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Early Experience With Endoscopic Sleeve Gastroplasty and Hints at Mechanisms of Action

Published:September 27, 2016DOI:https://doi.org/10.1016/j.cgh.2016.09.145
      It is widely recognized that obesity is major health concern in the United States, with more than 90 million Americans affected by the disease. Because of obesity-related comorbidities including but not limited to diabetes, heart disease, and cancer, the healthcare costs associated with obesity may account for up to 21% of US healthcare expenditures.
      • Cawley J.
      • Meyerhoefer C.
      The medical care costs of obesity: an instrumental variables approach.
      • Finkelstein E.A.
      • Trogdon J.G.
      • Cohen J.W.
      • et al.
      Annual medical spending attributable to obesity: payer-and service-specific estimates.
      Current therapies for obesity include lifestyle therapy, pharmacotherapy, endoscopic bariatric therapy, and bariatric surgery. Lifestyle therapy alone is the least effective therapy, possibly because of hunger and satiety hormone changes that result in increased hunger and desire to eat with weight loss.
      • Sumithran P.
      • Prendergast L.A.
      • Delbridge E.
      • et al.
      Long-term persistence of hormonal adaptations to weight loss.
      Bariatric surgery, namely Roux-en-Y gastric bypass and sleeve gastrectomy, is the most effective therapy. The mechanisms for weight loss with bariatric surgery are not completely understood, but the altered anatomy changes the response of several gut hormones, which have effects on hunger and satiety in addition to changes in gastric capacity, gut motility, and bile acids.
      • Albaugh V.L.
      • Flynn C.R.
      • Tamboli R.A.
      • et al.
      Recent advances in metabolic and bariatric surgery.
      • Pepino M.Y.
      • Bradley D.
      • Eagon J.C.
      • et al.
      Changes in taste perception and eating behavior after bariatric surgery-induced weight loss in women.
      Not only does this result in decreased food intake, but Roux-en-Y gastric bypass has also been shown to induce remission of food addiction,
      • Pepino M.Y.
      • Stein R.I.
      • Eagon J.C.
      • et al.
      Bariatric surgery-induced weight loss causes remission of food addiction in extreme obesity.
      further demonstrating the effect of this surgery on eating behaviors. Unfortunately, only 1% of patients who qualify for bariatric surgery pursue surgical options,
      • Dumon K.R.
      • Murayama K.M.
      Bariatric surgery outcomes.
      likely related to the risks, costs, recovery time, and food restrictions associated with bariatric surgery. There is increasing hope that minimally invasive endoscopic procedures would fill the treatment gap between medical therapies and bariatric surgery.
      In this issue of Clinical Gastroenterology and Hepatology, Abu Dayyeh et al
      • Abu Dayyeh B.K.
      • Acosta A.
      • Camilleri M.
      • et al.
      Endoscopic sleeve gastroplasty alters gastric physiology and induces loss of body weight in obese individuals.
      of the Mayo Clinic, Rochester describe their initial single center experience with endoscopic sleeve gastroplasty (ESG). This endoscopic procedure uses an available endoscopic suturing device that has been approved for the general purpose of endoscopic suturing of tissues. ESG is minimally invasive and done under general anesthesia, occasionally with an overnight hospital observation stay. This procedure was devised to endoscopically achieve a change in the gastric anatomy similar to that achieved with laparoscopic sleeve gastrectomy without the surgical resection of the fundus or body of the stomach (Figure 1).
      Figure thumbnail gr1
      Figure 1(A) Suturing device attached to the endoscope. (B) ESG with gastric restriction using endoscopically placed sutures.
      Figure reproduced with permission from Gastrointest Endosc 2015;15:1076.
      In this early report of the first 25 patients (patients followed for a median of 9 months), the results appear encouraging with 56% ± 23% excess weight loss at 9 months in 17 patients. The group also reports findings of physiologic and hormonal measurements in 4 patients. In these patients gastric emptying was delayed, which is opposite to the effect of sleeve gastrectomy where gastric emptying is accelerated.
      • Mans E.
      • Serra-Prat M.
      • Palomera E.
      • et al.
      Sleeve gastrectomy effects on hunger, satiation, and gastrointestinal hormone and motility responses after a liquid meal test.
      Calorie intake to reach maximum fullness in a liquid meal test decreased by 59%. There was a trend toward a decrease in ghrelin concentrations during a meal test. Although this was not statistically significant, ghrelin is expected to increase with weight loss, so the lack of an increase with ESG is an interesting finding. Whole-body insulin sensitivity measured by Homeostatic Model Assessment of Insulin Resistance improved as expected for the percent excess weight loss seen in these patients. Taken together, these limited data suggest that although gastric luminal dimensions after ESG and sleeve gastrectomy are very similar, the mechanism for weight loss may be very different. Although these subgroup studies are interesting and seem to demonstrate possible physiologic changes induced by of ESG, they should be interpreted with caution because of the small number of subjects evaluated. Further studies with additional subjects are needed for validation of these small pilot data. Moreover, the patients included in this study had on average lower body mass index than patients undergoing sleeve gastrectomy, making true comparisons between the 2 procedures difficult.
      Durability of ESG was also assessed in 9 patients at 3 months with repeat upper endoscopies. Approximately two-thirds had intact gastroplasties with fibrotic bands; one-third had partial breakdown of the gastroplasty. The group also compared their results with a similar group of patients treated at another center in Spain that had started an ESG program around the same time. They found similar results in weight loss with 53% mean excess weight loss at 6 and 12 months at both centers. However, only 10 subjects from the Mayo group were evaluated at 12 months, limiting the reliability of the weight loss durability at 12 months.
      Complications were seen in this series as might be expected with any new technique or device. Modifications of the technique and awareness of the full-thickness suturing that occurs with this procedure will hopefully reduce or eliminate these complications in the future.
      In summary ESG has the potential for providing an effective therapy for the many patients with obesity, in particular those patients with a body mass index between 30 and 40 kg/m2 who may not qualify for sleeve gastrectomy. ESG has the advantage of a single endoscopic procedure that may have effective weight control for more than a year in some patients, when compared with other clinically available endoscopic bariatric therapies. ESG in its current form is ready to be provided clinically in centers that have programs in endoscopic treatments of obesity and extensive experience with the use of the suturing device. Possible mechanisms for weight loss include a delay in gastric emptying and possible alteration in gut hormones, but further research is needed to clarify mechanisms of action and weight loss durability.

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