The pressure is on! Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: toward better patient allocation beyond pygmalionism

Abstract

Obesity, better termed adiposity-based chronic disease, is a remissive but not curable chronic disease with a management gap between medical and surgical interventions. Given the important role of the gastrointestinal tract in body weight regulation and metabolic control, in addition to the limited efficacy of lifestyle interventions, an expanding range of endoscopic and surgical interventions for the management of obesity and metabolic disease have been developed and have demonstrated efficacy in clinical trials.1Bazerbachi F. Vargas Valls E.J. Abu Dayyeh B.K. Recent clinical results of endoscopic bariatric therapies as an obesity intervention.Clin Endosc. 2017; 50: 42-50Crossref PubMed Scopus (26) Google Scholar, 2Vargas E.J. Rizk M. Bazerbachi F. Abu Dayyeh B.K. Medical devices for obesity treatment: endoscopic bariatric therapies.Med Clin North Am. 2018; 102: 149-163Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The use and adoption of some of these techniques have been limited by real-world effectiveness, cost, and risk profile that became evident only beyond the confines of clinical trials, leading to the demise of some of them. Of the available options, two gastric sleeve procedures, both aimed at reducing the gastric reservoir by creating a tubular sleeve configuration, are now gaining increased popularity and momentum. Laparoscopic sleeve gastrectomy (LSG) excises the greater curvature surgically (Fig. 1A), whereas endoscopic sleeve gastroplasty (ESG) imbricates the greater curvature of the stomach, creating a tubular structure without disruption of the gastric vascular or neuronal supply (Fig. 1B).3Abu Dayyeh B.K. Rajan E. Gostout C.J. Endoscopic sleeve gastroplasty: a potential endoscopic alternative to surgical sleeve gastrectomy for treatment of obesity.Gastrointest Endosc. 2013; 78: 530-535Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar LSG is currently the most common bariatric and metabolic surgery performed in the United States, and it has surpassed the time-tested Roux-en-Y gastric bypass (RYGB) in the annual number of operations performed.4ASMBSEstimate of Bariatric Surgery Numbers, 2011-2017.2018https://asmbs.org/resources/estimate-of-bariatric-surgery-numbersGoogle Scholar LSG is attractive because it is less technically demanding, has better postsurgical adverse events profile, and is successful in achieving clinically relevant long-term weight loss and improvement in comorbidities. However, recent research has shown a possible association between LSG and de novo or worsening gastroesophageal reflux disease (GERD), which is particularly prevalent in patients with obesity.5Oor J.E. Roks D.J. Ünlü Ç. et al.Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis.Am J Surg. 2016; 211: 250-267Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Although this association now attracts special attention, it is important to be cognizant of the complex interplay between obesity as a cause of GERD in itself, the GERD-improving effect of weight-loss, and the LSG-inherent characteristics that may be conducive to GERD. If the net sum of these parts is increased GERD, this might become an Achilles heel of LSG, limiting its applicability and appeal at a population level. In a prospective study, Coupaye et al6Coupaye M. Gorbatchef C. Calabrese D. et al.Gastroesophageal reflux after sleeve gastrectomy: a prospective mechanistic study.Obes Surg. 2018; 28: 838-845Crossref PubMed Scopus (33) Google Scholar have shown that de novo GERD is frequent at 1-year post LSG. Moreover, compared with RYGB in a prospective randomized trial, the incidence of worsening or de novo GERD after LSG in 101 patients was about 30%, with 9 patients requiring conversion to RYGB because of severe symptoms.7Peterli R. Wölnerhanssen B.K. Peters T. et al.Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial.JAMA. 2018; 319: 255-265Crossref PubMed Scopus (600) Google Scholar Furthermore, in 144 patients followed prospectively, the incidence of erosive esophagitis and nondysplastic Barrett’s esophagus after LSG was almost 60% and 13%, respectively.8Soricelli E. Casella G. Baglio G. et al.Lack of correlation between gastroesophageal reflux disease symptoms and esophageal lesions after sleeve gastrectomy.Surg Obes Relat Dis. 2018; 14: 751-756Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Indeed, several plausible mechanisms may explain why LSG patients could have new-onset or worsened GERD. First, the angle of His may be violated during LSG.9Himpens J. Dobbeleir J. Peeters G. Long-term results of laparoscopic sleeve gastrectomy for obesity.Ann Surg. 2010; 252: 319-324Crossref PubMed Scopus (562) Google Scholar, 10Burgerhart J.S. Schotborgh C.A. Schoon E.J. et al.Effect of sleeve gastrectomy on gastroesophageal reflux.Obes Surg. 2014; 24: 1436-1441Crossref PubMed Scopus (94) Google Scholar Second, the ensuing gastric sleeve compliance is significantly reduced from the preresection stomach baseline.11Mion F. Tolone S. Garros A. et al.High-resolution impedance manometry after sleeve gastrectomy: increased intragastric pressure and reflux are frequent events.Obes Surg. 2016; 26: 2449-2456Crossref PubMed Scopus (80) Google Scholar Third, LSG may be associated with some degree of neuronal autonomic disruption, which might account for the GERD-permissive changes in gastric motility, such as reduced normal contractions, increased intragastric pressure, and reduced accommodation.6Coupaye M. Gorbatchef C. Calabrese D. et al.Gastroesophageal reflux after sleeve gastrectomy: a prospective mechanistic study.Obes Surg. 2018; 28: 838-845Crossref PubMed Scopus (33) Google Scholar Fourth, the extent of the sleeve may play a role, inasmuch as data have previously shown that antrum-preserving LSG is less likely to induce reflux symptoms.12Toro J.P. Lin E. Patel A.D. et al.Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy.J Am Coll Surg. 2014; 219: 430-438Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar Finally, the increased esophageal afterload from LSG might trigger esophageal dysmotility in a pseudoachalasia pattern.13Ravi K. Sweetser S. Katzka D. Pseudoachalasia secondary to bariatric surgery.Dis Esophagus. 2016; 29: 992-995Crossref PubMed Scopus (14) Google Scholar It is easy to contrast how most of these potential alterations are not reproduced during ESG, although a formal assessment of the impact of ESG on these possibilities has not been yet performed. In this issue of Gastrointestinal Endoscopy, Fayad et al14Fayad L. Adam A. Schweitzer M. et al.Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study.Gastrointest Endosc. 2019; 89: 782-788Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar present the first case-matched study comparing, retrospectively, the outcomes of LSG versus ESG. Although their overall weight loss results are limited to short-term follow-up and are congruent with those in previous studies,15Lopez-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 (134) Google Scholar they do become provocative when viewed from two angles. First, LSG does not provide clinically meaningful superior weight loss when introduced to patients with class I and II obesity, compared with ESG in the short term. Second, in this matched cohort, there exists a striking difference in the development or worsening of GERD, favoring ESG as a less–GERD-provoking procedure. Although the authors did not provide data to show whether this effect was maintained in patients with class I and II obesity, their results and conclusions provide early insight into the pathophysiologic difference between these two procedures as they relate to GERD. This observation should be investigated in future prospective studies with a formal evaluation of esophageal and gastric physiologic measures beyond self-reported GERD questionnaires. In Greek mythology, Pygmalion, an artist and sculptor, was enamored with a statue he had carved. His work was so realistic, flawlessly mimicking the female form, that he would no longer find beauty in any human. Pygmalionism has thus become synonymous with the artist’s infatuation with his or her work, at times despite a lower perceived value. The study by Fayad et al14Fayad L. Adam A. Schweitzer M. et al.Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study.Gastrointest Endosc. 2019; 89: 782-788Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar adds to the newly growing body of ESG literature that demonstrates merit, not only as a minimally invasive intervention for mild to moderate obesity but also in the potential for better allocation of patients with different comorbidities who do not qualify or wish to pursue surgery. On the other hand, LSG has already demonstrated excellent midterm effectiveness and a clear impact on obesity-related co-morbidities. The pressure is now on to compare the real-world effectiveness, value, and adverse events profiles of these two interventions, in a head-to-head noninferiority randomized controlled trial for patients with class I and II obesity. Although the golden mean argument fallaciously asserts that truth is always in the middle, we are optimistic, after viewing this and other encouraging data, that endoscopic bariatric therapies such as ESG will provide an essential role in the continuum of obesity care in the foreseeable future. Dr Abu Dayyeh is a consultant for Boston Scientific, Metamodix, BFKW, and USGI; the recipient of research support from Aspire Bariatrics, GI Dynamics, Apollo Endosurgery, USGI, Medtronic, Spatz, and Cairns; and a speaker for Johnson & Johnson and Olympus. The other author disclosed no financial relationships relevant to this publication. Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched studyGastrointestinal EndoscopyVol. 89Issue 4PreviewEndoscopic sleeve gastroplasty (ESG) reduces the gastric lumen to a size comparable with that of laparoscopic sleeve gastrectomy (LSG). However, there is a paucity of research comparing outcomes between the 2 procedures. Our study compared the 6-month weight loss outcomes and adverse events of ESG with LSG in a case-matched cohort. Full-Text PDF