Endoscopic Revision of Bariatric Surgery Combined with AOMs Is Successful at Treating Weight Regain

New research from Cleveland Clinic highlights the importance of individualized patient selection and combination therapy to treat obesity and weight regain after bariatric surgery effectively. The study, “What are the outcomes of combining endoscopic revision of prior bariatric surgery with newer anti-obesity medications?” was recently presented during the Digestive Disease Week Conference.

Although bariatric surgery is the most effective treatment for obesity, patients can still experience weight regain following the procedure. Anti-obesity medications (AOMs) and endoscopic revision of bariatric surgery (ERBS) are considered effective and safe, but data about combining newer AOMs — such as GLP-1 agonists (semaglutide, tirzepatide, etc.,) — with ERBS is limited. The study, led by senior author Roberto Simons-Linares, MD, explored outcomes using a combination of AOMs and ERBS to treat patients who had regained weight following bariatric surgery.

Study design and findings

“In our single-center, retrospective study, we looked at 50 patients who had undergone bariatric surgery but had subsequently regained weight,” explains Dr. Simons-Linares. “We looked at the percentage of total body weight loss (%TBWL) at six and 12 months post-ERBS, and we compared these numbers between patients receiving different AOM regimens.”

Among the 50 patients included in the study, 29 suturing TORe, 11 Re-ESG, nine Argon Plasma Coagulation (APC)-TORe and one endoscopic revision of laparoscopic gastric plication were included. The average baseline BMI was 39.84 (±6.63) kg/m², and there were no significant differences in patient age, sex, baseline BMI or comorbidities between procedure types.

On average, the patients used an average of 2.2 (±1.02) AOMs post-ERBS: orlistat (2%), phentermine (15%), naltrexone-bupropion (2%), liraglutide (10%), tirzepatide (20%), semaglutide (32%), dulaglutide (4%), metformin (30%), topiramate (32%), and bupropion (20%).

In follow-ups, the percent of total body weight loss (%TBWL) among the patients at 1-, 3-, 6-, and 12-month post-surgery were 6.44% (±2.96%), 10.27% (±4.34%), 11.95% (±6.27%), and 15.49% (±8.40%), respectively.

“We found that 38% of these patients actually achieved a nadir weight following ERBS that surpassed their nadir weight following primary bariatric surgery,” says Dr. Simons-Linares.

The researchers found no significant differences in %TBWL and the number of AOMs used at six (P = .9136) or 12 months (P = .6007). Furthermore, no significant difference in %TBWL was found for ERBS + concomitant GLP1-agonists [TBWL 12.41%] vs ERBS without GLP1-agonist [TBWL 11.53%] at six months (P = .6917) or 12 months [TBWL 16.02% vs 14.50%] (P = .6975).

“The group that had endoscopic revisions plus GLP-1/GIP had 16% TBWL, which is about 1.1% more than patients without medication, which is great, but it didn't reach a statistical significance,” explains Dr. Simons-Linares. “This was a little surprising to me. We’ve heard a lot about GLP-1s recently, and I thought that the group of medications would have more than just a 1% weight loss difference. That seems, to me, very little. Still, context is important here – the cohort of patients who were given these medications probably had more severe disease that was harder to treat which is why they were given these medications.”

The research group hopes that larger, future studies with greater numbers of patients and longer follow-ups can assess the effect of these medications in combination with ERBS long-term.

Takeaways

The research group stresses that while these findings show that ERBS ± AOMs in combination is successful for treating obesity in patients with weight regain after bariatric surgery, patient selection is essential, and these findings do not indicate that a one-size-fits-all approach should be taken.

“These findings don’t convey that an endoscopic approach is better than a medication approach or vise-versa,” explains Dr. Simons-Linares. “These were all patients who were enrolled in the Bariatric and Metabolic Endoscopy Medical Home Program at Cleveland Clinic. Because this was a retrospective study, the patients who were initiated on GLP-1 medications were probably struggling more and clinically we decided to continue to treat or enhance their treatment of obesity and weight regain with GLP-1 medication.

He continues, “The findings from this study confirm what we’re already doing at Cleveland Clinic, but they may be an eye-opener for many practices. We are pioneers in doing a study like this one and adding to the current literature on bariatric metabolic endoscopy. Our study shows that the approach of combining these therapies can work very well, but patient selection is extremely important and establishing a comprehensive multidisciplinary program can aid patient selection tremendously.”

Patient care at Cleveland Clinic

Dr. Simons-Linares believes that the multidisciplinary approach Cleveland Clinic takes towards caring for patients with obesity improves patient selection when considering ERBS ± AOMs. When a patient comes to the Bariatric and Metabolic Endoscopy Program, they first meet with a registered dietician who specializes in bariatric and metabolic endoscopy obesity weight regain and go through a psychologist assessment as well by a specialized psychologist. They’ll meet with the patient, assess the patient and do a workup to make sure they’re not missing any other complications related to obesity or weight regain. Then they evaluate obesity as a chronic complex and relapsing disease and decide which approach makes the most sense for that particular patient.

“When we’re selecting a care path for a patient, we take a multidisciplinary approach to determine what specifically needs to be addressed, and we practice individualized medicine” explains Dr. Simons-Linares. “This is before we even start a medication or a procedure. In our program, we do both endoscopic procedures and anti-obesity medication treatments for obesity. We take patient preference into account as well as evidence-based literature of what interventions you need to treat certain other diseases that come with obesity.”

He continues, “I think that the most important message also is there is no one-size-fits-all approach to care. Obesity is complex and recurrent, and it can be a chronic relapsing disease. We try to educate the patient in these aspects. Their obesity is not their fault. It is a disease that can be difficult to treat, but as long as the patient understands that and is motivated and shows up to their appointments, usually, they will have a very good outcome. I tell my patients, ‘The less you need the better. But if you need a combination of tools to battle obesity, we're going to work with you to provide the best care we can.”