Endoscopic gastroplasty versus laparoscopic sleeve gastrectomy: a noninferiority propensity score-matched comparative study

Endoscopic Sleeve Gastroplasty for the Treatment of Metabolic Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an incisionless weight loss procedure that has been demonstrated to be safe and effective for the treatment of obesity; however, the efficacy of ESG for the treatment of comorbid type 2 diabetes mellitus (T2DM) and other components of metabolic syndrome (MetS) has been less well studied. We aimed to conduct a systematic review and meta-analysis of available literature to evaluate the outcomes of ESG on T2DM and MetS.

METHODS

Bibliographic databases were systematically searched for studies assessing the outcomes of ESG on T2DM and MetS. Studies were included if they reported at least one objective outcome related to T2DM or other components of MetS, including hyperlipidemia (HLD), hypertriglyceridemia, and hypertension (HTN). This study was deemed IRB exempt.

RESULTS

Ten studies with 4320 patients were included. At 12 months, ESG was associated with significant improvements in T2DM, HLD, and HTN, with risk difference of - 0.72 [95% CI, - 0.87 to - 0.58, p < 0.00001], - 0.65 [95% CI, - 0.78 to - 0.52, p < 0.00001], and - 0.60 [95% CI, - 0.66 to - 0.53, p < 0.00001], respectively. Disease improvement was defined as patients being able to stop some or all of their related treatment medications. Additionally, there were significant reductions in hemoglobin A1c (HGBA1c), fasting blood glucose, homeostatic model assessment for insulin resistance (HOMA-IR), low-density lipoprotein, and triglycerides.

CONCLUSIONS

ESG is an effective modality for the treatment of comorbid T2DM and MetS in patients with obesity. Additional studies are needed to establish long-term responses and to compare ESG against established pharmacologic and surgical techniques.

Endoscopic management of obesity and metabolic diseases

Obesity has become a global pandemic that is associated with a range of metabolic disorders. Traditional treatment options, such as lifestyle modification and anti-obesity medications, often exhibit limited efficacy and can lead to long-term weight gain, especially upon discontinuation of the medication. Although bariatric surgery is effective, its accessibility is constrained, and only a small percentage of eligible patients receive this intervention. Over the past two decades, endoscopic bariatric and metabolic therapies (EBMTs) have emerged as minimally invasive and effective alternatives for managing obesity and its related comorbidities. This article reviews primary gastric and small bowel EBMTs, their mechanisms of action, key supporting literature, and the metabolic outcomes associated with each device and procedure.

Strategies to Manage Obesity: Endoscopic Bariatric and Metabolic Therapies

Over the past two decades, numerous endoscopic bariatric and metabolic therapies (EBMTs) have been developed with the goal of providing additional effective and safe tools for the treatment of obesity. These treatments are an ultra-minimally invasive option for patients with class I, class II, and class III obesity. Many of these EBMTs can be utilized as primary therapies for treatment-naïve patients or as a treatment for weight regain after bariatric surgery. While the role of EBMTs is not to compete with bariatric surgery, which provides the most effective treatment of obesity, they provide greater weight loss than lifestyle modifications and pharmacotherapy; additionally, when combined with pharmacotherapy, they may help achieve surgical weight loss without the risk of invasive surgery. This review summarizes the most currently available EBMTs, including intragastric balloons (IGBs), endoscopic sleeve gastroplasty (ESG), and endoscopic surgical revision procedures for treating obesity.

Position statement and guidelines about Endoscopic Sleeve Gastroplasty (ESG) also known as "Endo-sleeve"

IS ESG EFFECTIVE IN THE TREATMENT OF OBESITY AND ASSOCIATEDCOMORBIDITIES?: Endoscopic Sleeve Gastroplasty (ESG) is more effective than lifestyle modifications alone for weight loss and improving obesity-related comorbidities. While it has less effect on weight loss compared to Laparoscopic Sleeve Gastrectomy (LSG) in the short to medium term, it offers similar comorbidities resolution to LSG. IS ESG A SAFE PROCEDURE, AND WHAT ARE ITS RISKS?: The safety profile of ESG is consistently supported in the literature. Surgical complications after ESG, ranging from 1.5 to 2.3%, such as bleeding, perforation, fistula, or upper bowel obstruction, are rare and typically managed endoscopically. The incidence of new-onset gastro-esophageal reflux disease (GERD) is deemed negligible and occurs less frequently after ESG compared to SG. WHAT ARE THE INDICATIONS AND MANAGEMENT METHODS?: Multidisciplinary care for patients undergoing ESG should be provided in an accredited center authorized to perform bariatric and metabolic surgery, with validation through a multidisciplinary consultation meeting (RCP). Perioperative management should be personalized and ideally modeled after the protocols already in place for bariatric and metabolic surgery to ensure satisfactory and lasting weight and metabolic outcomes. Adherence to follow-up visits is a significant predictor of successful weight loss outcomes after ESG. Additionally, all endoscopic surgical procedures should be documented in a registry affiliated with a recognized scientific society, as is standard for other bariatric surgical procedures. WHICH HEALTHCARE PROFESSIONALS CAN PERFORM ESG?: ESG must be performed by a practitioner trained in endoscopy and obesity management, capable of ensuring thorough preoperative care and comprehensive postoperative follow-up, supported by an experienced multidisciplinary team. In France, Notice No. 2021.0040/AC/SEAP of June 10, 2021, issued by the Haute Autorité de santé (HAS) college, specifies that "the technology of ESG via the trans-oral approach, involving wide plication of the greater gastric curvature […] with an endoscopic suture placement device, enables a gastroenterologist or a visceral and digestive surgeon to perform gastric plication through digestive endoscopy by placing sutures in the stomach". Ideally, this should take place in an accredited center authorized to perform bariatric and metabolic surgery, such as those approved by the Agence régionale de santé (ARS), in accordance with Article R6123-212 of December 2022 of the French Public Health Code. WHAT ARE THE RECOMMENDATIONS AND VIEWS OF OTHER INTERNATIONAL SCIENTIFICSOCIETIES?: ESG is an integral part of the therapeutic arsenal available to bariatric and metabolic surgeons, offering an effective and valuable treatment option for obesity in specific patient populations. The International Federation for the Surgery of Obesity (IFSO) Bariatric Endoscopy Committee, following a comprehensive systematic review and meta-analysis, endorsed ESG as an effective and valuable treatment for obesity. ESG is particularly beneficial for patients with class I and II obesity, as well as for those with class III obesity who are not suitable candidates for metabolic bariatric surgery. Additionally, it can be proposed as an addition to lifestyle interventions in adolescent patients with class II obesity. The SOFFCOMM endorses endoscopic sleeve gastroplasty (ESG) as an effective and valuable treatment for obesity and highlights the importance of appropriate patient selection, coupled with rigorous evaluation of long-term outcomes, to refine its indications further.

Endoscopic bariatric surgery for adults with overweight and obesity: a systematic review and network meta-analysis

BACKGROUND

Endoscopic bariatric surgery (EBS) is a new treatment for obesity. We compared the efficacy, safety, and probability of metabolic complications of different EBSs with laparoscopic sleeve gastrectomy (LSG).

METHODS

This systematic review and network meta-analysis (NMA) included searches of PubMed, Web of Science, and the Cochrane Library from January 1, 2017, to December 27, 2022, to find comparative trials of EBS procedures and EBS with LSG. We performed a frequentist model NMA to summarize the evidence and ranked the interventions according to SUCRA scores.

RESULTS

The search for this NMA yielded 14,160 articles, of which 18 eligible trials recruited 766,135 participants for procedures including LSG, endoscopic sleeve gastroplasty (ESG), nonadjustable intragastric balloon (NIB), BioEnterics Intragastric Balloon (BIB), and adjustable intragastric balloon (AIB). Definitive evidence suggests that LSG is most effective for weight reduction. Compared with LSG, NIB, SMD = -0.49 [95% CI -0.79, -0.18]; AIB, SMD = -0.41 [95% CI -0.76, -0.06] and ESG, SMD = -0.31 [95% CI -0.33, -0.29] in the index of percentage total weight loss under six months. In terms of safety outcomes, ESG had the lowest incidence of adverse events; the order of the observed incidence of adverse events from small to large was ESG, NIB, AIB, LSG, and BIB.

CONCLUSIONS

ESG is an effective and safe minimally invasive surgical method for people with overweight and obesity. Its 12-month effect is better than that of NIB, and its influence on lipid metabolism makes it more protective of the cardiovascular system and liver.

PROSPERO

CRD42022375343.

Endoscopic Sleeve Gastroplasty Versus Laparoscopic Sleeve Gastrectomy: A Comparison in Effectiveness and Safety Profile

BACKGROUND AND OBJECTIVES

Current treatment options for obesity typically involve a combination of lifestyle changes, medications, and bariatric surgeries. This study aimed to assess the safety profile of the endoscopic sleeve gastroplasty (ESG), which is a novel non-invasive approach, as compared to laparoscopic sleeve gastrectomy (LSG) and to correlate their weight loss effectiveness and complication risk in Lebanese patients.

SUBJECTS AND METHODS

This is a retrospective study, including 70 patients who underwent ESG at Fouad Khoury Hospital and 70 patients who underwent LSG at Trad Hospital, between September 2021 and March 2023. Data collection targeted the patients' medical records and included their demographic characteristics (age, sex, weight, height, BMI), comorbidities, and post-procedural information. Weight and BMI (pre-op, 6-months post-op, and 1-year post-op) were collected. Total body weight loss was calculated, and analysis was performed using SPSS version 25.

RESULTS

Patients who underwent ESG were distributed between 43 (61.4%) females and 27 (38.6%) males, with an average age of 38.07 ± 10.78 years. Patients who underwent LSG were distributed between 42 (60%) females and 28 (40%) males, with an average age of 33.99 ± 10.55 years. Both ESG and LSG resulted in significant weight loss, but LSG achieved greater total body weight loss at 6 and 12 months. ESG was associated with significantly shorter hospital stays (9.14 h vs. 27.77 h, p < 0.001) and fewer adverse events (8.5% vs. 17.1%, p = 0.111). New-onset GERD was more frequent after LSG (20% vs. 4.3%, p = 0.004).

CONCLUSION

ESG offers a less invasive approach with a potentially more favorable short-term safety profile and faster recovery, while LSG yields greater total body weight loss. ESG may be a suitable alternative for patients with a higher BMI. Further research is needed to assess long-term outcomes and cost-effectiveness.

IFSO Bariatric Endoscopy Committee Evidence-Based Review and Position Statement on Endoscopic Sleeve Gastroplasty for Obesity Management

BACKGROUND

Obesity is a significant global health issue. Metabolic and bariatric surgery (MBS) is the gold standard in the treatment of obesity due to its proven effectiveness and safety in the short and long term. However, MBS is not suitable for all patients. Some individuals are at high surgical risk or refuse surgical treatment, while others do not meet the criteria for MBS despite having obesity-related comorbidities. This gap has driven the development of endoscopic solutions like endoscopic sleeve gastroplasty (ESG), which offers a less invasive alternative that preserves organ function and reduces risks. A recent IFSO International Delphi consensus study highlighted that multidisciplinary experts agree on the utility of ESG for managing obesity in patients with class I and II obesity and for those with class III obesity who do not wish to pursue or qualify for MBS. This IFSO Bariatric Endoscopy Committee position statement aims to augment these consensus statements by providing a comprehensive systematic review of the evidence and delivering an evidence-based position on the value of ESG within the spectrum of obesity management.

METHODS

A comprehensive systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Cochrane guidelines.

RESULTS

Systematic Review: The systematic review included 44 articles encompassing 15,714 patients receiving ESG. The studies varied from large case series to cohort studies and a randomized controlled trial (RCT). The mean baseline BMI was 37.56 kg/m2. The review focused on weight loss outcomes and safety data.

META-ANALYSIS

Time point Mean %EWL Mean %TBWL 6 months 48.04 15.66 12 months 53.09 17.56 18 months 57.98 16.25 24 months 46.57 15.2 36 months 53.18 14.07 60 months 45.3 15.9 These results demonstrate significant weight loss following ESG.

SAFETY

The pooled serious adverse event (SAE) rate was 1.25%. This low rate of SAEs indicates that ESG is a relatively safe procedure.

QUALITY OF EVIDENCE

The quality of evidence from the included observational studies was assessed as very low, primarily due to the inherent limitations associated with observational study designs, such as potential biases and lack of randomization. In contrast, the quality of evidence from the single randomized controlled trial was rated as MODERATE, reflecting a more robust study design that provides a higher level of evidence despite some limitations.

CONCLUSIONS

The IFSO Bariatric Endoscopy Committee, after conducting a comprehensive systematic review and meta-analysis, endorses endoscopic sleeve gastroplasty (ESG) as an effective and valuable treatment for obesity. ESG is particularly beneficial for patients with class I and II obesity, as well as for those with class III obesity who are not suitable candidates for metabolic bariatric surgery. ESG provides significant weight loss outcomes and demonstrates a favorable safety profile with a low rate of serious adverse events. Despite the limitations of the included observational studies, the randomized controlled trial included in the analysis reinforces the efficacy and safety of ESG and provides an evidence-based foundation for the position statement. Thus, the IFSO position statement supports and provides an evidence base for the role of ESG within the broader spectrum of obesity management.

Therapeutic endoscopy: Recent updates and future directions

The landscape of therapeutic endoscopy has undergone a remarkable evolution over the past few decades, carving out a niche that merges innovative technology with advanced clinical practice. As we venture further into the 21st century, the horizon of this field continues to expand, driven by rapid advancements in technology and a deeper understanding of gastrointestinal pathology. This review article aims to shed light on the recent advances and future trajectories of therapeutic endoscopy, focusing on pivotal areas such as third space endoscopy, endoscopic resection techniques, artificial endoscopy, endoscopic ultrasound (EUS), the integration of artificial intelligence (AI), and endoscopic anti-reflux therapies.

Novel Devices for Endoscopic Suturing: Past, Present, and Future

Endoscopic suturing has been described in many applications, including the approximation of tissue defects, anchoring stents, hemostasis, and primary and secondary bariatric interventions. Primary endobariatric procedures use endoscopic suturing for gastric remodeling with the intention of weight loss. Currently, the only commercially available device in the United States is the OverStitch endoscopic suturing system (Apollo Endosurgery). We describe devices of potential that are currently in design and/or trials as devices for weight loss by gastric remodeling, including USGI incisionless operating platform used for the primary obesity surgery endoluminal 2.0 procedure, Endomina used for the Endomina endoscopic sleeve gastroplasty, and EndoZip.

Autonomic and Enteric Profiling May Help Predict Response to Diverse Obesity Therapies

PURPOSE

Changes in autonomic (ANS) and enteric nervous systems (ENS) may be involved in pathogenesis of obesity. We hypothesized that baseline autonomic and enteric parameters may predict outcomes of diverse obesity therapies.

MATERIAL AND METHODS

We studied ANS and ENS physiology in 37 patients (8 male, 29 female, age 45 years, weight 129.7 kg) at 4 centers in patients undergoing medical (9: low-calorie diet) versus invasive (22: 16 sleeve, 6 bypass) and semi-invasive (6: 2 band, 2 high energy stimulation, 2 aspiration) weight loss therapies. Weight loss was reported as percent weight loss from baseline to latest values at 1 year and in some up to 5 years; classified as < or > /= 20% for each group. ANS testing included sympathetic adrenergic function by measuring reflex vasoconstriction and postural adjustment ratio. ENS was measured non-invasively using cutaneous low-resolution electrogastrogram.

RESULTS

Percent weight loss was greater with the invasive (28.5%) than semi-invasive (9.1%) or non-invasive low-calorie diet (4.4%) (p < .001). Percent weight loss at 1 year (and up to 5 years) corresponded to the adrenergic measure of postural adjustment ratio (r = .42, p = .012), total pulse amplitude at rest (r = .56, p < .001), and electrogastrogram standing-to-rest difference (r = .33, p = .056).

CONCLUSION

Baseline autonomic and enteric function measures correspond to percentage with loss in this pilot study using diverse weight loss methods. Autonomic and enteric profiling has potential clinical use for evaluation and treatment of obesity but needed larger controlled trials.

A commentary review on endoscopic sleeve gastroplasty: Indications, outcomes and future implications

Metabolic and bariatric surgeries have been shown to be the most effective strategy to induce and maintain significant weight loss for people living with severe obesity. However, ongoing concerns regarding operative risks, irreversibility and excess costs limit their broader clinical use. Endoscopic bariatric therapies are pragmatic alternatives for patients who are not suitable for metabolic and bariatric surgeries or who are concerned regarding their long-term safety. Endoscopic sleeve gastroplasty has emerged as a novel technique of endoscopic bariatric therapies, which have garnered significant interest and evidence in the past few years. Its safety, efficacy and cost-effectiveness have been shown in various studies, while comparisons with sleeve gastrectomy have been widely made. This review brings together current evidence pertaining to the technicality of the procedure itself, current indications, safety and efficacy, cost-effectiveness, as well as its future role and development.

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.

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.

Update on Endoscopic Treatments for Obesity

PURPOSE OF REVIEW

Increased morbidity seen with rising obesity rates continues to place an unheralded burden on our health system. Lack of higher bariatric surgery utilization and limitations with lifestyle modification and pharmacotherapy highlights the need for additional therapies for obesity. Endoscopic bariatric and metabolic therapies (EBMT) are effective, safe treatments for obesity. Current FDA-approved EBMT are confined to gastric modalities while small bowel directed therapies are still considered investigational. This review highlights current modalities of EBMT.

RECENT FINDINGS

Many randomized controlled trials have been performed, including both open label and sham-controlled, which have demonstrated safety and efficacy of EBMT over lifestyle therapy alone. In addition, emerging evidence from clinical experience further supports EBMT for treatment of obesity. Current evidence supports the safety and efficacy of EBMT for obesity treatment in conjunction with lifestyle therapy. They can also be used concurrently with weight loss medications to increase total weight loss.

Endoscopic sleeve gastroplasty as an early tool against obesity: a multicenter international study on an overweight population

BACKGROUND AND AIMS

Endoscopic sleeve gastroplasty (ESG) is an effective, minimally invasive gastric remodeling procedure to treat mild and moderate obesity. Early adoption of ESG may be desirable to try to halt progression of obesity, but there are few data on its efficacy and safety for overweight patients.

METHODS

This was a multicenter, international, analytical case series. Six U.S., 1 Brazilian, 1 Mexican, and 1 Indian center were included. Overweight patients according to local practice undergoing ESG were considered eligible for the study. The end points were percent total weight loss (%TWL), body mass index (BMI) reduction, rate of BMI normalization, and rate of adverse events.

RESULTS

One hundred eighty-nine patients with a mean age of 42.6 ± 14.1 years and a mean BMI of 27.79 ± 1.17 kg/m2 were included. All procedures were successfully accomplished, and there were 3 intraprocedural adverse events (1.5%). The mean %TWL was 12.28% ± 3.21%, 15.03% ± 5.30%, 15.27% ± 5.28%, and 14.91% ± 5.62% at 6, 12, 24, and 36 months, respectively. At 12 and 24 months, 76% and 86% of patients achieved normal BMI, with a mean BMI reduction of 4.13 ± 1.46 kg/m2 and 4.25 ± 1.58 kg/m2. There was no difference in mean %TWL in the first quartile versus the fourth quartile of BMI in any of the time points. However, the BMI normalization rate was statistically higher in the first group at 6 and 12 months (6 months, 100% vs 48.5% [P < .01]; 12 months, 86.2% vs 50% [P < .01]; 24 months, 84.6% vs 76.1% [P = .47]; 36 months, 86.3% vs 66.6% [P = .26]).

CONCLUSIONS

ESG is safe and effective in treating overweight patients with high BMI normalization rates. It could help halt or delay the progression to obesity.

Practice patterns and outcomes of endoscopic sleeve gastroplasty based on provider specialty

Background and study aims Endoscopic sleeve gastroplasty (ESG) is performed in clinical practice by gastroenterologists and bariatric surgeons. Given the increasing regulatory approval and global adoption, we aimed to evaluate real-world outcomes in multidisciplinary practices involving bariatric surgeons and gastroenterologists across the United States. Patients and methods We included adult patients with obesity who underwent ESG from January 2013 to August 2022 in seven academic and private centers in the United States. Patient and procedure characteristics, serious adverse events (SAEs), and weight loss outcomes up to 24 months were analyzed. SPSS (version 29.0) was used for all statistical analyses. Results A total of 1506 patients from seven sites included 235 (15.6%) treated by surgeons and 1271 (84.4%) treated by gastroenterologists. There were no baseline differences between groups. Gastroenterologists used argon plasma coagulation for marking significantly more often than surgeons ( P <0.001). Surgeons placed sutures in the fundus in all instances whereas gastroenterologist placed them in the fundus in less than 1% of the cases ( P <0.001>). Procedure times were significantly different between groups, with surgeons requiring approximately 20 minutes more during the procedure than gastroenterologists ( P <0.001). Percent total body weight loss (%TBWL) and percent responders achieving >10 and >15% TBWL were similar between the two groups at 12, 18, and 24 months. Rates of SAEs were low and similar at 1.7% for surgeons and 2.7% for gastroenterologists ( P >0.05). Conclusions Data from a large US cohort show significant and sustained weight loss with ESG and an excellent safety profile in both bariatric surgery and gastroenterology practices, supporting the scalability of the procedure across practices in a multidisciplinary setting.

Observational cohort investigating health outcomes and healthcare costs after metabolic and bariatric surgery: a study protocol

INTRODUCTION

As the rate of obesity increases, so does the incidence of obesity-related comorbidities. Metabolic and bariatric surgery (MBS) is the most effective treatment for obesity, yet this treatment is severely underused. MBS can improve, resolve, and prevent the development of obesity-related comorbidities; this improvement in health also results in lower healthcare costs. The studies that have examined these outcomes are often limited by small sample sizes, reliance on outdated data, inconsistent definitions of outcomes, and the use of simulated data. Using recent real-world data, we will identify characteristics of individuals who qualify for MBS but have not had MBS and address the gaps in knowledge around the impact of MBS on health outcomes and healthcare costs.

METHODS AND ANALYSIS

Using a large US employer-based retrospective claims database (Merative), we will identify all obese adults (21+) who have had a primary MBS from 2016 to 2021 and compare their characteristics and outcomes with obese adults who did not have an MBS from 2016 to 2021. Baseline demographics, health outcomes, and costs will be examined in the year before the index date, remission and new-onset comorbidities, and healthcare costs will be examined at 1 and 3 years after the index date.

ETHICS AND DISSEMINATION

As this was an observational study of deidentified patients in the Merative database, Institutional Review Board approval and consent were exempt (in accordance with the Health Insurance Portability and Accountability Act Privacy Rule). An IRB exemption was approved by the wcg IRB (#13931684). Knowledge dissemination will include presenting results at national and international conferences, sharing findings with specialty societies, and publishing results in peer-reviewed journals. All data management and analytic code will be made available publicly to enable others to leverage our methods to verify and extend our findings.

Applicability of individualized metabolic surgery score for prediction of diabetes remission after endoscopic sleeve gastroplasty

Background

Endoscopic sleeve gastroplasty (ESG) is a safe and effective obesity treatment. The individualized metabolic score (IMS) is a validated score that uses preoperative variables predicting T2D remission (DR) in bariatric surgery.

Objectives

We evaluated the applicability of using the IMS score to predict DR in patients after ESG.

Design/Methods

We performed a retrospective review of patients with obesity and T2D who underwent ESG. We calculated DR, IMS score, and severity, and divided patients based on IMS category.

Results

The cohort comprised 20 patients: 25% (5) mild, 55% (11) moderate, and 20% (4) severe IMS stages. DR was achieved in 60%, 45.5%, and 0% of patients with mild, moderate, and severe IMS scores (p = 0.08), respectively. IMS score was significantly associated with DR (p = 0.03), with the area under the curve of the receiver operating characteristic for predicting DR 0.85.

Conclusion

These pilot data demonstrate that the IMS score appears to be useful in predicting DR after ESG.

Type 2 Diabetes Remission After Bariatric Surgery and Its Impact on Healthcare Costs

PURPOSE

Bariatric surgery is the most effective and durable treatment of obesity and can put type 2 diabetes (T2D) into remission. We aimed to examine remission rates after bariatric surgery and the impacts of post-surgical healthcare costs.

MATERIALS AND METHODS

Obese adults with T2D were identified in Merative™ (US employer-based retrospective claims database). Individuals who had bariatric surgery were matched 1:1 with those who did not with baseline demographic and health characteristics. Rates of remission and total healthcare costs were compared at 6-12 and 6-36 months after the index date.

RESULTS

Remission rates varied substantially by baseline T2D complexity; differences in rates at 1 year ranged from 41% for those with high-complexity T2D to 66% for those with low- to mid-complexity T2D. At 3 years, those who had bariatric surgery had 56% higher remission rates than those who did not have bariatric surgery, with differences of 73%, 59%, and 35% for those with low-, mid-, and high-complexity T2D at baseline. Healthcare costs were $3401 and $20,378 lower among those who had bariatric surgery in the 6 to 12 months and 6 to 36 months after the index date, respectively, than their matched controls. The biggest cost differences were seen among those with high-complexity T2D; those who had bariatric surgery had $26,879 lower healthcare costs in the 6 to 36 months after the index date than those who did not.

CONCLUSION

Individuals with T2D undergoing bariatric surgery have substantially higher rates of T2D remission and lower healthcare costs.

Medium-Term Weight Loss and Remission of Comorbidities Following Endoscopic Sleeve Gastroplasty: a Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to determine the short- and medium-term weight loss outcomes and comorbidity resolution following endoscopic sleeve gastroplasty. Our search identified 35 relevant studies containing data from 7525 patients. Overall, pooled short-term (12 months) total weight loss (TWL) was 16.2% (95% CI 13.1-19.4%) in 23 studies (n = 5659). Pooled medium-term TWL was 15.4% (95% CI 13.7-17.2%) in 10 studies (n = 4040). Diabetes resolution was 55.4% (95% CI 46-64%), hypertension resolution was 62.8% (95% CI 43-82%), dyslipidaemia resolution was 56.3% (95% CI 49-63%), and obstructive sleep apnoea resolution was 51.7% (95% CI 16.2-87.3%) in four studies (n = 480). This pooled analysis demonstrates that ESG can induce durable weight loss and resolution of obesity-associated comorbidities in patients with moderate obesity.

Endoscopic sleeve gastroplasty reintervention score using supervised machine learning

BACKGROUND AND AIMS

Reintervention after endoscopic sleeve gastroplasty (ESG) can be indicated because of postprocedural adverse events from various preinterventional or postprocedural comorbidities. We developed and internally validated an ESG reintervention score (ESG-RS) that determines the individualized risk of reintervention within the first 30 days after ESG.

METHODS

We used data from a sample of 3583 patients who underwent ESG in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database (2016-2021). The least absolute shrinkage and selection operator (LASSO)-penalized regression was used to select the most promising predictors of reintervention after ESG within 30 days. The predictive variables extracted by LASSO regression were entered into multivariate analysis to generate an ESG-RS by using the coefficients of the statistically significant variables. The model performance was assessed using receiver-operator curves by 10-fold cross-validation.

RESULTS

Eleven variables were selected by LASSO regression and used in the final multivariate analysis. The ESG-RS was inferred using 5 factors (history of previous foregut surgery, preoperative anticoagulation use, female gender, American Society of Anesthesiologists class ≥II, and hypertension) weighted by their regression coefficients in the multivariable logistic regression model. The area under the curve of the ESG-RS was .74 (95% confidence interval, .70-.78). For the ESG-RS, the optimal cutpoint was 67.9 (high risk vs low risk), with a sensitivity of .76 and specificity of .71.

CONCLUSIONS

The ESG-RS aids clinicians in preoperative risk stratification of patients undergoing ESG while clarifying factors contributing to a higher risk of reintervention.

Gallbladder plication as a rare complication of endoscopic sleeve gastroplasty: A case report

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure used in the treatment of obesity, with a complication rate of less than 2% of cases. There have been only two reported cases worldwide of gallbladder injuries as a major complication of ESG.

CASE SUMMARY

We present the case of a 34-year-old patient who developed a complication after ESG. The patient experienced epigastric and right hypochondrium pain 12 h after the procedure, and a positive Murphy's sign was identified on physical examination. Laboratory results showed a leukocyte count of 17 × 103/µL, and computed tomography indicated the presence of free fluid in the pelvic cavity and perihepatic recesses as well as a possible suture in the wall of the Hartmann's pouch toward the anterior surface of the stomach. A diagnostic laparoscopy was performed, revealing plication of the Hartmann's pouch wall to the anterior stomach wall. Laparoscopic cholecystectomy and lavage were carried out. The patient had a stable recovery and was discharged 72 h after surgery, tolerating oral intake.

CONCLUSION

Gallbladder plication should be suspected if signs and symptoms consistent with acute cholecystitis occur after ESG.

Endoscopic Sleeve Gastroplasty in Those With a Body Mass Index of 27-30

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) is safe and effective in patients with a body mass index (BMI) more than 30, with few cases reported in patients with overweight (BMI 27-30). However, evidence is lacking in the overweight group because the procedure is not currently performed routinely for such patients. In this study, we aim to evaluate the safety and efficacy of ESG in patients with a BMI between 27 and 30 who failed other weight loss modalities and/or had weight-related comorbidities.

METHODS

This was a subgroup analysis of data pertaining to adults with a BMI between 27 and 30 who underwent ESG as a primary weight loss intervention. Data were abstracted from our longitudinal, prospective single-center registry. We analyzed weight loss, comorbidity resolution, adverse events, revisions, and quality of life using the Bariatric Analysis and Reporting Outcome System.

RESULTS

Of 3,797 ESG procedures, 656 patients (17%) had a BMI of 27-30. The mean age was 33 ± 9 years and women comprised 94% (n = 616) of the sample. The mean % total weight loss at 6, 12, 24, and 36 months after ESG was 11.0 ± 7.2, 15.5 ± 6.3, 15.1 ± 8.3%, and 13.3 ± 9.9%, respectively. Eight of 22 patients with diabetes (36%) and 9 of 51 patients (18%) with hypertension experienced complete remission. Two patients were hospitalized with bleeding. Twenty-three patients (3.5%) underwent revision to laparoscopic sleeve gastrectomy or repeat ESG. Six more patients underwent suture removal. A total of 214 of 261 patients (82%) rated quality of life after ESG as good or better.

DISCUSSION

ESG seems to be well tolerated, safe, and effective in patients with a BMI of 27-30.

Impact of Pregnancy on Weight Loss After Endoscopic Sleeve Gastroplasty

PURPOSE

Obesity and pregnancy are strictly related: on the one hand, obesity-one of the most common comorbidities in women of reproductive age-contributes to infertility and obesity-related pregnancy complications, whereas pregnancy is a condition in which, physiologically, the pregnant woman undergoes weight gain. Endoscopic sleeve gastroplasty (ESG) may be used for the treatment of obesity in women of childbearing age.

MATERIALS AND METHODS

A retrospective analysis was conducted to evaluate weight trajectories, the evolution of obesity-related comorbidities, and lifestyle modification in women who became pregnant after ESG. A comparison was made between childbearing-age women who became pregnant after ESG and non-pregnant women.

RESULTS

A total of 150 childbearing-age women underwent ESG at a large tertiary medical center. Of these, 11 patients (33.4 ± 6.2 years) became pregnant after the procedure, following a mean time interval of 5.5 ± 3.9 months. Three women (two affected by polycystic ovary syndrome) reported difficulty getting pregnant before undergoing ESG. The mean preconception BMI was 31.9±4.0 kg/m2 (-7.24 ± 4.0 kg/m2 after ESG). Total body weight loss (TBWL, %) was 18.08 ± 8.00, 11.00 ± 11.08, and 12.08 ± 8.49, at the beginning of pregnancy, at the delivery, and at the first follow-up (19.6 ± 7.8 months after ESG). TBWL of at least 5% was achieved before pregnancy in all patients (73% reached a TBWL ≥ 10%). No significant differences in weight loss and QoL were found between the pregnancy and non-pregnancy groups up to 24 months after ESG.

CONCLUSIONS

Endoscopic sleeve gastroplasty allows for adequate weight loss before and after pregnancy in patients with obesity.

Metabolic and Bariatric Endoscopy: A Mini-Review

We are currently in a worldwide obesity pandemic, which is one of the most significant health problems of the 21st century. As the prevalence of obesity continues to rise, new and innovate treatments are becoming available. Metabolic and bariatric endoscopic procedures are exciting new areas of gastroenterology that have been developed as a direct response to the obesity crisis. These novel interventions offer a potentially reversible, less invasive, safer, and more cost-effective method of tackling obesity compared to traditional bariatric surgery. Minimally invasive endoscopic treatments are not entirely novel, but as technology has rapidly improved, many of the procedures have been proven to be extremely effective for weight loss and metabolic health, based on high-quality clinical trial data. This mini-review examines the existing evidence for the most prominent metabolic and bariatric procedures, followed by a discussion on the future trajectory of this emerging subspecialty.

Endoscopic sleeve gastroplasty in class III obesity: Efficacy, safety, and durability outcomes in 404 consecutive patients

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an effective therapy for class I-II obesity, but there are knowledge gaps in the published literature about its implementation in patients with class III obesity [body mass index (BMI) ≥ 40 kg/m²].

AIM

To evaluate the safety, clinical efficacy, and durability of ESG in adults with class III obesity.

METHODS

This was a retrospective cohort study that used prospectively collected data on adults with BMI ≥ 40 kg/m² who underwent ESG and longitudinal lifestyle counseling at two centers with expertise in endobariatric therapies from May 2018-March 2022. The primary outcome was total body weight loss (TBWL) at 12 mo. Secondary outcomes included changes in TBWL, excess weight loss (EWL) and BMI at various time points up to 36 mo, clinical responder rates at 12 and 24 mo, and comorbidity improvement. Safety outcomes were reported through the study duration. One-way ANOVA test was performed with multiple Tukey pairwise comparisons for TBWL, EWL, and BMI over the study duration.

RESULTS

404 consecutive patients (78.5% female, mean age 42.9 years, mean BMI 44.8 ± 4.7 kg/m²) were enrolled. ESGs were performed using an average of 7 sutures, over 42 ± 9 min, and with 100% technical success. TBWL was 20.9 ± 6.2% at 12 mo, 20.5 ± 6.9% at 24 mo, and 20.3 ± 9.5% at 36 mo. EWL was 49.6 ± 15.1% at 12 mo, 49.4 ± 16.7% at 24 mo, and 47.1 ± 23.5% at 36 mo. There was no difference in TBWL at 12, 15, 24, and 36 mo from ESG. TBWL exceeding 10%, 15%, and 20% was achieved by 96.7%, 87.4%, and 55.6% of the cohort at 12 mo, respectively. Of the cohort with the relevant comorbidity at time of ESG, 66.1% had improvement in hypertension, 61.7% had improvement in type II diabetes, and 45.1% had improvement in hyperlipidemia over study duration. There was one instance of dehydration requiring hospitalization (0.2% serious adverse event rate).

CONCLUSION

When combined with longitudinal nutritional support, ESG induces effective and durable weight loss in adults with class III obesity, with improvement in comorbidities and an acceptable safety profile.

Endoscopic sleeve gastroplasty using the novel single-channel suturing device: A multicenter experience

Background and aim

Endoscopic sleeve gastroplasty (ESG) is an effective treatment for obesity. Recently, a novel single-channel endoscopic suturing device has been made available to overcome the need for a double-channel endoscope. However, there is limited evidence evaluating its utility for ESG. In this multicenter study, we aim to assess the efficacy and safety of the single-channel suturing device for ESG.

Methods

We reviewed the records of 18 patients who underwent ESG using the novel device at the Singapore General Hospital, Singapore, and Siriraj Hospital, Bangkok, between 2020-2021. We adopted a "U" suture pattern. Our primary outcome was to assess technical feasibility and safety. The secondary outcome was to determine the percentage of total body weight loss at 1 year.

Results

The mean ± SD age and body mass index were 42 ± 8.5 years and 34.9 ± 4.4 kg/m², respectively. The majority were female (61%). ESG was technically successful in 94% (n = 17) of patients. Device dislodgement occurred in one patient. We used an average of five sutures (range, 4-8), and the mean ± SD procedure time was 96.5 ± 43.8 min. No complications occurred. The mean ± SD length of stay was 2.3 ± 1.5 days. The mean ± SD percentage of total body weight loss at 6 and 12 months were 16 ± 5.2% and 13.1 ± 5.8%, respectively. We found that >5%, >10%, and >15% total body weight loss was observed in 83.3%, 72.2%, and 56%, respectively.

Conclusion

ESG using the single-channel endoscopic suturing system is safe and effective for inducing weight loss at 1 year in patients with obesity.

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).

Novel Endoscopic Bariatric Therapies for the Management of Nonalcoholic Steatohepatitis

Obesity is strongly associated with nonalcoholic fatty liver disease as well as advanced forms of the disease such as nonalcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma. While lifestyle and diet modifications have been the cornerstone of treatment for NASH thus far, they are only effective for less than half of the patients. New endoscopic bariatric therapies (EBTs) have already proved to be safe and effective for the treatment of obesity and type 2 diabetes mellitus, and may provide an intermediate, less invasive, cost-effective option for patients with NASH. In this review, we aim to describe the data and evidence as well as outline future areas of development for endobariatric therapies for the treatment of NASH. In conclusion, EBTs present an effective and safe therapeutic modality for use in the growing pandemic of obesity-related liver disease and should be investigated further with large-scale trials in this patient population.

Comparative Effectiveness and Safety Between Endoscopic Sleeve Gastroplasty and Laparoscopic Sleeve Gastrectomy: a Meta-analysis of 6775 Individuals with Obesity

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic bariatric therapy that complements current medical and surgical therapeutic offerings for weight management and fills an unmet need. Few meta-analyses compared ESG to laparoscopic sleeve gastrectomy (LSG). However, these studies relied on indirect evidence derived from non-comparative studies. Comparative effectiveness data derived from direct comparative studies is needed. We performed a meta-analysis of studies that directly compared ESG with LSG.

METHODS

A comprehensive search of PubMed, Embase, and Cochrane databases was conducted. Single-arm studies were excluded. Pooled mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CIs) were obtained within a random-effect model.

RESULTS

Seven studies with 6,775 patients (3,413 with ESG vs. 3,362 with LSG) were included. There were significant differences in 6-month (MD - 7.48; 95% CI - 10.44, - 4.52; P < 0.00001), 12-month (MD - 9.90; 95% CI - 10.59, - 9.22; P < 0.00001), and 24-month (MD - 7.63; 95% CI - 11.31, - 3.94; P < 0.0001) TBWL% favoring LSG over ESG. There was a trend toward lower incidence of adverse events with ESG compared to LSG but did not reach statistical significance (RR 0.51, 95% CI 0.23-1.11, P = 0.09). The incidence of new-onset gastroesophageal reflux disease (GERD) was significantly lower after ESG compared to LSG, 1.3% vs. 17.9%, respectively (RR 0.10, 95% CI 0.02-0.53, P = 0.006).

CONCLUSIONS

ESG achieved clinically adequate but lower short- and mid-term weight loss when compared to LSG, with fewer adverse events, including GERD. Given the stomach-sparing nature of ESG and acceptable safety profile, it provides an acceptable alternative to LSG for patients with mild-to-moderate obesity.