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Endoscopic Sleeve Gastroplasty for Obesity: The Mayo Clinic Experience

Endoscopic Sleeve Gastroplasty for Obesity: The Mayo Clinic Experience

Despite the positive impact of bariatric-metabolic surgery, only 1% of qualified patients receive surgery because of limited access, patient preference, risks, and cost of surgery.1  Given this low utilization rate of surgery and limited efficacy of life-style and pharmacological interventions, a significant gap exists in our current approach to obesity contributing to unprecedented rates of the disease and escalation of co-morbid conditions resulting in an enormous economic burden on our health care system.Endoscopic bariatric therapies (EBTs) can potentially offer effective weight loss intervention at lower cost, and higher patient acceptability, potentially bridging the current obesity management gap.3 Multiple EBTs have targeted the stomach by reducing its volume or restricting its accommodation. The stomach plays a key role in appetite regulation.4  Furthermore, gastric volume reduction through creation of restrictive sleeves or pouches is an important component of bariatric surgical procedures such as Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy.

Barham K. Abu Dayyeh MD MPH Advanced Endoscopy and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester MN, USA Assistant Professor of Medicine, Mayo Medical School, Rochester, MN, USA

Early attempts at endoscopic gastric suturing for weight loss used superficial endoscopic suturing devices that only replicated the anatomic manipulation of marginally effective bariatric surgical procedures such as the vertical banded gastroplasty. 5, 6 Although these techniques and devices had limited clinical adoption, they paved the way for newer full thickness suturing systems and demonstrated the feasibility of endoscopic reduction of the gastric reservoir for management of obesity.

Endoscopic sleeve gastroplasty (ESG) is a transoral endoscopic gastric volume reduction technique that reduces gastric capacity by creating an endoscopic sleeve (Figure 1). This is accomplished by a series of endoluminally placed full-thickness sutures through the gastric wall, extending from the antrum to the gastroesophageal junction. This technique reduces the entire stomach along the greater curvature, creating a sleeve.

Figure 1: Endoscopic sleeve gastroplasty (ESG) is a transoral endoscopic gastric volume reduction technique that reduces gastric capacity by creating an endoscopic sleeve

ESG is created by using a commercially available endoscopic suturing device (Overstitch; Apollo Endosurgery, Austin, Tex) that requires a double-channel therapeutic gastroscope to operate. Full-thickness suture placement is aided by the use of a tissue helix device that captures the targeted suture placement site on the gastric wall and retracts it into the suturing arm of the device (Figure 2).

Figure 2: Full-thickness suture placement is aided by the use of a tissue helix device that captures the targeted suture placement site on the gastric wall and retracts it into the suturing arm of the device

We first demonstrated the feasibility of this technique at Mayo Clinic in humans in 2013.7 Since then multiple other groups demonstrated the safety and efficacy of this technique.8-10 A prospective Spanish study of 50 patients with baseline body mass index of 37.7 kg/m² showed a %excess weight loss of 53% and 57% at 6 and 12 months, respectively, with no serious adverse events. 9 Another multicenter study of 82 patients with BMI of 36.2 kg/m² demonstrated a %total body weight loss (%TBWL) of 17.8% and 19% at 6 and 12 months, respectively.10

Since these initial reports, we have been offering ESG clinically at the Mayo Clinic and found it to be a well-tolerated outpatient intervention, requiring less than two hours of endoscopy time after a short initial learning curve, with the majority of patients returning to a fully functional status within 1-3 days after the intervention. We have found the majority of suture plications to be intact at repeat endoscopy after three months with formation of fibrotic bridges (Figure 3).

Figure 3: suture plications to be intact at repeat endoscopy after three months with formation of fibrotic bridges

Finally, we have been studying the physiological perturbations resulting from creation of the ESG and demonstrated that ESG is associated with impairment of gastric emptying, increased satiation and metabolic effects that are potentially important to control the metabolic dysregulation associated with obesity.11

In our experience, ESG may have an important role in the treatment of patient with obesity who do not qualify or wish to undergo bariatric surgery. Thus, it may offer a paradigm shift in our management of obesity that targets current gaps in therapy and may allow us to gain ground in our losing battle against obesity.

Literature citing

  1. Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 2013;9:159-91.
  2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806-14.
  3. Abu Dayyeh BK, Edmundowicz SA, Jonnalagadda S, Kumar N, Larsen M, Sullivan S, Thompson CC, Banerjee S. Endoscopic bariatric therapies. Gastrointestinal endoscopy 2015;81:1073-86.
  4. Cummings DE, Overduin J. Gastrointestinal regulation of food intake. The Journal of clinical investigation 2007;117:13-23.
  5. Fogel R, De Fogel J, Bonilla Y, De La Fuente R. Clinical experience of transoral suturing for an endoluminal vertical gastroplasty: 1-year follow-up in 64 patients. Gastrointestinal endoscopy 2008;68:51-8.
  6. Brethauer SA, Chand B, Schauer PR, Thompson CC. Transoral gastric volume reduction as intervention for weight management: 12-month follow-up of TRIM trial. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery 2012;8:296-303.
  7. Abu Dayyeh BK, Rajan E, Gostout CJ. Endoscopic sleeve gastroplasty: a potential endoscopic alternative to surgical sleeve gastrectomy for treatment of obesity. Gastrointestinal endoscopy 2013;78:530-5.
  8. Sharaiha RZ, Kedia P, Kumta N, DeFilippis EM, Gaidhane M, Shukla A, Aronne LJ, Kahaleh M. Initial experience with endoscopic sleeve gastroplasty: technical success and reproducibility in the bariatric population. Endoscopy 2015;47:164-6.
  9. Lopez-Nava G, Galvao MP, Bautista-Castano I, Jimenez-Banos A, Fernandez-Corbelle JP. Endoscopic Sleeve Gastroplasty: How I Do It? Obesity surgery 2015;25:1534-8.
  10. Kumar N, Lopez-Nava G, Sahdala HNP, Manoel GN, Sharaiha RZ, Wilson EB, Shaikh S, Gomez E, Ryan MB, Zundel N, Thompson CC. Endoscopic Sleeve Gastroplasty: Multicenter Weight Loss Results. Gastroenterology 2015;148:S179-S179.
  11. Abu Dayyeh BK, Acosta A, Topazian M, Rajan E, Camilleri M, Gostout CJ. One-Year Follow-Up and Physiological Alterations Following Endoscopic Sleeve Gastroplasty for Treatment of Obesity. Gastroenterology 2015;148:S11-S12.

Apollo Endosurgery will be hosting a hands-on session at 7th BOMSS Annual Scientific Meeting on the new endoscopic suturing device. To register your interest in attending this event, please click here

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