Endoscopic Weight Loss TherapiesAugust 25, 2021
Endoscopic Weight Loss Therapies: Many of my patients find me because they feel they have reached a point where they have exhausted all non-invasive weight loss options. Despite being prescribed weight loss medications and modifying one’s diet and/or lifestyle, some patients still do not see the results they are looking for.
According to 2019 CDC estimates, 42.4% of Americans (over 130 million) suffer from obesity, yet the ASMBS estimates less than 1% of 24 million patients who qualify for bariatric surgery undergo the procedure. Others may find that despite suffering from class I obesity, a BMI of 30 to 35 often precludes them from qualifying for bariatric surgery. Furthermore, some patients have either already undergone bariatric surgery or are hoping to avoid surgery.
Endoscopic Weight Loss Therapies
Endoscopic weight loss therapies describe procedures that are performed through the mouth, leaving no external scars. Procedures are available for both those who have never undergone bariatric surgery, and for some patients who have.
Some of my patients seek an endoscopic option because their body mass index does not qualify them for bariatric surgery. Others feel strongly that an endoscopic procedure is a less invasive option that will give them just enough weight loss to proceed with another form of therapy, such as a knee replacement, that will ultimately improve their mobility and help them achieve long-term weight loss.
One reason why these procedures are not as widely known is that, unlike general gastroenterologists, a bariatric endoscopist like myself undergoes additional training to perform these technically advanced procedures. Additional training in obesity medicine is also important to treat patients with a more holistic approach.
All of these endoscopic procedures can be performed while patients are also on FDA-approved weight loss medications. Moreover, I also work at an institution where we can deliver in a multidisciplinary manner. I find this important because it means I work very closely with my surgical colleagues and experienced dietitians.
Revision of Prior Bariatric Surgery
Several years after bariatric surgery, some patients may experience weight regain due to structural changes to their anatomy. For patients who have previously undergone gastric bypass surgery, the stomach pouch or the outlet into the small intestine may have stretched out, rendering it incapable of providing that sensation of fullness after food intake.
Other structural problems like gastrogastric fistulas (abnormal connections between the stomach pouch and the bypassed stomach may form) allow food and drink to travel into the bypassed stomach, defeating the entire purpose of undergoing a gastric bypass.
Fortunately, there are endoscopic methods to revise some of these problems. For a dilated outlet, one widely studied method is the transoral outlet reduction procedure (TORe). The idea behind this procedure is to reduce the size of the outlet using cautery around the rim of the outlet or to suture, and more commonly both.
The average percentage of weight loss after the procedure is around 10%, although some patients have experienced greater weight loss outcomes. Results from data published from late 2019 show durable results 5 years out from the procedure.
Both repairs of a dilated gastric outlet and gastric fistulas are often performed using an endoscopic suturing device that allows us to place sutures using a scope that is passed through the mouth into the stomach pouch. Other devices are less commonly used, such as gastric plication devices that reduce the size of the stomach by pinching folds in a gastric pouch and anchoring them in place.
Weight Loss Procedures
There are currently several FDA-approved procedural methods to achieve weight loss for those who have yet to undergo a bariatric procedure (i.e., “primary” weight loss). There are currently two intragastric balloons available on the market. The Orbera intragastric balloon (Apollo Endosurgery) is a saline-filled balloon that remains in the stomach for 6 months before it is removed. It requires an endoscopic procedure for placement and removal. The Obalon balloon system (Obalon Therapeutics) is a series of three gas-filled balloons that do not require endoscopic placement and are placed over a 4 week period.
The balloon is delivered through a capsule that is swallowed by the patient and inflated through a catheter that extends from out of the mouth. The balloons do, however, require endoscopic removal after 6 months. Both balloon systems offer a reduction of around 10% total body weight.
Of the endoscopic options available for primary weight loss, another commonly performed procedure is Endoscopic Sleeve Gastroplasty. This procedure mimics the effects of a surgical sleeve gastrectomy by reducing the size of the stomach.
However, unlike the sleeve gastrectomy, where part of the stomach is removed altogether, the endoscopic sleeve is performed by placing a series of sutures within the stomach and narrowing the stomach cavity to about a third of its original size. This procedure offers around 20% total body weight loss after the first 2 years, with some data to show durable results five years out from the procedure.
The AspireAssist is an aspiration device that helps patients achieve weight loss using a tube placed through the skin into the stomach. Through this tube, about 30% of ingested stomach contents are aspirated 20-30 minutes after a meal. The aspiration device on average helps patients lose on average 12% of total body weight after a year and is limited to 115 activations (5 to 6 weeks of therapy) each time before requiring evaluation by a medical professional.
Another FDA-approved device is the Transpyloric Shuttle, which sits at the outlet of the stomach and slows stomach emptying, and causes the stomach to fill faster. Though it has shown total body weight loss outcomes also around 10%, the availability of this device is still rather limited.
Endoscopic Weight Loss Therapies In the Pipeline
There are a variety of devices currently at various stages of development, with some even currently under review by the FDA. Two fluid-filled intragastric balloons currently under review by the FDA are the Spatz3 balloon (Spatz Medical) and the Elipse balloon (Allurion Technologies).
The former is an adjustable balloon, which allows for volume adjustments to relieve discomfort from an overinflated balloon or to achieve greater weight loss outcomes with an under-filled balloon. The Elipse balloon is the first entirely procedure-less balloon that requires no endoscopic placement or removal.
There are other devices focused on the small bowel that is in the works, including sleeves that prevent absorption of calories across various segments of the gut to self-assembling magnets that create tracts that bypass one segment of the bowel to another. Some of these devices are focused on impacting diabetes and metabolic conditions rather than weight loss specifically. One such device deactivates cells in the small bowel that are thought to cause insulin resistance, as seen in diabetes. Many of these devices are still undergoing clinical trials, but the future appears promising.
More Options for Weight Loss
There are currently a variety of non-surgical procedural weight loss options available on the market, and even more in development. Like treatments for many other conditions, we may see weight loss strategies become less invasive over time. The common thread is how all these strategies can potentially help patients achieve clinically meaningful weight loss to improve cardiac and metabolic risk factors, as well as improve quality of life.
ABOUT THE AUTHOROne of the few bariatric endoscopy and advanced endoscopy dual-trained gastroenterologists in the world, Dr. Austin L Chiang is the Director of the Endoscopic Bariatric Program at Thomas Jefferson University Hospital, where he offers unique endoscopic weight loss solutions for those seeking a less invasive method of losing weight and improving metabolic conditions such as high blood pressure and diabetes. Customized treatments to enhance weight loss in those who previously underwent bariatric surgery are also available and effective.