Radiofrequency ablation for the treatment of weight regain after Roux-en-Y gastric bypass surgery

Advances in endobariatrics: past, present, and future

The obesity epidemic in the USA and worldwide is well documented and continues to grow. Endoscopic metabolic and bariatric therapies may offer a less invasive approach than surgical intervention. This article will review advances in endobariatrics over the last several decades, addressing the past and current state of bariatric and metabolic endoscopy. Food and Drug Administration-cleared devices and interventions currently under investigation are described including gastric devices, gastric remodeling procedures, small-bowel devices, duodenal ablation, as well as procedures to address weight regain after bariatric surgery. Future studies evaluating gastric and duodenal combination therapy, adjunctive pharmacotherapy, as well as individualized precision-health algorithms are underway.

From surgery to endoscopy: the evolution of the bariatric discipline

ABSTRACT

Obesity, with its increasing morbidity and prevalence, is now a worldwide public health problem. Obesity and its related comorbidities impose a heavy burden on societal health and the economy. The practice of bariatric surgery has evolved from its early surgical procedures, many of which are no longer routine operations. With clinical practice, research, and experience, bariatric surgery has gradually become an important last resort for the control of weight and obesity-related metabolic diseases in moderately and severely obese patients. However, there is still room for further improvements in bariatric surgical procedures, especially with regard to long-term issues and complications. Endoscopic weight loss technology has developed rapidly in recent years. The advantages of this technology include minimal invasiveness, an obvious weight loss effect, and few complications, thus filling the gap between medications and lifestyle adjustments and surgical treatment of obesity. Endoscopic weight loss technology may even replace surgical bariatric procedures. This review summarized the current status of bariatric metabolic surgery and newly developed bariatric endoscopic procedures.

Therapeutic endoscopy for the treatment of post-bariatric surgery complications

Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.

Endoscopic Approaches to Obesity Management

The field of endoscopic bariatric and metabolic therapy has rapidly evolved from offering endoscopic treatment of weight regain following bariatric surgery to providing primary weight loss options as alternatives to pharmacologic and surgical interventions. Gastric devices and remodeling procedures were initially designed to work through a mechanism of volume restriction, leading to earlier satiety and reduced caloric intake. As the field continues to grow, small bowel interventions are evolving that may have some effect on weight loss but focus on the treatment of obesity-related comorbidities. Future implementation of combination therapy that utilizes both gastric and small bowel interventions offers an exciting option to further augment weight loss and alleviate metabolic disease. This review considers gastric devices and techniques including space-occupying intragastric balloons, aspiration therapy, endoscopic tissue suturing, and plication interventions, followed by a review of small bowel interventions including endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically delivered devices to create incisionless anastomoses. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

The effect of sleeve ablation of gastric mucosa on body weight and glucose homeostasis in Sprague-Dawley rat model

BACKGROUND

The gastric mucosa is an important endocrine organ, most of which is resected in sleeve gastrectomy (SG). The effect of removing most of the gastric mucosa has not been studied.

OBJECTIVE

To assess the effect of ablating the gastric mucosa (an area proportional to that in SG), on obesity and diabetes in a rat model.

SETTING

The Affiliated Hospital of Xuzhou Medical University in Xuzhou Jiangsu, P. R. China.

METHODS

Among 34 fatty Sprague-Dawley rats, 26 randomly received low-dose streptozotocin (STZ) to induce diabetes and then were randomly assigned to gastric mucosa ablation (GMA, n = 10), sleeve gastrectomy (SG, n = 8), and sham (n = 8) groups. The remaining normal fatty rats were assigned to the non-diabetic gastric mucosa ablation (nGMA, n = 8) group. In the GMA groups, the gastric mucosa was thermally ablated using electrocautery. Rats were followed for 8 weeks postoperatively. Preoperative oral glucose tolerance test (OGTT), insulin tolerance test (ITT), and mixed meal tolerance test (MMTT) were repeated at designated time points postoperatively. Changes in body weight, food intake, and fasting blood glucose were also recorded.

RESULTS

Fasting ghrelin concentration and area under curve (AUC) decreased significantly (P < .05) in the GMA groups and the SG group after surgery. Gastrin concentration remained unchanged in SG but decreased significantly in the GMA groups after surgery. Significantly increased GLP-1 AUC was found in the GMA groups and the SG group postoperatively. The decrease in fasting blood glucose did not differ significantly between the diabetic GMA and SG groups after surgery. Glucose AUC during OGTT in both SG and diabetic GMA groups was decreased significantly from the preoperative level, but the decreased glucose AUC in the SG group was significantly greater (P < .05). The decrease in body weight and food intake in the SG group was significantly greater than in the GMA groups.

CONCLUSION

Ablation of most of the gastric mucosa along the greater curvature is effective in weight loss and glycemic control in a rodent model.

Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

Bariatric surgery and the endoscopist

Bariatric surgery is an effective treatment for obesity and its metabolic related disorders. With the numbers of bariatric procedures being performed rising annually endoscopists are now more likely than ever to encounter this patient cohort on routine diagnostic lists. Endoscopy plays a vital role in both the pre and postoperative periods to diagnose and treat certain complications associated with bariatric surgery. Preoperative endoscopy may be useful in identifying pathologies that then influence the type of bariatric surgery being proposed. Postoperative endoscopy has an established role in identifying and managing complications such as anastomotic leaks and gastrointestinal bleeding. As endoscopic techniques develop, these complications may be managed without the need for surgical intervention or revision. Increased knowledge and awareness of the indications for endoscopy, together with the altered anatomy and common complications of bariatric surgery, is paramount in managing these patients effectively.

Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos)

BACKGROUND AND AIMS

As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type.

METHODS

The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized.

RESULTS

Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving.

CONCLUSIONS

Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.

Development of Bariatric and Metabolic Endoscopy

Objective:

With the evolution of society and changes in human lifestyle, obesity is becoming increasingly prevalent worldwide, and obesity-related comorbidities such as diabetes, hyperlipidemia, hypertension, and coronary heart disease are more common. As a result, new devices and methods for bariatric and metabolic endoscopy are being developed for clinical use, offering new options for patients. This review discussed the progress in bariatric and metabolic endoscopy.

Data Sources:

This review was based on data in articles published in the PubMed database up to September 2017, with the following keywords: “obesity”, “endoscopy”, “weight loss”, and “metabolism”.

Study Selection:

Original articles about various endoscopic methods of weight loss and other reviews of bariatric and metabolic endoscopy were included and analyzed.

Results:

The technology of bariatric and metabolic endoscopy has advanced rapidly in recent years. The intragastric balloon (IGB), with its comparatively long period of development, is the most mature and widely used instrument. Multiple new endoscopic devices have been created in recent years, with different targets to achieve weight loss. Despite the proliferation of new devices, the lack of clinical data results in a shortage of clinical experience and instruction in the use of this new equipment.

Conclusions:

Bariatric and metabolic endoscopy would help obese people lose weight or prepare for bariatric surgery and hopefully alleviate some of the complications of bariatric procedures. Adequate studies and data are still needed for the new endoscopic devices.