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In response to the obesity epidemic, rates of bariatric surgery have increased, particularly laparoscopic sleeve gastrectomy, which is now the most commonly performed bariatric surgery worldwide. Laparoscopic sleeve gastrectomy excises the greater curvature of the stomach, resulting in a restricted tubular reservoir approximately 25% of its native volume. Although technically simple, safe, and effective for weight loss, sleeve gastrectomy is associated with increased health care utilization costs secondary to multiple known serious adverse events (SAEs), and increased prevalence of worsened or de novo GERD with unknown associated long-term risks of Barrett’s esophagus and esophageal adenocarcinoma.
Given these limitations, particularly in patients with lower body mass index (between 30 to 40 kg/m2), endoscopic sleeve gastroplasty (ESG) is an attractive minimally invasive endoscopic alternative to surgery that expands the therapeutic benefits of effective obesity interventions targeting the GI tract to patients who do not qualify for or wish to pursue bariatric surgery.
add to a growing body of literature that suggests ESG is ready for prime time in the evolving management paradigm of obesity and metabolic disease. In their first 1000 cases, the mean percentage of total body weight loss at 12 months was 15.0% ± 7.7%, with an SAE rate of <0.01, consistent with previously reported multicenter data.
Endoscopic sleeve gastroplasty (ESG) is a reproducible and effective endoscopic bariatric therapy suitable for widespread clinical adoption: a large, international multicenter study.
To synthesize the evidence available to date to support the safety and midterm efficacy of ESG, we have collected all unique cases reported as large multicenter series, with care to avoid duplicated follow-up study results, which when combined with these data total 1607 unique cases. Across these data, percentage of total body weight loss at 6, 12, and 18 or more months was 15.8, 17.1, and 17.3, respectively (Fig. 1).
Figure 1Meta-analysis of percent total body weight loss after ESG.
Endoscopic sleeve gastroplasty (ESG) is a reproducible and effective endoscopic bariatric therapy suitable for widespread clinical adoption: a large, international multicenter study.
stems from their very granular reporting of adverse events in these first 1000 cases. This information allows us to now set realistic expectations for the incidence and prevalence of SAE rates to be expected with ESG, particularly when combined with the international multicenter data now reported in the literature totaling 1607 unique cases. Across these 1607 cases, the SAE rate was 1.1%, with a total of 18 events, including 7 fluid collections, 6 cases of hemorrhage requiring blood transfusion and/or endoscopic treatment, 3 cases of refractory symptoms requiring endoscopic ESG reversal, 1 pneumoperitoneum and pneumothorax requiring percutaneous drainage, and 1 pulmonary embolism (Table 1). We anticipate the authors’ next 2000 cases will eventually be reported with an even lower adverse event rate as improvements in technique and perioperative care are made with time and experience.
Table 1Serious adverse events across all major endoscopic sleeve gastroplasty reports totaling 1607 cases
Endoscopic sleeve gastroplasty (ESG) is a reproducible and effective endoscopic bariatric therapy suitable for widespread clinical adoption: a large, international multicenter study.
Although weight loss outcomes and adverse event rates are in line with previous reports, the most notable difference in the experience of Alqahtani et al
from prior studies is the significant rate of postprocedure presentation to the emergency department. The reasons for this are multifactorial and likely involve technical and patient-specific factors. However, a notable difference in practice is the authors’ recommendation to patients for immediate presentation to the emergency department with any postprocedure symptoms of concern. This resulted in high utilization of this resource, whereby 215 patients (21.5%) were evaluated in the emergency department after the procedure. Our collective experience in the United States with readmission and emergency evaluation rate ranges from 1% to 5%, given that most of our patients are treated with postprocedure office visits and phone triage rather than compulsory emergency department evaluation.
Several important issues remain unanswered by current studies, preventing the widespread adoption of ESG. In the United States, appropriate Current Procedural Terminology coding and insurance coverage remain significant barriers to utilization of endobariatric techniques. The impact of ESG on obesity comorbidities needs to be formally assessed and will likely provide the information and impetus necessary to lobby for widespread coverage of the procedure. A multicenter randomized trial is currently under way in the United States, which we hope will help shed light on these issues. In the meantime, endoscopists are increasingly positioned to play a vital role in the future therapy of obesity—arguably our world’s most significant public health problem to date.
Disclosure
Dr Abu Dayyeh is a consultant for USGI and Olympus and the recipient of research support from Apollo Endosurgery. The other author disclosed no financial relationships relevant to this publication.
References
Fayad L.
Adam A.
Schweitzer M.
et al.
Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study.
Endoscopic sleeve gastroplasty (ESG) is a reproducible and effective endoscopic bariatric therapy suitable for widespread clinical adoption: a large, international multicenter study.
Questions related to the safety and long-term efficacy of endoscopic sleeve gastroplasty (ESG) are not yet answered. Here we report weight loss, morbidity, revisions, and comorbidity resolution during the first 18 months after primary ESG.
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