Endoscopic sleeve gastroplasty is an effective and safe minimally invasive approach for treatment of obesity: First Indian experience

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.

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.

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.

Four-year outcomes for endoscopic sleeve gastroplasty from a single centre in India

Background

Bariatric endoscopy has emerged for non-surgical treatment of obesity, providing a treatment option for weight loss and associated comorbidities. Outcomes of endoscopic sleeve gastroplasty (ESG) of 12 months have been published by our team and there is a need for longer follow-up period understanding the effects of ESG techniques.

Aim

This report emphasises on weight loss pattern in follow-up time points and monitors the post-procedure improvement in comorbidities with minimum 4-year follow-up of patients undergoing ESG at a single academic centre in India.

Subjects and Methods

This was a prospective cohort study. All procedures were performed by the same surgeon. Patients with a body mass index of >30 kg/m² (or >27 with comorbidities) underwent ESG for treatment of obesity. Patients were systematically followed yearly after their procedure. Data collected on the primary outcome and secondary outcomes were analysed and presented.

Results

612 patients (69.3% female) with a mean age of 40.70 ± 12.66 years and mean body mass index of 34.30 ± 5.05 kg/m² underwent ESG. Out of 612 patients, follow-up rates for a 1-2-3 and 4 years were 93.1%, 90.2%, 81.7% and 81.9%, respectively. The mean percentage total body weight loss was 18.19% (95% confidence interval [CI]: 17.72-18.57) and %EWL was 49.30% (95% CI: 48.91-49.68) with 90% of participants-maintaining a percentage of total weight loss of ≥5% and 70% of patients maintaining an EWL of ≥25% at 4 years, respectively. Resolution/improvement of comorbidities was 51.2% cases of T2DM, 65.8% cases of hypertension, 73.6% cases of dyslipidaemia and 89.9% remission were in obstructive sleep apnoea. No patient required an emergency intervention, and there was no mortality or significant morbidity.

Conclusions

This study shows acceptable results with ESG at 4 years in our unit. Regular monitoring by a multidisciplinary nurtures weight loss, resolution or improvement of comorbidities and improvement of quality of life with low perioperative complications. There is a need for more reports with this approach to determine the amount and duration of weight loss outcome and medical intervention.

The Attitude of Practitioners Towards Endoscopic Sleeve Gastroplasty

BACKGROUND AND AIM

Despite widespread adoption and encouraging results seen over the last 5 years, no consensus exists regarding the endoscopic sleeve gastroplasty (ESG) technique, training, or preprocedure and postprocedure management of the patient. The aim of our survey was to assess practice trends and preferences of bariatric endoscopists with respect to ESG.

METHODS

Using a digital platform, we conducted a worldwide survey by emailing a link with an electronic questionnaire to 1200 bariatric endoscopists trained to perform endoscopic suturing using the Apollo Overstitch suturing device (Apollo Endosurgery).

RESULTS

We received 221 responses that were included in the analysis. Fifty-one responders (36.4%) required 1 to 10 procedures, and 37 (26.4%) needed 11 to 20 procedures to become proficient at ESG. Ninety-six (68.6%) stated that lower body mass index thresholds should be adopted for Asian and Arab patients. There was no consensus on the ideal number of sutures, with 45 (32.1%), 42 (30%), 36 (25.7%), 13 (9.3%), and 4 (2.9%) recommending 4 to 6, 5 to 7, 6 to 8, 7 to 9, and 8 to 12 sutures, respectively. The primary barriers to establishing an endobariatric program were the inability to establish a cash pay model, 77 (95.1%); lack of institutional support, 61 (75.3%); and difficulty in establishing an ambulatory surgical center/hospital to perform ESG, 73 (90.1%).

CONCLUSIONS

ESG practice trends remain heterogenous among practitioners in regard to indication, technique, and preprocedure and postprocedure management. Specific ESG guidelines are warranted, and this survey will assist in providing the framework for these guidelines to be written.

Outcomes of Endoscopic Sleeve Gastroplasty in the Elder Population

Purpose

With the aging of the population and the epidemic spread of obesity, the frequency of older individuals with obesity is steadily growing. To date, no data evaluating the use of endoscopic sleeve gastroplasty (ESG) in the elderly have been published. In this case series, we evaluate the short- and medium-term outcomes of ESG in patients with obesity aged 65 years and older.

Materials and Methods

A retrospective analysis was done on a prospective database; patients aged 65 years and older were included in our analysis. EWL%, TBWL%, the Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire, and the presence of comorbidities were assessed.

Results

Eighteen patients aged 65 years and older underwent ESG between November 2017 and July 2021. The median age was 67 years and the mean baseline BMI was 41.2 kg/m². After ESG, the median TBWL% was 15.1%, 15.5%, and 15.5% at 6, 12, and 24 months, while the median %EWL was 39%, 37%, and 41% at 6, 12, and 24 months, respectively. The median BAROS score was 3.0, 3.4, and 2.5 at 6, 12, and 24 months, respectively. Six out of twelve patients with hypertension and 3/4 diabetic patients reduced or removed their medications within 12 months following ESG. Two out of six patients with OSA stopped therapy with CPAP. No adverse events were recorded.

Conclusion

According to our experience, ESG is a promising therapeutic option for elder individuals with obesity who fail non-invasive methods, and who refuse or are deemed not suitable for bariatric surgery because of age and comorbidities.

Graphical abstract

Endoscopic sleeve gastroplasty

Since its first description in 2013, robust evidence supporting the efficacy and safety of the endoscopic sleeve gastroplasty (ESG) has been on the rise. A large case series and meta-analysis report supported results up to 24 months, while some other studies already described 5-year data. If associated with pharmacotherapy, the ESG may help one to achieve weight loss similar to that of surgical sleeve gastrectomy. Though the results of the ongoing randomized trials on ESG are awaited, currently available data support the clinical use of the ESG, especially for patients who are refusing or unfit for bariatric surgery.

OverStitch Sx Endoscopic suturing system in minimally invasive endoscopic procedures: overview of its safety and efficacy and comparison to oversticthTM

INTRODUCTION

OverStitch endoscopic suturing enables advanced closure by tissue approximation via endoscopically placed sutures with the ability to customize suture patterns. Newer OverStitch generation also known as OverStitch Sx overcame the limitation of the previous generation and is compatible with 20 single channel scopes over four platforms with greater maneuverability and visibility.

AREAS COVERED

In this article we will focus on the differences between three generations of OverStitch. In addition, we will review existing literature on the efficacy of OverStitch in the management of full thickness defect closure, fistula and leaks repair, stent fixation, and bariatric surgeries along with its complications and limitations.

EXPERT OPINION

Assembling overstitch takes less than five minutes and the correct sequence of system assembly is the key for a successful procedure. Transition from the second-generation OverStitch to OverStitch Sx may require three to five cases for learning curve.

Safety and early efficacy of endoscopic sleeve gastroplasty (ESG) for obesity in a multi-ethnic Asian population in Singapore

Background and Aim

Endoscopic sleeve gastroplasty (ESG) is an alternative nonsurgical treatment option for obesity. However, most studies on the utility and efficacy of ESG are derived from the Western population. It is unknown if ESG elicits similar results in Asians with different fat distribution, sociocultural customs, and dietary practices. Our study aims to assess the safety and efficacy of ESG among a multi-ethnic Asian population.

Methods

We reviewed 35 patient records who underwent primary ESG for obesity at our unit. We followed a U-shaped suture pattern. Our primary outcome was to assess technical feasibility and safety. The secondary outcome was to determine the percentage total body weight loss (TBWL) at the last follow-up.

Results

The mean ± SD age and body mass index were 43.6 ± 11.3 years and 34 ± 4.9 kg/m², respectively. The majority were female (57%) and of Chinese ethnicity (51%). The procedure was technically successful in all patients. We used an average of five sutures (range, 4-7), and the mean ± SD procedure time was 65 ± 10 min. No major complications occurred, and the average length of stay was 1 day. Twenty-one patients completed 3 months of follow-up, and 10 patients 6 months. The mean ± SD TBWL at 3 and 6 months were 14.5 ± 4.8% and 16.2 ± 4.9%, respectively. We observed improvement in diabetes mellitus (87%), fatty liver (86%), and hypertension (58%) during the follow-up.

Conclusion

ESG is a safe and effective option for promoting weight loss in a multi-ethnic Asian population. ESG-induced weight loss may improve obesity-related comorbidities.

Personalized Approach for Obese Patients Undergoing Endoscopic Sleeve Gastroplasty

Obesity is a chronic, relapsing disease representing a major global health problem in the 21st century. Several etiologic factors are involved in its pathogenesis, including a Western hypercaloric diet, sedentariness, metabolic imbalances, genetics, and gut microbiota modification. Lifestyle modifications and drugs often fail to obtain an adequate and sustained weight loss. To date, bariatric surgery (BS) is the most effective treatment, but only about 1% of eligible patients undergo BS, partly because of its negligible morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, endoscopic, bariatric procedure, which proved to be safe and effective. In this review, we aim to examine evidence supporting the role of a personalized and multidisciplinary approach, guided by a multidisciplinary team (MDT), for obese patients undergoing ESG, from patient selection to long-term follow-up. The cooperation of different health professionals, including an endocrinologist and/or obesity medicine physician, a bariatric surgeon, an endoscopist experienced in bariatrics, a registered dietitian, an exercise specialist, a behaviour coach, a psychologist, and a nurse or physician extender, aims to induce radical and sustained lifestyle changes. We also discussed the relationship between gut microbiota and outcomes after bariatric procedures, speculating that the characterization of gut microbiota before and after ESG may help develop new tools, including probiotics, to optimize weight loss outcomes.

Endoscopic Procedures for Weight Loss

PURPOSE OF REVIEW

To provide updated evidence on the endoscopic procedures for weight loss and to bring personal insights on the future of endobariatrics.

RECENT FINDINGS

Intragastric balloons promote significant improvement in histologic and radiologic aspects of non-alcoholic steatohepatitis; the endoscopic sleeve gastroplasty is effective up to 5 years and seems particularly beneficial to patients with BMI≤40kg/m²; distal POSE is a promising technique but still lacks adequate clinical data; aspiration therapy triggers remarkable weight loss, but data on weight trends after removal of the device are still lacking; the satiety-inducing device, the sleeveballoon, the gastric mucosal devitalization, and the endoscopic magnetic partial jejunal diversion are promising procedures still under study and refinements. Several therapeutic options are necessary during obesity's natural history. Therefore, endobariatrics should act in harmony with lifestyle interventions, diet modification, psychological treatment, pharmacotherapy, and bariatric surgery seeking the best outcome in the long term.

Systematic Review of Innovation Reporting in Endoscopic Sleeve Gastroplasty

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a novel endoscopic procedure used to treat obesity-related comorbidities. Whilst its use is increasing in clinical practice, there is comparatively little understanding about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of ESG in the context of guidelines for evaluating innovative surgical devices and procedures.

METHODS

Systematic searches were used to identify all published studies reporting ESG insertion. Data collected included patient selection, governance arrangements, proceduralist expertise, technique description and outcome reporting.

RESULTS

Searches identified 2289 abstracts; 37 full-text papers were included (one prospective comparative cohort study, 16 retrospective cohort studies, 17 prospective cohort studies and three case reports). No randomized trials were identified. Eighteen studies were conducted prospectively. The number of patients in the included studies ranged from 1 to 1000. The lower BMI limit ranged from 27 to 35 kg/m². Research approvals were reported in 26 studies. Two studies reported on the learning curve. All studies reported some aspect of technical implementation, but many variations were noted. Suturing device used and suture pattern were the most commonly reported aspects (32 studies). Follow-up ranged from 1 to 24 months, but was 12 months or less in 28 studies. Forty-eight different outcomes were reported across all studies.

CONCLUSION

The literature on ESG has demonstrated some progression in reporting and analysis and the next stage of assessment should be a randomized controlled trial to demonstrate efficacy.

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.

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.

Laparoscopic sleeve gastrectomy versus endoscopic sleeve gastroplasty: a systematic review and meta-analysis

Background and study aims  Laparoscopic sleeve gastrectomy (LSG) is the current standard for bariatric surgery, but it is affected by several postoperative complications. Endoscopic sleeve gastroplasty (ESG) was created as a less invasive alternative to LSG. However, its efficacy and safety compared with LSG is unclear. Materials and methods  Relevant publications were identified in MEDLINE/Cochrane/EMBASE/OVID/ PROSPERO and NIH up to January 2020. Studies were selected that included obese patients with a baseline body mass index (BMI) between 30 and 40 kg/m² with a minimum of 12 months of follow-up and with reported incidence of complications. The mean difference in percentage of excess weight loss (%EWL) at 12 months between LSG and ESG represented the primary endpoint. We also assessed the difference in pooled rate of adverse events. The quality of the studies and heterogeneity among them was analyzed. Results  Sixteen studies were selected for a total of 2188 patients (LSG: 1429; ESG: 759) with a mean BMI 34.34 and 34.72 kg/m² for LSG and ESG, respectively. Mean %EWL was 80.32 % (± 12.20; 95 % CI; P  = 0.001; I² = 98.88) and 62.20 % (± 4.38; 95 % CI; P  = 0.005; I² = 65.52) for the LSG and ESG groups, respectively, corresponding to an absolute difference of 18.12 % (± 0.89; 95 % CI, P  = 0.0001). The difference in terms of mean rate of adverse events was 0.19 % (± 0.37; 95 %CI; χ ²  = 1.602; P  = 0.2056). Conclusions  Our analysis showed a moderate superiority of LSG versus ESG. No difference in terms of safety was shown between the two groups. ESG is a less-invasive, repeatable and reversable and acceptable option for mild-moderate obese patients.

Intragastric Balloon Versus Endoscopic Sleeve Gastroplasty for the Treatment of Obesity: a Systematic Review and Meta-analysis

BACKGROUND

We aimed to individually evaluate IGB and ESG procedures and compare the efficacy, durability, and safety of these procedures.

METHODS

Bibliographic databases were systematically searched for studies investigating the use of IGB and ESG for the treatment of obesity. Studies reporting percent total weight loss (%TWL) or percent excess weight loss (%EWL) with at least 12 months of follow-up were included.

RESULTS

A total of 28 studies were included in the final analysis. Only 1 study directly compared ESG to IGB, 9 studies evaluated ESG alone, while 18 studies evaluated IGB. At 12-month follow-up after ESG, mean %TWL was 17.51 (95% CI 16.44-18.58), and %EWL was 60.51 (95% CI 54.39-66.64). Mean %TWL and %EWL after IGB at 12 months was 10.35 (95% CI 8.38-12.32) and 29.65 (95% CI 25.40-33.91), respectively. Mean %TWL and %EWL after IGB were significantly decreased at 18 or 24 months compared to 6 months indicating weight regain after IGB removal. ESG achieved significantly superior weight loss compared to IGB, the difference in mean %TWL was 7.33 (95% CI 5.22-9.44, p value = 0.0001) at 12 months. Serious adverse events were observed in < 5% for both procedures.

CONCLUSION

Although ESG and IGB are safe and effective for weight loss, our study suggests that ESG results in more significant and sustained weight loss. Nevertheless, a variety of approaches are essential to care for this underserved population, and there are several factors other than weight loss that should be considered in selecting the ideal therapy for individual patients.

Efficacy and Safety of Endoscopic Sleeve Gastroplasty at Mid Term in the Management of Overweight and Obese Patients: a Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) has emerged as a promising technique in endoscopic bariatric and metabolic therapies (EBMTs). We aimed to perform a systematic review and meta-analysis to provide an update on its efficacy and safety.

METHODS

This is a systematic review and meta-analysis was performed following the PRISMA guidelines. MEDLINE, Cochrane, EMBASE, and LILACS were searched to identify the studies related to ESG.

RESULTS

Eleven studies with a total of 2170 patients were included. The average BMI pre-ESG was 35.78 kg/m2. Pooled mean %TWL observed at 6, 12, and 18 months was 15.3%, 16.1%, and 16.8% respectively. Pooled mean %EWL at 6, 12, and 18 months was 55.8%, 60%, and 73% respectively. No procedure-related mortality was reported.

CONCLUSION

ESG is a safe and effective procedure for primary obesity therapy with promising short- and mid-term results.

Outcomes of endoscopic sleeve gastroplasty; how does it compare to laparoscopic sleeve gastrectomy? A systematic review and meta-analysis

Background and study aims Endoscopic sleeve gastroplasty (ESG) is a novel moderately invasive technique in endo-bariatrics as compared to laparoscopic sleeve gastrectomy (LSG). Data is limited as to its efficacy and safety.

Methods We searched multiple databases from inception through August 2019 to identify studies that reported on ESG in the treatment of obesity. Our goals were to calculate the pooled rates of total weight loss (%TWL), excess weight loss (%EWL), and body mass index (BMI) at 1 month, 6 months, and 12 months with ESG. We included studies that reported on LSG, in a similar time frame as ESG, and compared the 12-month outcomes.

Results From eight studies on ESG (1815 patients), the pooled rates of %TWL at 1 month, 6 months, and 12 months were 8.7 (7.2–10.2), 15.3 (14.1–16.6) and 17.1 (15.1–19.1), respectively. The pooled rates of %EWL at 1 month, 6 months, and 12 months were 31.7 (29.3–34.1), 59.4 (57–61.8) and 63 (51.3–74.6), respectively. The pooled rates of BMI at 1 m, 6 m, and 12 m were 32.6 (31–34.3), 30.4 (29–31.8) and 30 (27.7–32.3, I2 = 97), respectively. At 12 months, the pooled %TWL, %EWL and BMI with LSG (7 studies, 2179 patients) were 30.5 (27.4–33.5), 69.3 (60.1–78.4) and 29.3 (27.1–31.4) respectively. On comparison analysis, %TWL with LSG was superior to ESG (P = 0.001). %EWL and BMI were comparable. All adverse events, bleeding and gastro-esophageal reflux disease were significantly lower with ESG when compared to LSG.

Conclusion ESG demonstrates acceptable weight loss parameters and seems to have a better safety profile when compared to LSG.