Endoscopic Weight Loss Procedures: Innovation in the Treatment of Patients with Obesity
By Jennifer Phan MD, Medical Director at the Hoag Irvine Advanced Endoscopy Center and Director of Bariatric Endoscopy, Irvine, CA
There is a current obesity epidemic in America, with rising rates of obesity seen across all populations and all states. The National Institute of Health (NIH) predicts that by 2030, nearly half of adults will be obese and roughly one in four adults will have severe obesity. The gold standard for obesity treatment is bariatric surgery, with decades worth of data demonstrating not only effective weight loss but also reduction in multiple obesity-related comorbid conditions such as liver disease and cardiovascular disease. However, only 1% of eligible patients will undergo surgery, likely due to fear of surgery itself. The anti-obesity medications, largely the GLP-1s, have revolutionized the treatment options for patients with obesity. The limitations primarily center on the need for lifelong GLP-1 medication use for weight control, with significant weight regain occurring if they are discontinued. With this in mind, studies have shown that roughly 20% of patients will discontinue their medications after one year due to cost, loss of insurance coverage, side effects, or personal choice.
The pace of endoscopic advancement is staggering in the field of weight loss and metabolic therapy. Treating patients with obesity will require multidisciplinary collaboration and innovation, and the field of gastroenterology is poised to play a key role.
Another option has been a game-changer in the treatment options for obesity – the use of endoscopy to bridge the gap between surgery and medications. This technique maximizes on what can be done through the mouth using just a thin flexible endoscope. A novel minimally invasive procedure called the endoscopic sleeve gastroplasty (ESG), uses the endoscope with a suturing platform at the tip to tighten the stomach to 30% of its original volume. The stomach is sutured into a “sleeve-like” shape, resulting in slow stomach motility and the feeling of being full faster. Patients, on average, can lose around 18-20% of their original body weight in 6-12 months, with improvements seen in obesity-related comorbidities such as hypertension and diabetes. This procedure involves no incisions, is typically performed as an outpatient procedure, and has a quick recovery time of 2-3 days. It is an option that allows for a definitive weight loss procedure while circumventing the fears of surgery. Multiple cost-benefit analyses have shown that ESG is more cost-effective than semaglutide within just two years of procedure, making this innovation a great option for patients.
This endoscopic approach to weight loss is also available for patients who experience weight regain after bariatric surgery. For instance, in patients who underwent prior gastric bypass and then experienced weight regain, the endoscope can be advanced to the stomach pouch. Then, the surgical connection between the stomach and the small intestine can be retightened through suturing. This procedure is called a transoral outlet reduction (TORE). Patients can lose anywhere from 8-10% of their body weight in 6 months from this single thirty-minute outpatient procedure. If patients experience weight regain following a sleeve gastrectomy where a part of their stomach is surgically removed, then retightening of the stomach can be performed through endoscopy via a similar iteration to the ESG (revision ESG).
Despite the randomized clinical trials and long-term outcome data for these endoscopic weight loss procedures, the large limiting factor to widespread adoption is insurance coverage. Currently, very few private insurers will consider coverage for endoscopic therapies despite the wide interest from patients and the gaping need for less invasive procedures. There has been momentum pushes from both GI societies and industry for coverage and universal clinical application in the hopes that these procedures become part of standardized care.
Although coverage is a limitation, there continues to be constant and fast-paced innovation within the endoscopic space for weight loss. This stems from the urgency to innovate, given the rising population of patients with obesity. New endoscopic suturing platforms have been created in the past few years, and endoscopic robotic systems are currently on the horizon. The gastrointestinal tract is also a current target for treating type 2 diabetes (T2DM). A specific portion of the small intestine, called the duodenum, is diseased in T2DM, leading to sugar and hormonal imbalances. Three current technologies exist to revitalize the diseased duodenum through either radiofrequency ablation or burning, pulse electrical field ablation, or vapor therapy. Although studies are in their infancy, initial results suggest significant improvement in patient hemoglobin A1C levels after a single treatment. This may become a revolutionary technology for T2DM patients.
The pace of endoscopic advancement is staggering in the field of weight loss and metabolic therapy. Treating patients with obesity will require multidisciplinary collaboration and innovation, and the field of gastroenterology is poised to play a key role.