Making a U-turn at the stomach

Abstract

Our world is amidst a crucial overweight and obesity pandemic that continues to grow, with 2 billion of the world’s population overweight and approximately 700 million adults with obesity.1https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweightDate accessed: July 2, 2019Google Scholar Once thought to be a disease of the rich and affluent, weight-related and metabolic diseases are on the rise across all socioeconomic classes and residential settings. The enduring physiologic and hormonal changes that occur with weight gain make sustainable weight loss with just diet and exercise, commonly known as lifestyle modification, not feasible for most people. Thus, more intense and invasive interventions are required, and until recently, bariatric surgery was the only option for many people desiring significant weight loss. Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass are the 2 most common surgical procedures performed worldwide. However, as pointed out in numerous prior discussions, fewer than 2% of people eligible for bariatric surgery will ever undergo these operations.2www.asmbs.org/resources/access-to-care-fact-sheetDate accessed: July 2, 2019Google Scholar The reasons are multifactorial and are related to fear of bariatric surgery and its nonnegligible morbidity and albeit very small mortality, the perception of some of these procedures being “irreversible,” and the lack of insurance coverage if there are not enough coexisting obesity-related conditions. Fortunately, we now have nonsurgical, incisionless, less invasive options for the management of obesity. Over the past 5 years, endoscopic bariatric therapies (EBTs) have blossomed into the mainstream and are becoming increasingly implemented in clinical practice across weight management programs and gastroenterologic and surgical clinics worldwide. EBTs are here to stay and are more present than ever! One EBT that has taken off with increasing popularity is the endoscopic sleeve gastroplasty (ESG), a primary gastric EBT that involves remodeling of the stomach by placing full-thickness sutures along the body of the stomach, thus reducing the volume of the stomach, which results in early satiety, reduced caloric intake, and subsequent weight loss. Previous studies have shown that ESG results in delayed gastric emptying, further promoting the weight loss effects through enhancing early satiety.3Abu Dayyeh B.K. Acosta A. Camilleri M. et al.Endoscopic sleeve gastroplasty alters gastric physiology and induces loss of body weight in obese individuals.Clin Gastroenterol Hepatol. 2017; 15: 37-43Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Published data on the ESG experience around the world are quickly growing, all demonstrating good weight loss outcomes in the first 2 years.4Storm A.C. Abu Dayyeh B.K. Endoscopic sleeve gastroplasty for obesity: defining the risk and reward after more than 1600 procedures.Gastrointest Endosc. 2019; 89: 1139-1140Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar However, although ESG has taken off around the world, there is significant heterogeneity about how ESG is performed and its implementation in practice. Suture patterns vary, reinforcing sutures are not always placed, and until more recently, the gastric fundus was also being plicated—a practice that has fallen out of favor owing to the increased risk of leaks and formation of perigastric fluid collections. In the current issue of Gastrointestinal Endoscopy, Barrichello and colleagues5Barrichello S. Hourneaux de Moura D.T. Hourneaux de Moura E.G. et al.Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study.Gastrointest Endosc. 2019; 90: 770-780Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar report their study, “Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study.” The study adds important observations to the field of bariatrics and also then leaves the audience with a few provocative questions. This multicenter retrospective study included 193 patients, the majority of them women in their fifth decade of life and with obesity, who underwent ESG. Data were collected from 7 centers, 6 from Brazil and 1 from the United States, with varying levels of expertise and experience with endoscopic suturing and ESG. All procedures were performed by the use of a “U” stitch pattern without a reinforcing layer. All patients lost weight, with significant reductions in body mass index (BMI) at both 6 months and 12 months. The average percentage total body weight loss (%TWL) was 14.25% at 6 months and 15.06% at the 1-year follow-up visit. Five significant adverse events occurred in the postprocedure period, all managed accordingly, and no deaths occurred. The overall outcome of this study is very positive and encouraging, and it also parallels what prior studies have shown. Lopez-Nava et al6Lopez-Nava G. Sharaiha R.Z. Vargas E.J. et al.Endoscopic sleeve gastroplasty for obesity: a multicenter study of 248 patients with 24 months follow-up.Obes Surg. 2017; 27: 2649-2655Crossref PubMed Scopus (132) Google Scholar first published a large retrospective study of 248 patients who underwent ESG at 3 centers of ESG expertise, demonstrating the safety and efficacy of the procedure, with %TWL outcomes of 15.17% at 6 months and 18.6% at 24 months. Similarly, 5 significant adverse events occurred, all managed accordingly. Most recently, Alqahtani et al7Alqahtani A. Al-Darwish A. Mahmoud A.E. et al.Short-term outcomes of endoscopic sleeve gastroplasty in 1000 consecutive patients.Gastrointest Endosc. 2019; 89: 1132-1138Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar also demonstrated similar weight loss outcomes in the first 1000 (that is correct: one thousand!) patients who underwent ESG at a single center, also demonstrating robust %TWL of 13.7% at 6 months and 15% at 12 months. Clearly, ESG, no matter in which country performed, results in similar weight loss. However, the majority of these published studies come from centers with significant endoscopic suturing and ESG experience and varying suture patterns used to plicate the stomach. Barrichello and colleagues5Barrichello S. Hourneaux de Moura D.T. Hourneaux de Moura E.G. et al.Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study.Gastrointest Endosc. 2019; 90: 770-780Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar report the first multicenter retrospective study of outcomes of ESG with only 1 uniform endoscopic suturing pattern used by bariatric endoscopists with novice ESG experience (with the exception of the 1 center in the United States). Furthermore, ESG was performed across a wider BMI spectrum. All ESG procedures were performed by use of a “U” stitch pattern without a reinforcing layer. Various suturing patterns have been described, including “V,” “Z,” and “U” patterns, in either interrupted or running fashion, and with or without reinforcing layers. These patterns have varying levels of complexity and learning curves; the “U” pattern is relatively easy to follow and comprehend and also allows for a more conservative use of suture material—a factor that comes into play when institutional and out-of-pocket costs are factored in. Reinforcing sutures are thought to strengthen the gastric sleeve, especially toward the distal body of the stomach, and may result in greater weight loss. However, this additional layer of sutures was not applied to the cohort in this study. Data are limited, and expert opinion varies on whether reinforcing sutures should be routinely performed at all. This study assessed the efficacy of ESG across a wider BMI spectrum, with the majority of patients having class I obesity (BMI 30–34.9), followed by class II obesity, class III obesity, and last the overweight category (n = 12). Although a small number, this latter category of patients is worth noting, inasmuch as EBTs are vastly offered for the adjunct treatment of obesity, not overweight. It is well known that in Brazil, intragastric balloon therapy is an option for people with BMI ≥25. Barrichello and colleagues demonstrated that ESG also benefited patients who were overweight (%TWL at 6 months 10.13% and at 12 months 8.91%), albeit not as robustly as patients with obesity. Thus, should ESG be offered only to patients with obesity, or should we be expanding the BMI criteria to offer this EBT to patients who are overweight and who hope to prevent progression to obesity? This study also attempted to identify prognostic factors for successful weight loss. Previously, Lopez-Nava et al6Lopez-Nava G. Sharaiha R.Z. Vargas E.J. et al.Endoscopic sleeve gastroplasty for obesity: a multicenter study of 248 patients with 24 months follow-up.Obes Surg. 2017; 27: 2649-2655Crossref PubMed Scopus (132) Google Scholar identified that %TWL at 6 months strongly predicted %TWL at 24 months after adjustment for age, gender, and baseline BMI.6Lopez-Nava G. Sharaiha R.Z. Vargas E.J. et al.Endoscopic sleeve gastroplasty for obesity: a multicenter study of 248 patients with 24 months follow-up.Obes Surg. 2017; 27: 2649-2655Crossref PubMed Scopus (132) Google Scholar Specifically, patients who did not achieve at least 10%TWL at 6 months were less likely to lose significant weight at the 24-month period. Barrichello and colleagues5Barrichello S. Hourneaux de Moura D.T. Hourneaux de Moura E.G. et al.Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study.Gastrointest Endosc. 2019; 90: 770-780Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar also set out to determine factors associated with weight loss, and in their multivariate regression analysis, age <41 years, male sex, and higher BMI were predictors for achieving a %TWL of >10%. These data should be interpreted with caution, given the relatively small cohort of patients studied, the majority all from 1 country. Last but certainly not least, the trend in weight loss after 6 months is also worth discussing. ESG results in clinically and statistically significant weight loss at all time points, but the degree of weight loss appears to slow down after the first 6 months across all BMI categories (%TWL of 14.25% at 6 months vs 15.06% at 12 months). This trend is also seen in prior published studies.6Lopez-Nava G. Sharaiha R.Z. Vargas E.J. et al.Endoscopic sleeve gastroplasty for obesity: a multicenter study of 248 patients with 24 months follow-up.Obes Surg. 2017; 27: 2649-2655Crossref PubMed Scopus (132) Google Scholar, 7Alqahtani A. Al-Darwish A. Mahmoud A.E. et al.Short-term outcomes of endoscopic sleeve gastroplasty in 1000 consecutive patients.Gastrointest Endosc. 2019; 89: 1132-1138Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar Could the early satiety effect that is brought on by changes in signaling between the brain and gut attenuate after a certain period of time? Does the gastric sleeve naturally loosen up in all patients? Furthermore, how persistent is the delayed gastric emptying that has been observed with ESG?3Abu Dayyeh B.K. Acosta A. Camilleri M. et al.Endoscopic sleeve gastroplasty alters gastric physiology and induces loss of body weight in obese individuals.Clin Gastroenterol Hepatol. 2017; 15: 37-43Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar Is there a critical time point when further intervention may be needed to prevent deceleration of weight loss, especially in patients who begin to lose their sense of restriction with eating, begin to experience hunger intermittently, or both? Perhaps there is a role for starting adjunct pharmacotherapy early during the course of ESG therapy (assuming lifestyle modification is being followed stringently). The number of people affected by obesity is ever growing, and nonsurgical options are becoming more popular and accessible around the world. The management of obesity and metabolic diseases falls along a wide, fluid spectrum. Although still in its early period, ESG has already been demonstrated to be safe, to be effective, and to have durable outcomes in the first 2 years. Key questions that remain to be answered include the ideal suturing pattern that results in the most effective and durable weight loss, and how to measure, modify, and continue to support ongoing weight loss after the initial “honeymoon” period with ESG. ESG is here to stay, so perhaps the next time you are counseling a patient on weight loss interventions, consider making a U-turn back around toward endoscopic gastric therapy. The author disclosed no financial relationships relevant to this publication. Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter studyGastrointestinal EndoscopyVol. 90Issue 5PreviewObesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform “U” stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. Full-Text PDF