Recent bariatric surgical interventions aimed to reduce procedural complications and burden while maximizing the beneficial effects. Since bariatric surgery has been established as an alternative to diabetes mellitus treatment, it has attracted attention as a new treatment for this disease. However, although previous studies have described bariatric surgery as the most effective treatment for metabolic obesity disease, it is associated with a high morbidity rate, mortality rate, and economic burden . While the mortality rates of surgical interventions have decreased in recent years, the adverse events related to bariatric surgery remain considerably high.
The use of endoluminal techniques in the field of metabolic obesity disease has diverse promising applications including endoscopic gastroplasty, intragastric balloon, endoluminal malabsorptive bariatric procedures, and gastric electrical stimulation (GES) for the modulation of gastric emptying. This review discusses recent trends and roles in endoscopic bariatric therapies using the currently available endoluminal and transgastric technologies.
Endoluminal interventions performed entirely by using flexible gastrointestinal endoscopy offer an alternative approach to the treatment of obesity that is safer and more cost-effective than current surgical approaches . The use of endoluminal techniques in the field of metabolic obesity disease has several promising applications, such as endoscopic gastroplasty, intragastric balloon, endoluminal malabsorptive bariatric procedures, and gastric electrical stimulation (GES) for the modulation of gastric emptying (Table 1). The weight loss effects of endoscopic bariatric treatment are higher than drugs but lower than bariatric surgery, although the complications rates are less than the latter.
Therapeutic approach to obesity treatment. The effect of endoscopic bariatric treatment for weight loss is greater than that of drugs but lower than that of bariatric surgery, but endoscopic bariatric treatment features fewer complications than bariatric surgery. VBG, vertical band gastroplasty; RYGB, Rouxen-Y gastric bypass; DS, duodenal switch; BPD, biliopancreatic diversion.
Restrictive endoscopic procedures-
- Intragastric balloon
- Ullorex Oral Intragastric Balloon Spatz Adjustable Intragastric Balloon
- Heliosphere Bag (Helioscopie Medical Implants, Vienna, France)
- Pear-shaped Semistationary Antral Balloon
- Silimed Gastric Balloon
- Endogast-Adjustable Totally Implantable Intragastric Prosthesis
- Endoscopic gastroplasty techniques
- Intragastric gastroplasty EndoCinch
- Overstitch endoscopic suturing system
- Malabsorptive endoscopic procedure
ROLE OF RESTRICTIVE ENDOSCOPIC PROCEDURES IN OBESITY TREATMENT
Intragastric balloons were developed to treat obesity by filling the stomach to induce early satiety. Although this technique was introduced 30 years ago, it was abandoned due to adverse events and balloon deflation. Since then, after several upgraded product developments, several intragastric balloons have been commercialized. The BioEnterics Intragastric Balloon /Orbera Intragastric Balloon has long been utilized for weight loss and is still used today. This device consists of a silicone balloon strong to gastric acid and a self-sealing valve that is filled with isotonic saline and methylene blue. In recent years, several other balloon devices for weight loss have been developed, such as the Ullorex Oral Intragastric Balloon ,Integrated Dual Balloon System, BaroNova Polymer Pill, Spatz Adjustable Intragastric Balloon, Heliosphere Bag, pear-shaped Semistationary Antral Balloon, Silimed Gastric Balloon, and Endogast-Adjustable Totally Implantable Intragastric Prosthesis. However, these balloon devices also have several limitations, such as migration, rupture, gastric erosion, ulcers, perforation, technical problems, and clinical intolerance.
ROLE OF ENDOSCOPIC GASTROPLASTY TECHNIQUES IN THE MANAGEMENT OF OBESITY
Endoluminal gastroplasty involves the reduction of gastric volume via the creation of a mucosa-to-mucosa tissue apposition, sleeve gastro mucosa-to-mucosa apposition, or stomach sleeve similar to surgical sleeve gastrectomy. Endoscopic gastroplasty uses natural orifice transluminal endoscopic surgery to reduce or eliminate the trauma of access incisions. The endoscopic suture device is the crucial device used in NOTES and endoluminal gastroplasty.
ROLE OF MALABSORPTIVE ENDOSCOPIC PROCEDURE IN OBESITY TREATMENT
Another endoscopic procedure for the treatment of metabolic obesity disease involves malabsorption techniques. The endoluminal malabsorptive device was designed for endoscopic duodenojejunal bypass, allowing for weight loss and control over diabetes mellitus. The proximal small bowel interventions are very efficient in blocking nutrient absorption; therefore, proximal small bowel bypass may contribute to obesity treatment and improved glucose control in diabetics.
EVOLVING BARIATRIC ENDOSCOPIC TECHNIQUE FOR OBESITY TREATMENT
GES, which is used to treat gastroparesis that is unresponsive to medical treatment, is awaiting FDA approval. GES devices are implanted subcutaneously along the abdominal wall, and they generate electrical pulses via bipolar leads in the muscular gastric layers.
GES systems were recently introduced to treat obesity. These devices stimulate a targeted gastric region and impair gastric electrical slow-wave activity, causing gastric distension, inhibiting peristalsis, and leading to delayed gastric emptying and increased satiety. Various GES devices have been developed and studied for metabolic obesity disease, such as the Enterra/Transcend Implantable Gastric Stimulator, the Endostim, the Intrapace Abiliti Gastric Stimulator, Maestro VBLOCK therapy system and the Diamond/Tantalus II system. Several GES systems have been applied in humans as a treatment for obesity and metabolic disease, while several clinical studies have shown significant results with fewer adverse events.
Obesity is a chronic relapsing multi-factorial disease that is associated with substantial morbidity and mortality. Most therapeutic approaches to weight loss include lifestyle modification, pharmacotherapy, and bariatric surgery. Recent advances in endoluminal technology for the treatment of obesity and metabolic diseases have been promising. Reversible approaches that do not require the patient to commit to permanent surgical modifications of the gastrointestinal tract are of particular interest. Endoscopic bariatric treatment must be an attractive option to both patients and physicians. The application of endoscopic bariatric technology as a treatment for obesity remains ambiguous; however, with more research of evidence overcoming previous therapeutic limitations, endoscopic bariatric therapy will find its role in obesity treatment.
The overall treatment of obesity requires a multidisciplinary team approach. Diet, nutrition, physical activity, and behavioral modifications are important along with several medical tools that support adherence to low-calorie food intake. The development of new endoscopic techniques allows the endoscopist to play an increasingly important role in the management of obesity. There is also hope that minimally invasive endoscopic technological advancements will lead to an effective therapy to help the millions of people currently afflicted with metabolic obesity disease worldwide. Each device will require careful assessment through clinical trials to determine their safety, efficacy, and durability. Finally, the endoscopic bariatric approach will have the initiative in a continuum of obesity treatment care.