Endoscopic Obesity Management - How It Is Done?

Introduction:

Obesity is the most common and challenging condition worldwide. Therefore, endoscopic procedures like sleeve gastroplasty, intragastric balloons, and gastric bypass revision are performed in patients with a BMI (body mass index) of 35 or above with conditions like high blood pressure or diabetes. It is done when normal weight loss practices like exercising and dieting do not show positive results.

What Is an Endoscopy?

An endoscope is a flimsy, compressible tube-like structure with a camera and a light at one end. It is used to view the abnormalities in the internal organs like the stomach, intestine, and gallbladder. Depending on the site of evaluation or treatment, it is inserted through the mouth, nose, or rectum. This procedure is called endoscopy. Endoscopy also treats and manages certain conditions like gallstones, cholestasis, and colon polyps.

What Is Obesity?

Obesity is a complex disease that results from the intake of too many calories by excessive consumption of fat-rich foods rather than calories burnt by physical activity. Obesity occurs when a person's BMI (body mass index) is 25 or above and is overweight. Obesity causes serious health problems. However, the weight can be reduced by exercising and following a few lifestyle modifications.

Obesity is classified based on the BMI (body mass index).

1. Overweight, not obese - BMI is 25.0 to 29.9.

2. Class I obesity - BMI 30.0 to 34.9.

3. Class II obesity - BMI 35.0 to 39.9.

4. Class III obesity - BMI 40.0 or greater.

What Are the Treatment Options for Obesity?

Obesity can be managed by exercising regularly and consuming low-fat and low-carbohydrate foods. However, suppose these procedures do not give satisfactory results. In that case, endoscopic treatment may be considered, provided the patient has associated conditions like hypertension (high blood pressure) or diabetes (a chronic condition where the processing of blood sugar is affected and results in elevated blood sugar levels).

What Are the Eligibility Criteria for Endoscopic Obesity Management?

1. If the BMI is less than 40 without any medical problems or conditions.

2. If the BMI ranges between 30 to 35, associated with medical conditions like high blood pressure, high cholesterol levels, diabetes, or sleep apnea (difficulty in breathing while lying down).

3. If there is weight gain after Roux-en-Y gastric bypass surgery (a weight loss surgery where a pouch is created in the stomach and is connected directly to the small intestine).

What Are the Types of Endoscopic Obesity Treatment?

• Restrictive Procedures: In restrictive procedures, the gastric or stomach volume is reduced by placing a space-occupying substance and stapling or suturing them.

• Fluid-Filled Intragastric Balloons: Bioenterics intragastric balloon is an elastic silicone balloon. It is placed in the stomach through endoscopy. Around 400 to 700 ml (milliliter) of saline is filled with a stained marker like methyl blue into the balloon through a self-sealing valve. It is then left undisturbed for six months. The balloon is then removed by deflating and emptying the saline through a catheter. Finally, the balloon is removed with special extracting tweezers. Also, they are removed only at the end of the treatment. Side effects like nausea and vomiting occur. However, side effects like balloon perforation, gastric erosion, or early balloon deflation are rare.

• Air-Filled Balloons: In addition to fluid-filled balloons, air-filled silicone balloons are also placed in the stomach in weight loss treatments. Air or gas is filled into the balloons and placed like fluid-filled balloons. However, air-filled balloons are more effective and are well tolerated than fluid-filled balloons. They are light compared to fluid-filled balloons, but the weight loss rates are similar to other types. However, there are a few side effects, like early deflation and no signs of device failure, as they are not filled with a stained marker like methyl blue. If the balloon is enormous, it may cause discomfort to the patient.

• Semi-Stationary Antral Balloon: A pear-shaped silicone balloon is placed in the gastric antrum. The balloon is 30 cm (centimeters) long and has a 7 g (grams) metallic counterweight at one end. When the balloon is placed in the gastric antrum (the narrow part of the stomach), it induces early satiety (feeling full or satisfied). In addition, it blocks the pylorus, prolongs gastric emptying, and induces duodenal satiety receptors. It can be placed for up to six months in the stomach.

• Transpyloric Shuttle: The transpyloric shuttle is a device that looks like a round bulb attached to a cylindrical small bulb. These devices are made of silicone and are inserted endoscopically with a catheter. The round bulb prevents the device's movement, and the cylinder bulb moves freely in the pylorus (a stomach opening into the duodenum) during peristalsis. This device promotes weight loss by inducing satiety by delaying gastric emptying, leading to reduced food intake.

• Endo-Cinch Suturing System: Endocinch suturing system involves attaching a capsule to the endoscope to suction the stomach tissue and suture the site to create a narrow passage. The sutures are placed in a crosslinked manner.

• Restore Suturing System: In this technique, multiple gastric plications (the stomach is folded into itself) are achieved with endoscopy. It results in effective weight loss.

• Trans-Oral Gastroplasty: In transoral gastroplasty compressible staplers are introduced into the stomach to create a pouch in the lesser curvature of the stomach. The staplers are placed with a guide wire endoscopically. Side effects like vomiting, nausea, pain and dysphagia (difficulty in swallowing) were observed.

• Trans-Oral Endoscopic Restrictive Implant System: A restrictor with a 10 mm (millimeter) width is placed in the stomach endoscopically to create a restricted food passage.

• Primary Obesity Surgery Endoluminal: Primary obesity surgery endoluminal procedure is a minimally invasive procedure with four channels to resume the procedure. An endoscope and three specialized instruments are used through these channels to reduce the size of the stomach. It is a safe and well-tolerated procedure for weight loss.

• Endomina Suturing System: This procedure uses an endomina triangulation platform, a one-time use suturing device placed in the stomach endoscopically. This helps achieve large plications with transmural sutures.

• Malabsorptive Procedures: In malabsorptive procedures, malabsorption is artificially created by avoiding the food entering the duodenum (first part of the small intestine) and jejunum (middle part of the small intestine).

• Duodenal-Jejunal Bypass Sleeve: Duodenal-jejunal bypass sleeve is a 60 cm (centimeter) long sleeve that is compressible and placed in the duodenal bulb into the proximal jejunum. The duodenal-jejunal bypass sleeve is open at both ends and is self-expandable. In addition, it has projections called barbs that help them stay fixed to the site in the gastrointestinal tract. This allows the passage of undigested food into the proximal jejunum. Also, it prevents the contact of secretions from the pancreas, duodenum, and biliary tract. This helps delay digestion and interferes with the body's metabolic function. As a result, it helps achieve weight loss and also helps control obesity-related health risks. The duodenal-jejunal bypass sleeve stays in the stomach for 3 to 12 months.

• Gastroduodenal Duodenal-Jejunal Bypass Sleeve: Gastroduodenal duodenal-jejunal bypass sleeve is placed in the gastroesophageal junction and extends about 120 cm (centimeter) into the small intestine through the stomach. In addition, a gastro duodenojejunal bypass is done to create a direct passage between the esophagus and the small intestine to avoid nutrition absorption in the stomach, duodenum, and jejunum.

• Gastric Aspiration: In gastric aspiration therapy, a customized gastrostomy tube is placed into the stomach endoscopically, and the contents are emptied precisely 20 minutes after a meal.

• Gastric Function or Emptying Regulation: Botulinum toxin is a neurotoxin obtained from the bacterium Clostridium botulinum. It causes short-term paralysis by blocking the neurotransmitter acetylcholine. It relaxes the muscle that takes part in food movement to the stomach, resulting in feeling full, less hungry, and reduced food intake. It helps reduce weight.

• Gastric Electrical Stimulation: In gastric electrical stimulation, an implantable gastric stimulation device and tantalus or diamond system meal-activated system are implanted through the laparoscopic method, and to stabilize the device, an endoscope is used. This device is activated while eating. It receives electrical signals through gastric contractions, resulting in reduced food intake, decreased appetite-stimulating hormones, increased appetite-inhibiting hormones, and delayed gastric emptying. It is well tolerated and effective; the treatment lasts about six months.

• Vagal Blockade: In vagal blockade (V-BLOC), a lead implant is placed laparoscopically in the front and the back of the vagal trunk close to the gastroesophageal junction. This lead implant intermittently transmits high-frequency, low-energy electrical signals to block the vagus nerve transmissions. This results in feeling less hungry and having early satiety.

What Is the Percentage of Excess Weight Loss (EWL) in Endoscopic Obesity Management?

• Fluid-Filled Intragastric Balloons: At six months, there is 34 to 42 % EWL (excess weight loss).

• Air or Gas-Filled Intragastric Balloons: At six months, 18 % EWL.

• Semi-Stationary Antral Balloon: After four months, 6.5 kgs (kilograms) of weight loss.

• Transpyloric Shuttle: At three months, 25 % EWL.

• Endo-Cinch Suturing System: At three months, 40 % EWL.

• Restore Suturing System: At 12 months, 28 % EWL.

• Trans-Oral Gastroplasty: At six months, 25 to 46 % EWL.

• Trans-Oral Endoscopic Restrictive Implant System: At six months,30 % EWL.

• Primary Obesity Surgery Endoluminal: At 12 months, 45 % EWL.

• Endomina Suturing System: At 12 months, 29 % EWL.

• Duodenal-Jejunal Bypass Sleeve: At three months, 12 to 24 % EWL.

• Gastroduodenal Duodenal-Jejunal Bypass Sleeve: At three months, 40 % EWL. At 12 months, 54 % EWL.

• Vagal Blockade: At 12 months, 17 % EWL.

• Gastric Aspiration: At six months, 41 % EWL. At 12 months, 50 % EWL.

• Gastric Electrical Stimulation: Five kilograms of weight is lost after six months.

Conclusion:

Obesity is a chronic condition that is widely seen all over the world. Therefore, a multidisciplinary approach is needed to prevent, treat, and control the condition from worsening. Endoscopic procedures are beneficial in obesity management procedures that are less invasive, safe, reversible, and cost-effective than other surgical options. However, it needs continuous monitoring to evaluate the patient's effectiveness and safety. Although various new endoscopic procedures are available for obesity treatments, they need more research on their efficacy. But these procedures mentioned are safe and efficient and are followed by most bariatric (concerned with people who are obese) surgeons worldwide.