Endoscopic solutions for weight loss

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.

Evolution of NAFLD and Its Management

The global prevalence of nonalcoholic fatty liver disease (NAFLD) is estimated to be 25% and continues to rise worldwide in the setting of the obesity epidemic. This increase is especially concerning because NAFLD is often a progressive disease that can be associated with significant complications such as liver cirrhosis, hepatocellular carcinoma, and an increase in liver-related and overall mortality. Because of the devastating complications and comorbidities, NAFLD is a very costly disease for the healthcare system, with estimated annual direct medical costs exceeding $100 billion in the United States alone. Given this progressive course, it is imperative to make the diagnosis in patients with risk factors (metabolic syndrome, weight gain, and insulin resistance/diabetes). Once the diagnosis is made, the focus should shift to treatment and monitoring for the development of associated complications. Given that currently no pharmaceutical intervention is approved for the treatment of NAFLD, focus shifts instead to mitigation of risk factors through avoidance of foods that are rich in red meat, trans fats, refined carbohydrates, and high-fructose corn syrup; are low fiber; and have high energy density. The landmark of treatment, however, continues to be weight loss and improvement of insulin resistance, often through a multimodality approach. The current manuscript reviews the clinical phenotypes of NAFLD, its risk factors, and pathogenesis, as well as treatment options including lifestyle modifications and dietary interventions, medical therapies, endoscopic bariatric interventions, and bariatric surgery.

EUS-Guided Intragastric Injection of Botulinum Toxin A in the Preoperative Treatment of Super-Obese Patients: a Randomized Clinical Trial

BACKGROUND

Obesity is a disease that is highly prevalent in Brazil, and the associated comorbidities represent a major global public health challenge. Botulinum toxin type A (BTX-A) is a potent neurotoxin and inhibitor of gastric smooth muscle activity. In theory, BTX-A administration should promote early satiety and weight loss because it delays gastric emptying by inhibiting acetylcholine-mediated peristalsis, which is primarily responsible for gastric motility. Because results in the literature are discrepant, the efficacy of intragastric injections of BTX-A as a primary treatment for obesity remains unknown. The objective of this prospective, double-blind, single-center randomized study was to evaluate the effects of endoscopic ultrasound-guided intragastric BTX-A injections, as a bridge to bariatric surgery, in super-obese patients.

METHODS

Thirty-two super-obese patients were randomized to one of two groups: BTX-A, in which 200 units of BTX-A were injected into the gastric antrum and body; and control, in which the same injections were performed with 0.9% saline. Weight, body mass index (BMI), and loss of excess weight were measured monthly over a 6-month period. Gastric emptying scintigraphy was performed before and after the procedure.

RESULTS

The patients in both groups showed significant weight loss over the course of the study (p < 0.001). There were no statistically significant differences between the groups regarding weight loss, excess weight, total loss of excess weight, total weight loss, or change in BMI.

CONCLUSIONS

Intragastric injection of BTX-A does not appear to be an effective method of achieving preoperative weight loss in super-obese patients.

Exclusively endoscopic approach to treating gastric perforation caused by an intragastric balloon: case series and literature review

Background and study aims  Obesity is a serious disease, resulting in significant morbidity and mortality. Intragastric balloons (IGBs) have been in use since the 1980s. After the insertion of an IGB, complications such as migration of the device and even severe gastric perforation can occur, requiring laparoscopic surgery. Here, we report three cases of gastric perforation after IGB insertion. In all three cases, the perforation was successfully repaired through an exclusively endoscopic approach.

Bariatric Arterial Embolization for Obesity: A Review of Early Clinical Evidence

Obesity is a worldwide public health epidemic that leads to increased morbidity, mortality, and cost burden to health care. Although bariatric surgery has been recognized as a standard invasive treatment for obesity, it is accompanied by relatively high morbidity and cost burden, as well as limited treatment outcome. Therefore, alternative treatments with lower morbidity and cost for surgery that target patients who are obese, but not morbidly obese, are needed. A minimally invasive trans-catheter procedure, named bariatric arterial embolization or bariatric embolization (BAE), has been identified as a potential solution, based on its safety and preliminary efficacy profiles. The purpose of this review is to introduce up-to-date clinical data and discuss future directions for BAE for the treatment of obesity.

Bariatric embolization: a new and effective option for the obese patient?

Obesity is a public health epidemic in the United States, which results in significant morbidity, mortality, and cost to the healthcare system. Despite advancements in traditional therapeutic options for the obese patients, there is a treatment gap for patients in whom lifestyle modifications alone have not been successful, but for whom bariatric surgery is not a suitable option. Areas covered: This treatment gap needs to be addressed and thus, complimentary or alternative treatments to lifestyle changes and surgery are urgently needed. Recent evidence suggests that embolization of the gastric fundus ('Bariatric Embolization'), which is predominantly supplied by the left gastric artery, may affect energy homeostasis by decreasing ghrelin production. The purpose of this special report is to discuss the background, rationale and latest data on this topic, as well as provide the latest data from the ongoing BEAT Obesity clinical trial. Expert commentary: A multipronged approach is essential in the treatment of obesity. Bariatric embolization looks to treat the hormonal imbalances which contribute to obesity. If proven successful in the long-term, bariatric embolization represents a potential minimally invasive approach to treat obesity offered by interventional radiologists.

Endoscopic Sleeve Gastroplasty Significantly Reduces Body Mass Index and Metabolic Complications in Obese Patients

BACKGROUND & AIMS

Endoscopic sleeve gastroplasty (ESG) is an incisionless, minimally invasive bariatric procedure that reduces the length and width of the gastric cavity to facilitate weight loss. We performed a prospective study to evaluate the effects of ESG on total body weight loss and obesity-related comorbidities.

METHODS

We collected data from 91 consecutive patients (mean age, 43.86 ± 11.26 years; 68% female) undergoing ESG from August 2013 through March 2016. All patients had a body mass index (BMI) greater than 30 kg/m² and had failed noninvasive weight-loss measures or had a BMI greater than 40 kg/m² and were not considered as surgical candidates or refused surgery. All procedures were performed with a cap-based flexible endoscopic suturing system to facilitate a triangular pattern of sutures to imbricate the greater curvature of the stomach. Patients were evaluated after 6 months (n = 73), 12 months (n = 53), and 24 months (n = 12) for anthropometric features (BMI, weight, waist circumference, blood pressure) and underwent serologic (hemoglobin A1c), lipid panel, serum triglycerides, and liver function tests. The primary outcomes were total body weight loss at 6, 12, and 24 months. Secondary outcomes were the effects of ESG on metabolic factors (blood pressure, diabetes, hyperlipidemia, steatohepatitis) and safety.

RESULTS

The patients' mean BMI before the procedure was 40.7 ± 7.0 kg/m². Patients had lost 14.4% of their total body weight at 6 months (80% follow-up rate), 17.6% at 12 months (76% follow-up rate), and 20.9% at 24 months (66% follow-up rate) after ESG. At 12 months after ESG, patients had statistically significant reductions in levels of hemoglobin A1c (P = .01), systolic blood pressure (P = .02), waist circumference (P < .001), alanine aminotransferase (P < .001), and serum triglycerides (P = .02). However, there was no significant change in low-density lipoprotein after vs before ESG (P = .79). There was one serious adverse event (1.1%) (perigastric leak) that occurred that was managed non-operatively.

CONCLUSIONS

ESG is a minimally invasive and effective endoscopic weight loss intervention. In addition to sustained total body weight loss up to 24 months, ESG reduced markers of hypertension, diabetes, and hypertriglyceridemia.

Recent Trends in Endoscopic Management of Obesity

Obesity remains a tremendous public health, clinical, and scientific challenge globally. Conventional approaches in the management of obesity offer limited potential for sustained weight loss. Bariatric surgery, although it represents the most effective weight loss treatment, has its own risks and is associated with substantial costs and limited patient applicability. Endoscopic weight loss procedures are considered as the major breakthrough in the management of obesity. Endoluminal interventions performed entirely through the gastrointestinal tract have evolved as a result of an attempt to replicate some of the anatomical features and the physiological effects of the traditional weight loss surgery while being reversible, less invasive, and more cost-effective. Restrictive procedures act to decrease gastric volume by space-occupying devices and/or by suturing or stapling techniques that alter gastric anatomy, whereas malabsorptive procedures tend to create malabsorption by preventing food contact with the duodenum and proximal jejunum. Other procedures act by influencing gastric function (gastric botulinum injections, gastric pacing, and vagal nerve blocking) or by gastric aspiration. It is important to underline that the majority of endoscopic weight loss procedures are still being evaluated and are not yet available routinely. Even though some of the techniques and devices that have recently emerged have demonstrated promising short-term results, evidence on their safety and long-term efficacy from well-designed and well-conducted research should be given before they can become an inherent part of everyday clinical practice. Given the rapid development of endoscopic weight loss procedures, this review considers the current state and recent trends in endoscopic management of obesity.

Gastric electrical stimulation for obesity

Obesity is a growing health problem worldwide with a major impact on health and healthcare expenditures. Medical therapy in the form of diet and pharmacotherapy has limited effect on weight. Standard bariatric surgery is effective but is associated with morbidity and mortality, creating an unmet need for alternative therapies. One such therapy, the application of electrical stimulation to the stomach, has been studied extensively for the last two decades. Though pulse parameters differ between the various techniques used, the rationale behind this assumes that application of electrical current can interfere with gastric motor function or modulate afferent signaling to the brain or both. Initial studies led by industry failed to show an effect on body weight. However, more recently, there has been a renewed interest in this therapeutic modality with a number of concepts being evaluated in large human trials. If successful, this minimally invasive and low-risk intervention would be an important addition to the existing menu of therapies for obesity.

Role of endoscopy in the bariatric surgery of patients

Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett's esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.

A new endoscopically implantable device (SatiSphere) for treatment of obesity--efficacy, safety, and metabolic effects on glucose, insulin, and GLP-1 levels

BACKGROUND

The endoluminal mechanical device SatiSphere is a new endoscopically implantable device designed to delay transit time of nutrients through the duodenum. It consists of a 1-mm nitinol wire with pigtail ends and several mesh spheres mounted along its course, released in the duodenum and gastric antrum to conform to the duodenal C loop configuration and thereby self-anchor.

METHODS

The objective is to test the safety, efficacy, and effect on body weight in a 2:1 randomized study, as well as incretin secretion in a subgroup.

RESULTS

Of 31 included cases (11 men, mean age 42.9 years, mean BMI 41.3 kg/m2), 21 patients treated with endoscopic device insertion with scheduled device removal after 3 months were compared with 10 controls. In 10 of 21 patients, device migration occurred, in two cases necessitating emergency surgery, which led to termination of the trial. Weight loss after 3 months was 6.7, 4.6, and 2.2 kg in the groups completing therapy, all treatment cases using intention to treat (ITT) analysis and controls. Excess weight loss was significantly increased by endoluminal mechanical device insertion (18.4, 12.2, and 4.4% in completers, ITT analysis group and controls; p = 0.02 for completers vs. controls). Measuring glucose, insulin, and glucagon-like peptide 1 (GLP-1) following a mixed-meal test with the device in place and after removal (n = 7), the device delayed glucose absorption and insulin secretion and altered kinetics in GLP-1 levels.

CONCLUSIONS

The device might be short-term effective in reducing body weight, which might be mediated through alterations in incretin metabolism. However, frequent device migration necessitates device modifications.

[Intraluminal/endoscopic procedures in the treatment of obesity]

Few effective therapeutic tools are currently available to fight the increasing prevalence of obesity and its associated comorbidities. Bariatric surgery is the only treatment with proven long-term effectiveness, but is associated to a high surgical risk and significant economic costs because of its technical complexity and the characteristics of patients. This is leading to development of new endoscopic procedures with less clinical risks and economic costs, while maintaining the benefits in terms of morbidity and mortality, which could even serve as a bridging element before surgery in cases where this is unavoidable, allowing for preoperative weight loss and control of comorbidities in order to improve anesthetic risks and possible complications. The purpose of this review was to analyze the most relevant and promising endoscopic techniques currently available.

Bariatric procedures: an update on techniques, outcomes and complications

PURPOSE OF REVIEW

Obesity is a rising epidemic, and it is projected that over 700 million people will be obese by 2015. As the number of people with morbid obesity rises, so will the number of bariatric procedures performed. The goal of this article is to review current surgical and endoscopic options for weight loss in morbidly obese patients including their efficacy and complications.

RECENT FINDINGS

New bariatric surgical techniques have been developed with the goals of maximizing weight loss and metabolic outcomes, while minimizing complications. In addition, there is a role for therapeutic endoscopy in treating obesity as well as managing bariatric surgical complications. As the metabolic effects of bariatric surgery are better elucidated, bariatric surgeries may provide a role in treatment of metabolic syndrome in mildly obese individuals. For those with insufficient weight loss, revisional bariatric surgeries have been performed with varying success.

SUMMARY

Bariatric surgery is an effective treatment for obesity and its comorbidities. Several bariatric surgeries are available, and a multidisciplinary approach is recommended for choosing the best procedure for the appropriate candidate, along with providing long-term follow-up care to maximize outcome.

Role of the gastroenterologist in managing obesity

Obesity has become a major public health problem as a consequence of its prevalence, negative impact on morbidity, mortality and quality of life and its associated direct and indirect healthcare costs. The etiology of obesity is multifactorial and reflects complex interactions of genetic, neurohumoral, environmental, behavioral and possibly, microbial factors. Available treatments for obesity include diet and exercise, behavioral modification, medications and surgery. Gastroenterologists are becoming increasingly involved in the care of obese patients. Although much of this care has historically centered on the preoperative and postoperative care of the bariatric patient, gastroenterologists are also evaluating and managing a variety of gastrointestinal symptoms and disorders that occur more commonly among obese individuals and are increasingly involved in the primary treatment of obesity. In this review, the gastrointestinal symptoms and disorders that are associated with obesity will be reviewed, the gastrointestinal contribution to the pathogenesis of obesity will be described and the current treatment options of obesity and where the gastroenterologist typically plays a role in the management will be discussed.

Update on treatment strategies for obesity

Obesity is a disease that is defined as the accumulation of excessive amounts of body fat and is associated with increased risk of serious illness, disability, and death. In clinical practice, obesity is best assessed by calculating body mass index and measuring waist circumference. Treatment options are determined based on the body mass index, waist circumference, and adverse health consequences the patient is experiencing or is at an increased risk for facing in the future. Today, overweight and obesity impacts the majority of patients we treat in our clinical practices. Although endocrinologists are uniquely positioned to treat one of the major consequences of our current obesity epidemic, type 2 diabetes, we also need to be positioned and prepared to effectively treat one of its major causes-obesity. Type 2 diabetes and obesity are very much intertwined. Treatment of each disease affects the other. For these reasons, endocrinologists need to be experts in the treatment of obesity as well as diabetes. They should keep up with advances in obesity treatment including lifestyle, pharmaceutical, and surgical strategies. These strategies offer opportunities for improving the overall treatment for our obese patients today and will continue to improve and expand over the next decade.

Gastric electrical stimulation for the treatment of obesity: from entrainment to bezoars-a functional review

GROWING WORLDWIDE OBESITY EPIDEMIC HAS PROMPTED THE DEVELOPMENT OF TWO MAIN TREATMENT STREAMS: (a) conservative approaches and (b) invasive techniques. However, only invasive surgical methods have delivered significant and sustainable benefits. Therefore, contemporary research exploration has focused on the development of minimally invasive gastric manipulation methods featuring a safe but reliable and long-term sustainable weight loss effect similar to the one delivered by bariatric surgeries. This antiobesity approach is based on placing external devices in the stomach ranging from electrodes for gastric electrical stimulation to temporary intraluminal bezoars for gastric volume displacement for a predetermined amount of time. The present paper examines the evolution of these techniques from invasively implantable units to completely noninvasive patient-controllable implements, from a functional, rather than from the traditional, parametric point of view. Comparative discussion over the available pilot and clinical studies related to gastric electrical stimulation outlines the promises and the fallacies of this concept as a reliable alternative anti-obesity strategy.

Endoscopic approaches to obesity

Given the emerging role of endoscopic procedures in the treatment of obesity and rapid changes in endoscopic technologies and techniques, this review considers the current state of endoscopic management of obesity. Endoluminal interventions performed entirely through the GI tract by using flexible endoscopy offer the potential for an ambulatory weight loss procedure that may be safer and more cost- effective compared with current surgical approaches. Endoscopic techniques attempt to mimic the anatomic features of bariatric surgery. Accordingly, there are two main endoscopic weight loss modalities - restrictive and malabsorptive. Restrictive procedures act to decrease gastric volume by space-occupying prosthesis and/or by suturing or stapling devices, while malabsorptive procedures tend to create malabsorption by preventing food contact with the duodenum and proximal jejunum. The former include intragastric balloon treatment, endoluminal vertical gastroplasty, transoral gastroplasty and transoral endoscopic restrictive implant system, while the latter include duodenojejunal bypass sleeve. Gastroduodenojejunal bypass sleeve is a combination of both procedures. Except for intragastric balloon, all mentioned procedures are rather new, tested on a small number of human subjects, with a high rate of success, but with limited knowledge on safety and long-term efficacy. The role of gastric electrical stimulation and intragastric injections of botulinum toxin in obesity treatment is also considered as is the role of minimally invasive bariatric endoscopic interventions.