Exploring Endoscopic Bariatric Weight Loss: What Do We Need to Know?

Dr. Nandi:
Welcome to GI Insights on ReachMD. I'm Dr. Neil Nandi. Endoscopic bariatric weight loss has evolved dramatically and has become an established discipline that supplements established surgical options. But as the field evolves, there are still many questions that clinicians continue to ask: Who is an appropriate candidate? What are the specific procedures that currently exist to accomplish weight loss via an endoscope? And why should we even consider an endoscopic approach with all the innovations that have occurred in laparoscopic surgery?

Joining me to provide his insights on advanced endoscopy for bariatric weight loss is Dr. Austin Chiang. Dr. Chiang is the Director of the Endoscopic Bariatric Program at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, where he brings patients the latest innovations in endoscopic bariatric weight loss. You may recognize Dr. Chiang as the First Chief Social Media Officer for Jefferson Health. Indeed, when Dr. Chiang is not wielding his superpower command of social media to disseminate truth and dispel online misconception, he is deep in the bowels of endoscopy, helping patients lose weight safely.

Welcome to GI Insights, Dr. Chiang.

Dr. Chiang:
Thank you so much for having me. I'm excited to be here.

Dr. Nandi:
So as we all know, obesity has been and continues to be a growing epidemic in the USA and other parts of the world. surgical options such as laparoscopic Roux-en-Y and sleeve gastrectomy have proven very effective. And I believe the data is even better for sustained weight loss with Roux-en-Y. But with the advent of endoscopic approaches, when and why, Austin, should GI clinicians consider endoscopic weight loss over bariatric? And are there clear guidelines on what factors to consider?

Dr. Chiang:
I think that a lot of it has to do with personal preference of the patient. But at the same time, there are also some patients who may not be appropriate for surgery, whether it's their surgical candidacy or performance status. So these options exist to help those patients out. And I think it's important to also keep in mind that after undergoing endoscopic procedures, surgery is often still an option. So it still provides another option for patients if they choose to do something before they proceed to surgery.

Dr. Nandi:
Can you please briefly describe some of the different types of endoscopic weight loss procedures?

Dr. Chiang:
Well, there are two general categories: one is primary endoscopic procedures for patients who've never undergone surgical weight loss before, and the other is revision procedures for patients who have previously undergone surgery. So for revision procedures often in the past, if somebody has gotten a gastric bypass procedure, there is something we can do called the endoscopic stoma reduction or transoral outlet reduction, where we can basically reduce the size of the gastro jejunal anastomosis to help patients feel full again and promote that sensation of satiety. For patients who have never undergone a surgical procedure before there are several FDA-approved options. One is the intragastric balloon. The other is aspiration therapy. And the endoscopic sleeve gastroplasty utilizes the endoscopic suturing device to basically create a series of stitches in the stomach and reduce the size of the stomach to a third of its original size.

Dr. Nandi:
You know, I find that really interesting that you mentioned that you are able to endoscopically, almost tighten up, if you will the anastomosis in those patients who've already had surgery, because it's not uncommon for us to see patients who have regained weight after a Roux-en-Y. So that's pretty intriguing that you're able to do that.

But some of the other procedures that you mentioned also have their pros and cons. Can you please elaborate on what are some of the risks or pros and cons of the different you know, non-surgical endoscopic procedures you mentioned?

Dr. Chiang:
I think some of the pros are that it's less invasive than surgery. Clearly, these different approaches vary a lot. For intragastric balloon, it's a balloon that sits in the stomach that remains in the stomach for a limited amount of time before having to be removed. Now some of these balloons require endoscopic placement, others do not. But ultimately, they are temporary. They only sit in the stomach for about six months before having to be removed. So the effects could be more limited than say the endoscopic sleeve gastroplasty where there are a series of stitches placed and those stitches are not absorbable and meant to stay in place. So the result is presumably a little more durable.

The cons of this procedure, of either of these procedures is that, you know, generally speaking as you had mentioned, the weight loss outcomes are a little bit less than surgery. But the trade-off is that it does tend to be less invasive, length of stay is shorter and generally considered safer.

Dr. Nandi:
So do you think that any of these could be used as a bridge to a Roux-en-Y in case the patient has, you know, very high obesity? Are any of these procedures used as a bridge to lose some weight just to get to a safer state?

Dr. Chiang:
Absolutely. I think some patients are seeking these procedures to undergo other types of surgeries, whether it's transplant or an orthopedic surgery which can potentially allow them to, you know, regain some mobility, lose more weight, and then undergo a bariatric surgery if need be.

Dr. Nandi:
For those just tuning in, you're listening to GI Insights on ReachMD. I'm speaking with Dr. Austin Chiang, Director of the Bariatric Endoscopy Center at Jefferson Health, on his insights on advanced endoscopic weight loss interventions.

Now, Austin, we were just talking about some of the pros and cons. You mentioned balloons, and those have been around for quite a while. How have they evolved? I've read presentations or case reports of those sometimes causing obstructions. Does that still occur? Is it still a concern?

Dr. Chiang:
It's very, very rare. There are several different types of balloons available on the market right now; two mainly. One is a single saline-filled balloon and the other is a series of three gas-filled balloons. There was another FDA-approved option with kind of a dual saline-filled balloon system which currently is not being marketed, although it may come back. The rates of obstruction are very, very rare. Some of the other kind of feared complications like leakage or deflation are also very rare. Most commonly, we see a good amount of discomfort, nausea and vomiting immediately after the procedure, but that tends to resolve after several days. And one of the disadvantages of these balloons is that they're not adjustable, and they do often require endoscopic placement or removal. But all of these three drawbacks are currently being re-engineered. And there are balloons in the pipeline that could potentially be approved by the FDA very soon.

Dr. Nandi:
Oh, that's exciting. I think technology is always continuously evolving.

So then of these different procedures that are at your disposal, when a patient comes to you, what kind of factors do you weigh to help them decide which procedure you're going to provide them?

Dr. Chiang:
I think that I often will ask their personal preference and kind of get a sense of what their expectations are with this procedure  if they are a surgical candidate. And I believe that their expectations are more well suited for a surgical procedure, then I will obviously refer them for surgical consultation as well. But aside from that, I think that some of the things that may prevent patients from getting surgery may be a deciding factor that can only where endoscopic procedures may be the only option for them.

Dr. Nandi:
I think you've done a really good job just kind of summarizing some of these advances. We talked about gastric balloon therapy. And then of course a marvel in my mind of the endoscopic sleeve gastrectomy. Are there any closing remarks that you want to leave our clinicians out there when they're considering who to refer to surgery or endoscopy to you for referral?

Dr. Chiang:
I think that if there's any consideration about patients wanting to lose weight and undergo a procedure, then a referral would never hurt to be evaluated by an endoscopic bariatric endoscopist like myself. I do want to emphasize that, you know, a procedure is one element within a much greater weight management plan that often includes a multidisciplinary effort from dieticians, psychiatrists, and other specialists. So this is just one part of the equation that can help patients achieve that caloric deficit to help them lose weight.

Dr. Nandi:
Absolutely. I think a multidisciplinary approach is the best approach. You mentioned nutrition, fitness, behavioral counseling. And again, since no two patients are alike, it's really nice to know that we have both surgical and endoscopic options that we can tailor to an individual patient's needs.

Austin, I really want to thank you for making the time and sharing your GI insights on our program today. Before we close, do you have any other parting thoughts?

Dr. Chiang:
Thank you so much for having me. I really appreciate it. Again, I think if there's anyone who thinks that their patient can benefit potentially from an endoscopic procedure, then it never hurts to refer to be evaluated and and I look forward to seeing the technology evolve and seeing where this entire field goes.

Dr. Nandi:
Thank you so much, Austin, for your time. For ReachMD I'm Dr. Neil Nandi. To access this episode and others from GI Insights, please visit ReachMD.com/GIInsights, where you can Be Part of the Knowledge. Thanks for listening.