For individuals seeking assistance with weight loss who are not candidates for or prefer to avoid bariatric surgery, endoscopic weight loss procedures offer minimally invasive alternatives. These procedures, performed using a thin, flexible tube with a camera called an endoscope, can achieve greater weight loss than medication alone, although typically less than traditional bariatric surgery.
Understanding Endoscopic Weight Loss Procedures
Endoscopy involves inserting a thin, flexible tube with a light and camera at its tip into the body through a small opening, such as the mouth, to reach the stomach and small bowel. This allows doctors to view internal organs and perform procedures without major incisions. Endoscopic weight loss procedures require specialized gastroenterologists and surgeons with advanced training in GI endoscopy.
Like all weight loss interventions, lifestyle changes are crucial for the success of nonsurgical weight loss options. A bariatric team typically evaluates a patient's condition and commitment to adopting these changes.
Types of Endoscopic Weight Loss Procedures
Several types of endoscopic weight loss procedures are available, each with its own unique approach and benefits.
Gastric Balloon
The gastric balloon is a temporary procedure suitable for adults with a BMI between 30 and 40. After administering a mild sedative, a doctor inserts a soft, durable balloon into the stomach using an endoscope passed through the mouth. The balloon is then filled with a saline solution to occupy space in the stomach, promoting a feeling of fullness and reducing food intake. The gastric balloon is typically removed after six months. Rapid weight loss often occurs during the first four months after placement. However, in the initial days following placement, patients may experience abdominal pain, nausea, and vomiting. There are three Food and Drug Administration-approved (FDA-approved) balloons: the Orbera (Apollo Endosurgery Inc, Austin, TX, USA), the Obalon (Obalon Therapeutics, Carlsbad, CA, USA), and the Reshape DuoTM.
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Orbera: The Orbera is a liquid-filled 6-month or 12-month indwelling device and is most employed IGB worldwide. It has been marketed for more than 20 years in numerous countries and continents. Twenty-one patients were enrolled and received preprocedural and postintervention liver biopsies and magnetic resonance elastography (MRE). Non-alcoholic fatty liver disease score (NAS) improved in 90% of patients. Fibrosis improved in 50% of individuals in MRE and 15% of histologic specimens. Mean serum liver enzymes also decreased significantly. Intriguingly, total body weight loss (TBWL) did not correlate with reductions in NAS and fibrosis. Beyond organic improvement, Gadd et al. evaluated the impact of IGB treatment on mental health and quality of life. Pooling 9 different studies via meta-analysis with a total sample of 371 patients, the authors demonstrated a considerable improvement in the postprocedural quality of life.
Endoscopic Sleeve Gastroplasty (ESG)
Endoscopic sleeve gastroplasty (ESG) is a newer, minimally invasive weight-loss procedure suitable for individuals with a BMI greater than 30. During ESG, folds are stitched into the stomach to reduce its size by approximately 70%. This restriction limits the amount of food and drink a person can consume, leading to a feeling of fullness sooner. No part of the stomach is cut or removed; only stitches hold the folds in place. While the procedure can be reversed, scar tissue may remain. Studies indicate that approximately 60% of people lose about 20% of their total body weight during the first year after surgery.
ESG Technique Refinements: Since the first description in 2013, the ESG technique suffered several technical refinements. That includes using the helix to grasp tissue, per protocol CO2 insufflation, increasing the number of bites per suture (from 6 up to 12), and adding reinforcement sutures in between the first suturing line. With the current technique, the ESG has been proven reproducible and safe worldwide, not only in academic centers but also in community health units. Interestingly, although some authors recently described improved outcomes employing different suturing patterns, other data suggest that weight loss outcomes are unrelated to the suture pattern. Still concerning technical refinements, Itani et al. proposed association with argon plasma coagulation to enhance fibrosis in the plication line, resulting in a superior sleeve-like lumen. Albeit clinical data are lacking, the rationale seems appropriate as adequate endoscopic anatomy correlates with better outcomes during follow-up.
Several systematic reviews assessing the efficacy of the ESG were published in 2020. ESG is effective in the short-term and promotes average %TBWL up to 20% at 24 months. From a series of 216 patients, 38 were eligible for a 5-year follow-up assessment. Among them, 18% were lost to follow-up. The remaining individuals presented a mean %total body weight loss (%TBWL) of 15.9% (95% CI, 11.7-20.5). Sixty-one percent of patients sustained at least 10% TBWL at 5 years. At 12 and 24 months, the mean %TBWL was 16.2% ± 8.3% and 13.7% ± 8.0%, respectively. Another recent article assessed the impact of adjunct pharmacotherapy with liraglutide. This glucagon-like peptide-1 agonist amplifies insulin secretion, delays gastric emptying, and upregulates satiety by a central effect on the hypothalamus In an international cohort study, Badurdeen et al. employed a propensity score analysis to match 26 patients receiving GLP-1 at month 5 after ESG to 26 individuals declining it. At 12 months (7 months after introducing pharmacotherapy), patients from the GLP-1 group presented superior weight loss and greater reduction in percent body fat . This study is of paramount importance as it proves synergism between endoscopic and pharmacological approaches.
Transoral Outlet Reduction (TORe)
Transoral Outlet Reduction (TORe) is a minimally invasive procedure designed for individuals who have regained weight after gastric bypass surgery. Using an endoscope, the procedure reduces the size of the gastric outlet-the opening between the stomach pouch and small intestine-to slow stomach emptying and enhance feelings of fullness. During the procedure, the doctor decreases the size of the opening between the gastric pouch (created during the bypass) and the small intestine. To access the area, they pass an endoscope through the mouth and then stitch (suture) the bypass opening to make it smaller.
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Endoscopic Gastric Plication (Distal POSE)
This procedure uses an endoscope with a plication device to fold the stomach in on itself to make the stomach smaller and shorter.
Aspiration Therapy
This procedure involves placing a small tube in your stomach that connects to a port (device) placed in your abdomen. Using this system, you can remove a portion of your meals through the tube shortly after you eat.
Restorative Obesity Surgery, Endoluminal (ROSE)
This procedure is for people who’ve already had gastric bypass surgery but regained weight. This can happen if there is a stretching of the outlet, which is where your stomach and small intestine meet.
Argon Plasma Coagulation (APC)
This procedure is for people who’ve already had gastric bypass surgery but regained weight. A laser-like beam is applied around the outlet, which is where your stomach and small intestine meet, to shrink its size.
Sleeve in Sleeve (SIS)
This procedure is for people who’ve already had surgical sleeve gastrectomy but regained weight. This can happen if the sleeve becomes more dilated.
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Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
BPD/DS is a more complex procedure involving two steps. First, a portion of the stomach is removed to create a smaller stomach pouch similar to a sleeve gastrectomy. Then, a significant portion of the small intestine is bypassed to reduce the absorption of calories and nutrients. This procedure results in significant weight loss and is particularly effective for individuals with a very high BMI or severe obesity-related health conditions.The smaller stomach, shaped like a banana, allows patients to eat less food. The food stream bypasses roughly 75% of the small intestine, the most of any commonly performed approved procedures. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after surgery. Even more than gastric bypass and sleeve gastrectomy, the BPD-DS affects intestinal hormones in a manner that reduces hunger, increases fullness and improves blood sugar control.
Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S)
The Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy, referred to as the SADI-S is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. A loop of intestine is measured several feet from its end and is then connected to the stomach. When the patient eats, food goes through the pouch and directly into the latter portion of the small intestine. The food then mixes with digestive juices from the first part of the small intestine. This allows enough absorption of vitamins and minerals to maintain healthy levels of nutrition.
Adjustable Gastric Band
The Adjustable Gastric Band is a device made of silicone that is placed around the top part of the stomach to limit the amount of food a person can eat. It has been available in the United States since 2001. The impact on obesity related diseases and long-term weight loss is less than with other procedures. The feeling of fullness depends upon the size of the opening between the pouch and the rest of the stomach. The opening size can be adjusted with fluid injections through a port underneath the skin. Food goes through the stomach normally but is limited by the smaller opening of the band.
Primary Obesity Surgery Endoluminal (POSE)
The primary obesity surgery endoluminal (POSE) involves the employment of the Incisionless Operating Platform (IOP) (USGI Medical, San Clemente, CA, USA). The IOP is a 4-component device that allows endoscopic control of a full-thi
Revisional Procedures
There are times when people have trouble reaching their weight loss goals -- or even gain weight -- after gastric bypass, because of stretching that may occur at the connection between the stomach and small intestine, also known as gastrojejunostomy. In this case, an endoscopic gastric bypass revision may be recommended.
Revisional ESG (r-ESG)
An r-ESGis done when a patient has either regained weight or lost insufficient weight after a previous ESG or surgical sleeve gastroplasty. The doctor may remove stitches and create a new pattern of sutures.
Comparing Endoscopic Procedures to Bariatric Surgery
Endoscopic weight loss procedures offer several advantages over traditional bariatric surgery, including being minimally invasive with no external incisions, resulting in a faster recovery and the ability to return home the same day.
However, it’s important to have realistic expectations. In terms of expected weight loss, patients can expect to lose about 50% of their excess weight with endoscopic procedures, as compared to about 60% with traditional surgery. Major complications with endoscopic procedures are very rare (less than 1%), whereas the rate can be higher for traditional surgeries.
Risks and Considerations
While endoscopic weight loss procedures are generally safe, potential risks and side effects exist. Common side effects include abdominal pain, nausea, and sore throat, which typically subside within a few days. More serious complications are rare but can include gastric and esophageal perforations and small bowel obstruction.
It is also possible to not lose enough weight or to regain weight after any type of weight-loss procedure, even if the procedure itself works correctly. This weight gain can happen if you don't follow the recommended lifestyle changes.
Preparing for Bariatric Endoscopy
Before undergoing bariatric endoscopy, patients may meet with multiple specialists, including a dietician to discuss dietary restrictions, and a psychologist to ensure mental preparedness for lifestyle changes. Your doctor will also review your medications and confirm your readiness for the procedure. Afterwards, a special bariatric diet is required for a few weeks, starting with liquids only during the first week.
The Importance of a Comprehensive Approach
Successful weight loss, regardless of the method, requires a comprehensive approach that includes commitment to nutrition, physical activity, emotional health, and resilience. A team-based approach involving a surgeon, dietitian, psychologist, nurse case manager, and obesity medicine specialist is essential for guiding patients through each step of the journey. Continued healthy eating, regular physical activity, adherence to appointments with obesity medicine providers, and taking prescribed vitamins and mineral supplements are crucial for long-term success.