/2. Air-filled balloons do not significantly change the time of GE, which could account for their low efficacy. Antral botulinum toxin injections produced small temporary increases in GE time, which were not associated with weight loss. Changes in GE time after surgical and endoscopic bariatric interventions correlated with weight loss and might be used to select interventions, based on patients' physiology.

The Use of the OverStitch for Bariatric Weight Loss in Europe

Technological advances have permitted minimally invasive treatment of many gastrointestinal diseases. With the advent of endoscopic full-thickness suturing, it has become possible to replicate some of the surgical procedures. Endoluminal bariatric procedures to remodel and reduce the gastric volume similar to surgery is evolving as a treatment option for obesity. Some of these methods also have been extended to treat weight regain after gastric bypass surgery. There is a steep learning curve to gaining proficiency with different endoscopic gastric remodeling or gastroplasty techniques. This article describes a simplified technique of endoscopic sleeve gastroplasty using the OverStitch suturing device.

Biomaterials in Gastroenterology: A Critical Overview

In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.

Intragastric Balloons: An Emerging Therapy for Nonalcoholic Steatohepatitis and Fibrosis?

Weight loss through lifestyle intervention remains the mainstay treatment for nonalcoholic steatohepatitis (NASH). Nevertheless, only a minority of patients undergoing lifestyle intervention are able to achieve the weight loss threshold that reverses NASH histologic features. This case report demonstrates a minimally invasive method of treating NASH using an intragastric balloon. With endoscopic ultrasound-guided liver biopsy at the time of intragastric balloon removal, we demonstrate a significant improvement in NASH histologic features including steatosis, ballooning, lobular inflammation, and fibrosis. This endoscopic method may offer an alternative solution to patients with NASH who fail lifestyle intervention.