Endoluminal bariatric and metabolic therapies: Part 1 — Endoscopic sleeve gastroplasty

Dec. 12, 2023

Bariatric surgery has been shown to be an effective treatment for obesity and its metabolic comorbidities, but its use is limited by factors including patient preferences, costs, availability and strict selection criteria. Endoluminal bariatric and metabolic therapies (EBMTs) are gaining acceptance as effective treatments for promoting weight loss and metabolic improvements.

In a review article published in Current Opinion in Gastroenterology, Vivek Kumbhari, M.B., Ch.B., Ph.D., and Dilhana S. Badurdeen, M.B.B.S., M.D., gastroenterologists at Mayo Clinic in Florida, describe and summarize the current state of EBMTs and clinical outcomes associated with these approaches.

In this summary, part 1 of a series, Drs. Kumbhari and Badurdeen focus on recent findings and new developments related to endoscopic sleeve gastroplasty (ESG).

Endoscopic sleeve gastroplasty (ESG)

This minimally invasive, reversible procedure uses a full-thickness endoscopic suturing device to reduce stomach volume by approximately 70%. The endoscopist creates an endoscopic sleeve by placing full-thickness sutures in the gastric body starting at the incisura.

"ESG continues to be the focus of researchers worldwide. This procedure may be appealing for patients who have experienced suboptimal outcomes after medical treatments, or for patients who are ineligible for or averse to bariatric surgery," explains Dr. Badurdeen.

Key research findings related to ESG include the following:

  • Safety and efficacy. The Multi-center ESG Randomized Interventional Trial (MERIT-Trial) examined the efficacy and safety of ESG in 209 patients with class 1 or class 2 obesity who failed to achieve and maintain weight loss with a nonsurgical program. The results from this study were published in The Lancet in 2022 and demonstrate that ESG, combined with lifestyle modifications, is a safe and effective intervention that can help patients achieve and maintain significant weight loss, as well as important improvements in metabolic comorbidities.
  • Long-term durability and safety. Drs. Kumbhari and Badurdeen note that a recent study examining this issue reported a mean percentage of total body weight lost (%TBWL) of 15.9% at five years.
  • Mechanism of weight loss after ESG. Several studies examining this question suggest that possible mechanisms include increased satiation, delayed gastric emptying, and altered gastrointestinal hormones and insulin sensitivity.
  • ESG plus pharmacological therapy versus ESG alone. One study involving 224 patients found that incorporating anti-obesity pharmacological therapy within six months after ESG resulted in a higher %TBWL than that achieved with ESG alone. The same study showed that patients treated with ESG first, followed by medication, resulted in a higher %TBWL than those who were treated with medication first.
  • Effectiveness of revisional ESG after weight recidivism following laparoscopic sleeve gastrectomy. A multicenter study of 82 patients reported a %TBWL of 6.6%, 10.6%, 13.2% and 15.7% at one, three, six and 12 months, respectively, with only one moderate adverse event that was successfully managed through endoscopic dilation.
  • Newer procedure techniques. According to Drs. Kumbhari and Badurdeen, additional research is examining newer techniques and approaches, including the following:
    • Technique combining suturing with thermal ablation using argon plasma coagulation to stimulate a fibrotic reaction and improve durability.

    • Oscillating circles gastroplasty (OCG), combining endoscopic suturing with mucosal resection using band ligation.

      Both of these approaches yielded promising %TBWL at different follow-up periods. But the OCG technique had longer procedure times.

    • Gastroplasty with endoscopic myotomy (GEM), which involves an antral myotomy and standard ESG.

"Overall, our review demonstrates that ESG is a safe intervention that can function as an effective bridge between lifestyle counseling, pharmaceutical interventions and bariatric surgery, the most effective treatment," says Dr. Kumbhari. "Ongoing research is aimed at enhancing the effectiveness and durability of ESG."

For more information

Bakheet N, et al. Endoluminal bariatric and metabolic therapies: State-of-the-art. Current Opinion in Gastroenterology. 2023;39:362.

Abu Dayyeh BK, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): A prospective, multicentre, randomised trial. The Lancet. 2022;400:441.

Refer a patient to Mayo Clinic.