CHICAGO – Conventional weight loss surgery – whether laparoscopic banding or laparoscopic sleeve gastrectomy – represents an important treatment option for individuals struggling to fight obesity. Not every patient seeking weight loss surgery is a candidate for these procedures, however.
Now, these individuals may have another option.
A study presented Saturday at Digestive Disease Week (DDW) 2017 in Chicago and featured in the meeting's press conference suggested that individuals with obesity who are not candidates for weight loss surgery may benefit from nonsurgical endoscopic sleeve gastroplasty (ESG), a procedure performed at a growing number of medical centers around the U.S.
During the ESG, a physician uses an endoscope to create tucks in the stomach, accordion-style, by suturing pleats to reduce its volume, leaving patients to feel fuller faster to help diminish their appetite, explained Reem Sharaiha, assistant professor of medicine at Weill Cornell Medicine and attending physician at New York-Presbyterian/Weill Cornell Medical Center. The procedure is distinct from laparoscopic sleeve gastrectomy, which involves an incision to place a tube in the abdomen and allow doctors to reduce the stomach's volume, and laparoscopic banding, which involves an incision and insertion of a tube to place a band around the stomach and restrict food intake.
Sharaiha and colleagues followed 278 patients who underwent either ESG (n=91), laparoscopic sleeve gastrectomy (n=120) or laparoscopic banding (n=67). Regardless of their procedure, patients went to an academic bariatric center of excellence for one year of follow-up as part of their treatment.
At the end of that time, patients who chose laparoscopic sleeve gastrectomy surgery achieved the greatest percentage of total body weight loss at 29.28 percent, compared to 17.57 percent for ESG patients and 14.46 percent for laparoscopic banding patients. Patients who received endoscopic treatment had a dramatically lower complication rate (1 percent) than those who received surgical treatment (10 percent for laparoscopic sleeve gastrectomy and 11 percent for laparoscopic banding).
Patients who underwent ESG also had shorter hospital stays and lower costs than those who underwent laparoscopic surgery, according to the researchers. ESG patients typically left the hospital on the same day of treatment, while laparoscopic sleeve gastrectomy patients stayed for about three days and laparoscopic banding patients for 1.5 days. Correspondingly, ESG resulted in an average institutional procedure cost of $12,000, compared to $22,000 for laparoscopic sleeve gastrectomy and $15,000 for laparoscopic banding.
A single-center study of 25 ESG patients published last year in Endoscopy International Open reported the procedure was associated with a favorable safety profile, with minor pain and nausea as the main side effects. No bleeding episodes or long-term complications occurred.
Considering the toll of obesity on U.S. health outcomes and expenses, additional treatment measures are urgently needed, Sharaiha pointed out. From a public health perspective, obesity – associated with heart disease, stroke, diabetes and certain cancers – is thought to be the second-leading cause of preventable death from medical causes in the U.S., after tobacco use. More than one in three U.S. adults is considered obese, with a body mass index of 30 or more, according to the Centers for Disease Control and Prevention, which estimated the related medical cost in the U.S. at approximately $147 billion in 2008.
Despite this trend, only 2 percent of individuals eligible for weight loss surgery undergo these procedures each year. The reasons range from fear of surgical risks to the cost of surgery, which is not universally covered by insurers.
In general, individuals with a body mass index (BMI) above 40 are candidates for weight loss surgery, Sharaiha added, noting that individuals deemed to have contraindications and those who choose not to have surgery are still candidates for ESG. In addition, individuals with a BMI of 30 to 40, who are typically not referred for laparoscopic surgery, may be candidates for ESG.
"We're not suggesting the endoscopic approach should replace the two surgical options," Sharaiha emphasized. However, the study – the first to compare the three treatments – suggested ESG offers another safe, reliable and cost-effective option that patients and health care providers should consider when discussing weight management treatments, she said.
In terms of insurance coverage, about 10 percent of patients in the ESG study received approval for the procedure because they were at high risk or had comorbidities that required weight loss but were not candidates for surgery, according to Sharaiha. But the impact of a high percentage of private pay patients in the study might have been a confounding variable, she acknowledged.
"When people pay for a procedure or are motivated to undergo weight loss procedure, they may do better," Sharaiha said. "We tried to control for our findings on various confounders, but pay isn't something we looked at."
The study also was not designed to address larger questions about clinical benefits associated with ESG, but Sharaiha said patients studied by her team, including those with diabetes and prediabetes, showed improvement in hemoglobin A1c scores.
"In addition to that, we also saw improvement in blood pressure, in liver function tests and in waist circumference," she said. "This is definitely a new and exciting field."