Obesity’s complex etiology and its nature as a chronic, relapsing disease necessitate a multispecialty approach to management.
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Dietary and lifestyle modification, pharmacotherapy and bariatric surgery have been the traditional mainstays of comprehensive obesity treatment programs. Each modality has potential benefits and limitations, and none by itself is universally applicable to patients struggling with obesity. Bariatric surgery is the most effective intervention for weight loss, but less than 1% of eligible patients undergo bariatric procedures annually. Even in the most successful bariatric programs, some patients may regain weight postoperatively, which illustrates the importance of longitudinal care and close follow up.
In the last decade, bariatric endoscopy has emerged as an additional therapeutic option, helping fill the gap between medical treatment and bariatric surgery.
Cleveland Clinic recently has begun a bariatric endoscopy program that is integrated into the institution’s overall multispecialty bariatric weight loss initiatives. The program provides a comprehensive range of endoscopic procedures to address various needs: as primary therapies for patients with obesity; as secondary treatment when patients have regained weight after bariatric surgery; and to address complications stemming from bariatric surgery.
“Not all patients have the same needs,” says newly appointed Director of Bariatric Endoscopy Roberto Simons-Linares, MD. “Bariatric endoscopy is in a kind of sweet spot in terms of invasiveness and efficacy. With its addition at Cleveland Clinic, we have an even greater variety of programs and options available for patients.”
A viable primary therapy
Obesity — defined as a body mass index (BMI) of 30 or higher — is a common, serious and costly disease that affects nearly half of all adults in the United States, according to the Centers for Disease Control and Prevention. It is associated with significant health risks, including heart and kidney disease, stroke, diabetes and certain cancers. Obesity disproportionately affects Black and Hispanic adults and people of lower socioeconomic status.
Traditional bariatric surgery is considered an appropriate option for patients with Class 2 obesity (BMI of 35 to < 40) and comorbidities, and for any patients with Class 3 or severe obesity (BMI > 40). Until the advent of bariatric endoscopy, patients who did not qualify for or did not want to undergo weight-loss surgery were limited to pharmacotherapy and lifestyle/dietary modification as primary treatment.
Primary bariatric endoscopy procedures include:
- Reduction of gastric size using full-thickness and durable endoscopic sutures for the endoscopic sleeve gastroplasty (ESG) procedure.
- Implantation of a space-occupying, satiety-inducing intragastric balloon.
- Placement of a device similar to a percutaneous endoscopic gastronomy tube for aspiration therapy, allowing a patient to remove as much as 30% of gastric contents after a meal to reduce intestinal absorption.
- Small bowel therapies to reduce absorption involving either implantation of an endoluminal duodenal-jejunal bypass liner or the application of heat to resurface the duodenal mucosa. Both procedures are considered investigational and are not yet approved for widespread clinical use.
Dr. Simons-Linares and other members of the multidisciplinary obesity care team work together to determine whether endoscopy or another approach is the most suitable primary treatment for a patient with obesity, while taking the patient’s preferences into account and providing personalized care.
“We collaborate closely with our bariatric surgery partners as well as specialists in obesity medicine, endocrinology, cardiovascular disease, hypertension and sleep medicine, among others,” he says. “Sometimes bariatric endoscopy is the best option, and other times a patient is better served with a surgical gastric bypass and I will refer them to my colleagues. The whole point is doing what’s best for the individual patient.”
Bariatric endoscopy may also serve as an interim treatment for patients who need to lose weight to qualify for surgeries such as joint replacement or organ transplant, and as a means for patients with obesity who have recovered from cancer to lose weight, improve their health and reduce the risk of cancer recurrence.
Secondary uses and complication management
While traditional bariatric surgery to create a restricted or malabsorptive anatomy can produce substantial initial weight loss and improve comorbidities such as diabetes and hypertension, some patients may regain weight postoperatively.
The etiology of postoperative weight regain is complex, but may sometimes be due in part to eventual dilatation of the gastrojejunostomy or expansion of the gastric pouch in gastric bypass patients or dilation (stretching) of the gastric sleeve anatomy in sleeve patients. There are several minimally invasive endoluminal procedures that are effective alternatives to surgical revision for regained weight, including:
- The transoral outlet reduction (TORe) procedure for gastric bypass patients, which involves endoscopic (scarless) suturing through the mouth to decrease the gastrojejunostomy stoma diameter, with or without gastroplasty to decrease the size of the gastric pouch.
- The sleeve-in-sleeve procedure for patients with a prior gastric sleeve, which involves endoscopic revision with suturing through the mouth to reduce stomach sleeve volume.
Endoscopy also can be useful to assess and manage complications resulting from surgery, including:
- Gastrojejunal anastomosis strictures/stenosis in gastric bypass patients.
- Gastric sleeve stenosis or narrowing.
- Marginal anastomotic ulceration.
- Gastro-gastric fistula or other post-bariatric surgery gastrointestinal fistulas.
- Biliary problems in gastric bypass (using the endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography [EDGE] procedure).
- An abnormal gastric remnant (i.e., excluded stomach) in gastric bypass patients (using the Gastric Access for Temporary Endoscopy [GATE] procedure).
- Complex GI bleeding in bariatric surgery patients.
- Dumping syndrome in gastric bypass patients.
- Postsurgical leaks or fluid collection (using stents, pigtails, suturing, endoluminal vacuum therapy, over-the-scope clips and other methods).
Since the program’s launch in August 2021, Dr. Simons-Linares and his team have utilized bariatric endoscopy for all types of obesity treatment: primary, secondary and to address postsurgical complications.
The importance of advanced training
Dr. Simons-Linares received his bariatric endoscopy training in a dedicated fellowship at Boston’s Brigham and Women’s Hospital, Harvard Medical School, under the tutelage of Christopher Thompson, MD, one of the pioneers of the field. Specialized training from experienced teachers at a high-volume bariatric treatment center is essential for good outcomes, especially in complex cases, he says.
“Our program at Cleveland Clinic provides the full spectrum of bariatric endoscopy,” Dr. Simons-Linares says. “We benefit from the large volume of bariatric surgery patients and patients with obesity that we treat. As our bariatric endoscopy program grows over the next year or two, I don’t see any barrier to starting our own bariatric endoscopy fellowship to train future experts in these advanced bariatric procedures.”