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London 2012: Future of Obesity Treatment

Endoscopic therapies

Surgery more effective but a higher risk
Lifestyle or medical therapy reduce the risk but are less effective
Endoscopic therapies could be used as a 'bridge therapy'
Christopher Thompson

In a presentation on endoscopic therapy, Dr Christopher Thompson, Harvard Medical School, Boston, US, asked ‘Can obesity be treated using an endoscope?’ 

He began his talk by acknowledging that all the current bariatric procedures are effective on an individual patient basis, although they do have limitations including complications, post-surgical nutritional deficiencies, post-surgery regime compliance and cost. In addition, he said that lifestyle changes (diet) and medical therapy did not work in the long term and had so far provide unsuccessful, respectively.

“Therefore, we have surgery which tends to be more effective but a higher risk and lifestyle or medical therapy which reduce the risk but are less effective,” commented Thompson. “I think the less invasive endoscopic approaches could provide the solution as a low risk, highly-effective bariatric procedure.”

He said that there could be an array of endoscopic treatment modalities to treat patient’s condition. For example, endoscopic procedures could be utilised to treat a patient’s metabolic disease (diabetes) before they become obese, they could be used to intervene earlier before the patient’s condition worsens (ie. BMI<30) or these newer endoscopic procedures could be used at a bridge therapy to assist patients in losing sufficient weight so they can have additional surgery (eg orthopaedic or cardiac surgery).

Thompson described several different endoscopic approaches currently on the market or under development including suturing devices, gastric balloons, staplers, plicating devices and implantable sleeves. Each one of there may have a role in certain categories of procedures, for example the suturing device may have a role in bridge therapy or early intervention, he added. 

He explained that the aim of bridge therapy is to achieve significant weight loss over a relatively short period of time and the durability of the procedure is not of crucial importance as this is a temporary intervention. One such procedure is an intra-gastric balloon (air filled balloons, fluid filled balloon, double balloons), which has been shown to lead to effective weight-loss, with few complications.

“For early intervention,” Thompson said, “Safety is paramount and durability and repeatability do become important for these procedures.” He said that obesity is missing a component that is seen when treating other conditions. For example, an orthopaedic or cardiac patient’s treatment pathway can include lifestyle changes, medical therapy, minimally-invasive intervention (arthroscopy and angioplasty) to major intervention (replacement and bypass). Currently, Thompson argued that there was no minimally invasive option.

He then explained the step-by-step methodology of endoluminal vertical gastroplasty using a transoral approach to suture the anterior and posterior gastric walls. Thompson cited the series by Dr Roberto Fogal who reported 64 patients achieved EWL 58.1% at 12 months. He also mentioned the Transoral Gastric Volume Reduction as an Intervention for Weight Management (TRIM) study that treated 18 patients using the RESTORe Suturing System and reported modest decreases in weight, BMI and waist circumference. However, the plications were not durable and the effects of the procedure varied widely among the study participants. 

Thompson also mentioned the endosleeve and the benefits of a new technology, magnets. These can be place endoscopically and can be manipulated to form shapes and could be particularly helpful in suturing.

“In conclusion, in order to treat obesity it is necessary to have a multi-disciplinary approach and different treatment paradigms to facilitate intervention at a variety of different stages of the disease,” he concluded. “The long term efficacy, safety and cost effectiveness need to be assessed, but I am hopeful that they will utilised in the fight again obesity.”

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