The Journal of the Arkansas Medical Society Med Journal Jan 2020 | Page 6

Commentary
by Benjamin Tharian, MD
Role of Endobariatrics
in Metabolic Medicine
O
besity is a global pandemic with in-
creasing prevalence. World Health
Organization (WHO) classifies over-
weight as Body Mass Index (BMI) of
25.0 to 29.9 and obesity as BMI of 30 or high-
er. As per 2016 statistics, 39% of all adults
(men and women) were overweight. Obe-
sity was noted in 11% and 15% in men and
women, respectively. This accounts for two
billion adults with overweight category and
more than one-half billion as obese. 1 With
this increasing trend, obesity-related com-
plications are on the rise. 2 A multifaceted ap-
proach is required to target this concerning
trend. Increasing awareness among youth
about overweight and obesity and early life-
style changes, including pharmacotherapy,
are recommended. Individuals who fail the
above options could be considered for bar-
iatric surgery. Though bariatric surgery is
effective in weight loss, it has a 30-day mor-
tality rate of 0.3% and a complication rate
of 7-10%. 3 Thus, techniques to reduce these
complications and increase the rate of weight
loss and reversing the metabolic profile of pa-
tients led to a new field of endoscopy called
Endobariatric and metabolic therapy (EMT).
This involves the use of flexible gastrointes-
tinal endoscopes via a natural orifice instead
of the open or laparoscopic route; a safer and
highly cost-effective procedure, it offers an
advantage of no skin incision, though bariat-
ric surgery remains the gold standard.
EBT was introduced for the first time in
1980 with intragastric balloon placement. 4
EBT underwent major improvements since
then, with the approval of multiple devic-
es by the FDA. The goal of EBT is to achieve
targeted, sustained weight loss with the im-
provement of metabolic profile of the individ-
ual, with the least complications and a high
safety profile. These procedures could be
utilized for weight loss and improving meta-
154 • The Journal of the Arkansas Medical Society
bolic profile, or they could be a bridge to ob-
taining some amount of weight loss before a
definitive bariatric surgery could be planned.
These procedures include a wide variety of
procedures targeting gastric and small intesti-
nal segments of the gastrointestinal tract. All
the procedures aim for calorie restriction but
decreasing the absorption.
EBT could be gastric or small intestinal.
Three gastric balloons are approved for use so
far – Orbera, 5 Reshape Duo, 6 and Obalon 7 – and
few are under investigation. 8 These balloons
could be introduced either non-endoscopical-
ly or endoscopically and inflated to a variable
volume (250 – 900 mL) to fill the gastric lumen
creating a sensation of fullness. The number
of balloons varies with the type of device.
Most of these balloons are tolerated well with
improvement of the metabolic profile, includ-
ing diabetes, hypertension, hyperlipidemia,
osteoarthritis, and respiratory-related compli-
cations. Adverse events related to these intra-
gastric balloons include mucosal ulcerations,
nausea, vomiting, and (rarely) bowel obstruc-
tion and perforation. Other techniques such as
endoscopic sleeve gastroplasty (ESG), stapling
devices, transpyloric shuttle, magnetic anas-
tomotic system, and aspiration therapy have
been introduced. These procedures include
suturing part of the stomach, inflating balloon
along the transpyloric area, and aspirating
contents of the stomach with a gastrostomy
tube and siphon assembly.
The goal of small intestinal procedures
includes bypassing the biliopancreatic limb
of the intestine so that the food enters directly
from the gastric lumen to mid to distal jeju-
num. This augments rapid improvements in
glycemic control and resolution of type II di-
abetes. 9 Some of the techniques include duo-
denal-jejunal bypass (Endobarrier), Duodenal
Mucosal Resurfacing (DMR, Revita), bypass
sleeve (ValenRx Endoluminla Bypass), and
use of self-assembling magnets for enteral
bypass in the small intestine (Incisionless
Anastomotic System). 10,11 These techniques
may mimic Roux-en-Y gastric bypass, result-
ing in weight loss and improved glycemic
status. Adverse effects of these procedures
include migration of devices, nausea and
diarrhea post-procedure, gastrointestinal
bleeding, sleeve obstruction, infection, and
perforation. 12
The goal of small intestinal
procedures includes bypassing
the biliopancreatic limb of the
intestine so that the food enters
directly from the gastric lumen
to mid to distal jejunum.
A learning curve exists for the endosco-
pists to master these new techniques. The
type of device used (gastric or small intestinal)
should be individualized with a detailed dis-
cussion about benefits and risks. As new tech-
niques such as endoscopic suturing and over-
the-scope clip devices are available for closing
the defects in the intestine and controlling the
bleeding, most of the complications can be
managed endoscopically without the need for
open surgery. With time and increasing expe-
rience related to these procedures, the safety
profile and excess weight loss will continue to
improve. Endobariatrics should be considered
as a new tool available as part of the multi-dis-
ciplinary care for these patients.
References
1. WHO | Overweight and obesity: World
Health Organization; 2019 [updated 2019-
03-18 14:26:01. Available from: https://
www.who.int/gho/ncd/risk_factors/over-
weight_text/en/.
2. Biener A, Cawley J, Meyerhoefer C. The
www.ArkMed.org