CME INDIA Presentation by Dr. Rakesh Kalapala, MD (Med), DNB (Gastro), FSGEI. Director Endoscopy (Center for Obesity and Metabolic Therapy), Asian Institute of Gastroenterology, Hyderabad, Telangana, India.

Are Conventional Bariatric Surgeons’ Days Outnumbered?

Why Endo bariatric surgery could be a new revolution?

• It is well known that bariatric surgery improves diabetes remission, reduces cardiometabolic risk. It is superior to conventional treatment in promoting remission of prediabetes/type 2 diabetes. It reduces cardiometabolic too.
• Very recently Endoscopic bariatric therapies are being increasingly used as a new tool in the fight against the obesity epidemic. Obesity related comorbidities like non-alcoholic fatty liver disease, type 2 diabetes mellitus, coronary heart disease, chronic renal disease, and some types of cancer (e.g., endometrial, breast, and colon) are modern days greatest enemies. Although modern day bariatric surgeries are very safe still the complications and restrictions could be very distressing.
• Now Endo bariatric physicians are offering an alternative to more invasive surgery and a more effective option than diet and lifestyle modifications. It is expected that in days to come such procedures will gain much wider application and may revolutionize the scenario.

Quick Take-Away

• Endo bariatric surgeries are becoming an essential tool for improving sustained weight loss in obese patients without long-term adverse effects.
• Interestingly, when compared to traditional bariatric surgery, these are effective at controlling metabolic comorbidities, lowering adverse risk events, and improving overall weight loss among obese patients.

A Glimpse of Gastric Endo bariatric therapies, 2022

• Intragastric balloon therapy.
• Endoscopic sleeve gastroplasty (ESG).
• Aspiration therapy.
• Small -Bowel Endo bariatric therapies like:
  • Duodenal mucosal resurfacing (DMR).
  • Duodenal-jejunal bypass liner (DJBL) device.
  • Endoluminal magnetic partial jejunal diversion.

The mechanisms driving the weight loss and improved metabolic parameters following ESG

New Techniques are the logical progression

Endo Bariatric Molecular mechanisms

Credit: Goyal H, Kopel J, Perisetti A, et al. Endobariatric procedures for obesity: clinical indications and available options. Therapeutic Advances in Gastrointestinal Endoscopy. January 2021. doi:10.1177/2631774520984627

Endoscopic Bariatric & Metabolic Therapies

Gastric

• Weight loss with metabolic effects DEPENDENT on weight loss

Small Bowel

• Metabolic effects INDEPENDENT of weight loss, but some weight loss may be seen

Rule of ‘10’

• 10% weight loss is good enough

Top 10 Reasons to Drop 10 % of Your Body Weight

1. Lower your blood pressure.
2. Lower your blood sugar levels, insulin sensitivity, and diabetes risk.
3. Lower your triglycerides, total cholesterol, and LDL (low-density lipoprotein) cholesterol—the bad kind.
4. Raise your HDL (high-density lipoprotein) cholesterol—the good kind.
5. Lower your risk of certain cancers.
6. Decrease pain from arthritis and other inflammatory conditions.
7. Promote better sleep patterns.
8. Increase energy levels.
9. Increase your self-esteem.
10. Enhance your sex life.

Intervention on the Stomach

Endoluminal Restrictive Approaches

Gastric Remodelling by Endoscopic Technique

NAFLD and Obesity: Bariatric Endoscopy

Credit: Rakesh et al, Indian Jour Gastro 2021

Intervention on Small Bowel

Next Generation Solution

Clinical Results – Asian Institute of Gastroenterology

• Initial Conclusions
  • Implant can be placed and retrieved endoscopically in less than 30 minutes.

Endoscopic View by Duodenal mucosal resurfacing (DMR)

The dual efficacy effect of DJLB’s maximizes metabolic outcomes

Glycemic Control

• Average 1.5% A1c drop.
• 55% of patients reach therapeutic goal.
• Better fasting and postprandial glucose control.
• No increased risk for hypoglycemia.

Weight loss

• Average 13% weight loss.
• Progressive and continuous.

Cardio-metabolic Improvement

• CV risk factor reduction.
• Significant reductions in blood pressure, total cholesterol, low density lipoproteins, and triglycerides.

Combination RCT

GLP-1analogs

Lira / Semaglutide

The Future holds great Promise

CME INDIA Learning Points

The management of the metabolic complications of obesity remains a burning issue

The weight loss is still the primary treatment recommendation.

• In 2022, we have early evidence showing that Endo bariatric techniques (minimally invasive, non-surgical procedures) are emerging at a fast pace.
• They bring not only significant and durable weight loss but also long-term improvement in obesity-related metabolic comorbidities.
• Both gastric and small bowel EBTs promote effective weight loss. It can help ameliorate hepatic steatosis, early liver fibrosis, insulin resistance, and cardiovascular disease risk.
• Further advancement on endo bariatric techniques might bring new hope and convention bariatric surgery may be talk of past.

References:

1. Lopez-Nava, G, Negi, A, Bautista-Castano, I, et al. Gut and metabolic hormones changes after endoscopic sleeve gastroplasty (ESG) vs. laparoscopic sleeve gastrectomy (LSG). Obes Surg 2020; 30: 2642–2651.
2. Thompson, CC, Abu Dayyeh, BK, Kushnir, V, et al. Aspiration therapy for the treatment of obesity: 4-year results of a multicenter randomized controlled trial. Surg Obes Relat Dis 2019; 15: 1348–1354.
3. Machytka, E, Buzga, M, Zonca, P, et al. Partial jejunal diversion using an incisionless magnetic anastomosis system: 1-year interim results in patients with obesity and diabetes. Gastrointest Endosc 2017; 86: 904–912.
4. Jirapinyo, P, Thompson, CC. Endoscopic bariatric and metabolic therapies: surgical analogues and mechanisms of action. Clin Gastroenterol Hepatol 2017; 15: 619–630.



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