What's New in Bariatric Treatments

Losing weight isn’t solely about looking and feeling good. Healthcare professionals are beginning to realize obesity is an incurable chronic disease that causes inflammation and multiple comorbidities, including heart disease and cancer. “It’s important that providers from different disciplines engage patients in life-long treatments to keep the disease under control in order to prevent it from having an adverse impact on their overall health,” says Barham Abu-Dayyeh, MD, MPH, a gastroenterologist at the Mayo Clinic in Rochester, Minn.

Bariatric surgery has evolved significantly over the last 20 years, from open procedures with high complication rates and long hospital stays to laparoscopic procedures with lower risks and reduced lengths of recoveries. Despite these advances, only about 2% of overweight individuals who qualify for weight-loss surgery elect to have it done because of a lack of insurance coverage and worries about the invasiveness of procedures that permanently alter their stomachs and GI tracts without the guarantee of meaningful or sustained weight loss. “Patients grow frustrated with years of living with excess pounds,” says Dr. Abu-Dayyeh, who focuses on the development of minimally invasive endoscopic therapies for obesity and gastrointestinal and metabolic diseases. “There’s now a spectrum of tools available to help them lose weight quickly.”

The field of primary gastric remodeling is growing and provides an option for patients who don’t qualify for or don’t want to undergo more invasive surgery, says Ali Tavakkoli, MD, a bariatric surgeon at Brigham and Women’s Hospital in Boston. 

Endoscopic approaches — anatomy maintaining devices delivered through the patient’s mouth to remodel the stomach — offer alternative treatments to laparoscopic procedures and have the potential to revolutionize the field of bariatric surgery. There are two general categories of endoscopic devices currently in use. One is a temporary space-occupying prosthesis such as a gastric balloon placed in the stomach for six months to a year. The patient’s stomach anatomy is preserved, but the efficacy of the treatment goes away when the device is removed. The second, gastric remodeling, is beginning to gain significant momentum and offer patients a more appealing option, according to Dr. Abu-Dayyeh.

• Endoscopic sleeve gastroplasty. This is currently the primary gastric remodeling treatment. 

It involves using sutures to reduce the size of the stomach through the greater curvature to make it tube-like and shrink its longitudinal axis to make it shorter. It delays gastric emptying, induces early satiation and significantly reduces body weight. “The procedure makes patients feel full more quickly and for longer,” says Dr. Abu-Dayyeh. “Patients can eat about 800 calories a day without feeling miserable or hungry. They lose a sufficient amount of weight to put comorbidities of obesity such as diabetes and fatty liver in good control.”

Long-term outcomes data for endoscopic sleeve gastroplasty is not yet available, but Dr. Tavakkoli says early research indicates patients with BMIs between 30 and 40 lose 10% to 15% of their weight after undergoing the treatment. The short-term risks and long-term outcomes, as well as the safety of subsequent bariatric surgery if it’s needed, are still being studied.

“Patients feel enabled after undergoing gastric remodeling procedures,” says Dr. Abu-Dayyeh. “It’s a gradual intervention, so they’re able to lose weight without feeling miserable about it.”

• Revisional bariatric surgery. This intervention reestablishes weight loss in patients who had undergone gastric bypass or sleeve gastrectomy procedures. It involves placing sutures to reduce the size of the gastric pouch or the gastric anastomosis between the gastric pouch and the intestine. Patients go home the day of the procedure and are placed on a strict liquid diet. Research has shown the intervention results in modest weight loss, according to Dr. Tavakkoli. 

Gastric remodeling techniques have more durability — two to five years — than gastric balloons, according to Dr. Tavakkoli. Plus, he says, endoscopic approaches do not involve removing parts of the stomach, so the stitches can be retightened if patients begin to regain weight.

Maintaining weight loss is not a passive endeavor. After the disease is in remission, providers must initiate an active weight maintenance program.
— Dr. Barham Abu-Dayyeh

Less invasive endoscopic procedures can be performed based on a patient’s specific weight-loss needs and medical profile, says Dr. Tavakkoli, adding, “These factors will help us move the field forward and benefit more of the population, allowing individuals to live longer and healthier lives.”

Dr. Abu-Dayyeh says medication management might be appropriate for patients who need to lose 20 pounds, endoscopic interventions are effective treatments for patients with 20 to 50 pounds of excess weight and patients with 50 or more pounds to shed are likely suitable candidates for laparoscopic bariatric surgery.

There is a critical need to improve access to these treatment options and advance the science of bariatric surgery, according to Dr. Tavakkoli, who says, “We need to help patients determine which procedure is best for them and help them get a better sense of possible outcomes through the use of more accurate web-based calculators, which are based on hormonal markers and lead to more predictable results.”

Increasing numbers of providers are recognizing that weight management is critical to improving a patient’s quality of life, says Dr. Tavakkoli. “Obese individuals who lose weight experience less arthritis and reverse diabetes and hypertension,” he adds. “Data also shows reducing obesity lowers cancer and cardiovascular mortality.”

The successful treatment of obesity is twofold, according to Dr. Abu-Dayyeh. It requires putting the disease into remission by ridding patients of as much excess body fat as possible and introducing multiple strategies to maintain the weight loss. He says endoscopic procedures have a high success rate in getting obesity into remission, but they shouldn’t be the only element of weight management programs. Providers must also engage patients to make lifestyle interventions that involve changing their eating habits and levels of physical activity, and intervene as soon as patients begin to regain weight with medication maintenance, the retightening of an endoscopic procedure or graduating them to a more invasive surgical strategy.

“Maintaining weight loss is not a passive endeavor,” says Dr. Abu-Dayyeh. “After the disease is in remission, providers must initiate an active weight maintenance program to put patients in a stable plateau for five to 10 years, which will have a positive impact on their overall health.”

Endoscopic procedures get at the issue of patient acceptance, and therefore have the potential to increase access to the care overweight individuals need, points out Dr. Abu-Dayyeh. “They’re often hesitant to undergo bariatric surgery because it’s invasive and alters anatomy, and concerns persist about what happens when weight is regained because revision surgery is high-risk,” he explains. “Endoscopic approaches are well positioned to increase access to minimally invasive weight-loss procedures, which resonate with patients.” 

Increasing access to endoscopic procedures could send more patients down a life-saving path. “They begin to look and feel better, and see that their overall health is improving,” says Dr. Abu-Dayyeh. “They’re then more engaged in wanting to maintain the weight loss.”

Additional endoscopic techniques are being developed that would bypass or resurface portions of the small intestine to enhance metabolic benefits for conditions such as fatty liver disease or diabetes, according to Dr. Abu-Dayyeh. “In the future, surgeons could choose to perform procedures on the stomach and intestines in combination — and add them to medication management or minimally invasive weight-loss surgery to enhance overall outcomes,” he says. “We’re just starting to realize the potential of endoscopic interventions and look forward to them playing an important role in the full spectrum of care, not only as primary treatments, but as a way to increase access to bariatric surgery.” OSM