Feb. 12, 2022

Endoscopic approaches have become a valuable tool in managing obesity. The endoscopic sleeve gastroplasty (ESG) is a novel, minimally invasive gastric reduction procedure that attempts to replicate the volume reduction achieved through a traditional sleeve gastrectomy surgery.

ESG can be performed as an outpatient procedure, with minimal long-term complications and a low incidence of associated serious adverse events. ESG may be a viable option for patients with a body mass index lower than recommended for bariatric surgery who haven't been successful in maintaining weight loss with lifestyle modification alone. ESG is also appealing to payers, as it is cost-effective when compared with bariatric surgery.

Despite the widespread adoption of and encouraging results associated with ESG over the last five years, consensus related to ESG technique, training, and pre- and post-procedure patient management have yet to be established. Using a digital platform, a team of Mayo Clinic researchers conducted a worldwide survey to assess practice trends and preferences of bariatric endoscopists with respect to ESG. The results of that survey were published in the Journal of Clinical Gastroenterology in 2021.

Co-authors Vivek Kumbhari, M.B.Ch.B., Ph.D., and Dilhana S. Badurdeen, M.B.B.S, explain that the researchers emailed a link to an electronic questionnaire to 1,200 bariatric endoscopists who received training to perform endoscopic plication using a suturing device. From this pool of 1,200 potential survey participants, 221 responded. Dr. Kumbhari is a gastroenterologist and chair of Gastroenterology and Hepatology at Mayo Clinic in Florida. Dr. Badurdeen is a gastroenterologist at Johns Hopkins Medicine in Baltimore and will transition to Mayo Clinic in Florida in May 2022.

The researchers note that they believe their survey to be the largest anonymous international survey of endoscopists on this topic. The survey questionnaire addressed five categories of information: team structure, the ESG procedure, adverse events, barriers to starting an endobariatric program and other bariatric procedures.

"Overall, the response data collected demonstrated differing approaches to ESG technique, training, or pre- and post-procedure management of the patient," says Dr. Kumbhari. "For example, survey respondents who were proceduralists used a varying number of sutures, bites per suture and suture patterns when discussing their approach to and processes for the procedure."

One unexpected finding within the survey data was the importance that bariatric endoscopists attributed to both pre-procedure and post-procedure follow-up performed by a multidisciplinary team. "Our survey data indicated that the majority of respondents performing this procedure have a robust support team," explains Dr. Badurdeen.

Although the survey results suggest that attitudes toward ESG and practice trends remain heterogenous among practitioners, the results will provide a fundamental structure for development of future guidelines.

"Our data provide a perception of provider attitude about how ESG is being performed around the world and highlight the value of industry-led training and physician proctorship, which are unconventional in gastrointestinal endoscopy," says Dr. Kumbhari. "Most importantly, our results provide a foundation and framework to conceptualize future studies and guidelines. This survey is a steppingstone toward setting up a registry to document the overall outcome of ESG and is a reasonable approach to advancing the practice of ESG."

The researchers note that future randomized controlled trials investigating the optimal technique are crucial. Procedural modifications to enhance durability of the tubular gastric lumen, and technique variations to achieve weight loss outcomes similar to those of bariatric surgery with clinically significant metabolic improvement will likely broaden the adoption of ESG.

"We believe that endoscopic procedures will be the eventual solution to the core obesity epidemic," says Dr. Badurdeen. "They are conceivably safer than bariatric surgery and more cost-effective. Patients desire a less invasive procedure that is as effective as bariatric surgery. Combination therapy using ESG and obesity medications has demonstrated augmented weight loss outcomes nearing those of bariatric surgery. Similarly, bariatric endoscopists — both gastroenterologists and bariatric surgeons — have indicated a desire for a procedure that is effective but also easy to perform with minimal serious adverse events."

The co-authors also explain that future widespread adoption of ESG could mean that gastroenterology and bariatric surgery societies will offer formal training in endobariatric procedures and provide preoperative, intraoperative and postoperative management algorithms to optimize outcomes. In addition, future research will likely target the pathophysiology of obesity at a cellular and human behavioral level so that treatment can be personalized.

For more information

Badurdeen D, et al. The attitude of practitioners towards endoscopic sleeve gastroplasty. Journal of Clinical Gastroenterology. In press.

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