The Approach to the Treatment of Morbid Obesity Through Endoscopic Gastroplasty (ESG) Volume 54- Issue 3

De Sena Gabriele¹*, Mauro Maria², Bentivoglio Davide², D’apice Flavia², Sglavo Nicola², Della Rocca Antonella², Di Chiara Maria Rosaria², Russo Antonella² and Porpora Danilo²

• ¹University of Ostrava, Czech Republic
• ²University of Campania Luigi Vanvitelli, Italy

Received: December 16, 2023; Published: January 05, 2024

*Corresponding author: De Sena Gabriele, University of Ostrava, Czech Republic

DOI: 10.26717/BJSTR.2024.54.008547

Abstract PDF

Abbreviations: ESG: Endoscopic Sleeve Gastroplasty; T2DM: Type 2 Diabetes; OSAS: Obstructive Sleep Apnea Syndrome; GERD: Gastroesophageal Reflux Disease; AHT: Arterial Hypertension; EWL: Excess Weight Loss; EB: Endoscopic Bariatric

The global epidemic of obesity has become a significant health concern, associated with substantial morbidity and mortality. Over the span of four decades, from 1975 to 2016, the prevalence of obesity worldwide has nearly tripled [1]. Despite efforts through lifestyle modifications and pharmacotherapy, achieving sustained weight loss remains a challenge for most individuals. Bariatric surgery stands out as a proven, long-term solution for weight loss, particularly in patients with class III and class II obesity-related comorbidities. However, this surgical intervention, while effective, is irreversible and carries inherent risks. Compounding the issue, less than 1-2% of eligible patients ultimately undergo bariatric surgery [2-4]. To address this treatment gap, endoscopic bariatric (EB) procedures have emerged as a minimally invasive alternative, bridging the divide between medical and surgical approaches to combat the obesity epidemic. Among these, Endoscopic Sleeve Gastroplasty (ESG) has gained prominence [5]. ESG, introduced in 2012 by Thompson and Hawes, employs a minimally invasive technique utilizing an endoscopic suturing device (such as the OverStitch by Apollo Endosurgery (Figures 1 & 2) or the Endomina System (Figure 3)) to apply full-thickness sutures in the stomach. This approach aims to reduce gastric capacity and modify gastric motility, offering an alternative to traditional bariatric surgery [6]. Since its inception, ESG has garnered increasing interest, with numerous studies highlighting its safety and efficacy [7-9].

The procedure represents a promising avenue for the management of severe obesity, providing a minimally invasive option with potential benefits that extend beyond those of conventional surgical interventions. Executing the Endoscopic Sleeve Gastroplasty (ESG) demands meticulous attention to specific procedures. The procedure necessitates general anesthesia administered by an anesthesiologist, with insufflation using CO2. Unlike traditional practices, there is no mandatory stomach marking for orientation before commencing the procedure. Suturing patterns play a crucial role, with the square/rectangle or U pattern commonly chosen (Figure 4), involving the application of 4–6 sutures in each case. It is essential to refrain from suturing the antrum while focusing on reducing the greater gastric curvature (Figure 5). Addressing the fundus, endoscopists typically aim to reduce the most distal part (Figure 6). To enhance patient safety, antibiotics should be infused either before or immediately after the procedure. Remarkably, hospital discharge can be facilitated on the same day, emphasizing the minimally invasive nature of ESG. The ESG procedure technique displays variability across studies, with notable devices such as the double-channel Apollo OverStich System (Figure 1), the single-channel Apollo OverStich SX System (Figure 2), and the Endomina System (Figure 3) being employed [10-12].

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

ESG is specifically indicated for the upper gastrointestinal tract post-reduction in diameter and length of the stomach, with a primary focus on preserving the fundus. The procedural goal is to achieve a tube-like reduction along the greater curvature, rather than maximal lumen reduction [8,13].

Absolute contraindications for ESG encompass active gastric ulcers in the body or fundus, congestive gastropathy, gastric polyposis, gastric or esophageal varices, and uncontrolled or untreated psychiatric disorders [8,14].

In preparation for ESG, a preoperative endoscopy is imperative, performed by any endoscopist or the one executing the procedure. Additionally, a comprehensive laboratory work-up is mandatory. Pre-operative anticoagulation for deep vein thrombosis prophylaxis should align with clinical criteria. Ensuring a surgeon’s participation in the team is crucial, especially when the ESG is conducted by a gastroenterologist. A multidisciplinary team, including a dietitian and psychologist, is essential for comprehensive patient follow-up [8,14].

Post-procedure, patients may receive recommended medications for the adaptation period, such as PPI, fosaprepitant; ondansetron, hyoscine/scopolamine, steroid (dexamethasone), and analgesics. PPIs should be continued for 1–3 months post-procedure [8,11,14].

Routine use of metoclopramide is discouraged, and NSAIDs should be avoided. Typically, antibiotic therapy is unnecessary post-procedure. Deep vein thrombosis prophylaxis should be considered based on clinical evaluation. Follow-up should extend for at least 12 months. The most commonly reported complication is hematemesis, attributed to the internal nature of the sutures in ESG procedures, potentially causing gastric irritation and vomiting even with minor bleeding [8,11,14].

Obesity, along with its associated complications such as type 2 diabetes, arterial hypertension, and dyslipidemia, constitutes a significant public health challenge. Laparoscopic sleeve gastrectomy (LSG) currently stands as the predominant bariatric surgical procedure. However, the Endoscopic Sleeve Gastroplasty (ESG) technique, while similarly focusing on the greater curvature of the stomach, presents several notable distinctions. Unlike LSG, ESG entails no abdominal incisions, eliminates the need for an operating room, and, in certain cases, is reversible. ESG induces remodeling while preserving the stomach’s innervation and blood supply, providing potential repeatability and conversion to bariatric surgery if necessary [15]. ESG emerges as a particularly effective method for weight loss in patients unwilling or unable to undergo surgery, surpassing the outcomes achieved through drug treatments and physical exercise alone. Moreover, it might be considered a preparatory treatment for individuals with excessive obesity, for whom immediate bariatric surgery is contraindicated due to technical reasons. However, it’s essential to note that data on the reduction of co-morbidities and associated biological parameters are still evolving and await widespread validation, similar to the established evidence for traditional bariatric surgery.

A significant contribution to the evolving knowledge on ESG comes from the MERIT trial, a major prospective randomized American multicenter study published in 2022. Among the 209 participants with class I or II obesity, those in the ESG group, coupled with lifestyle modification, demonstrated remarkable success. At 52 weeks, 77% achieved 25% or more excess weight loss (EWL) compared to only 12% in the control group. Impressively, this positive trend continued, with 68% maintaining an EWL of 25% or more at 104 weeks. Notably, ESG showcased broader health benefits, with 80% of participants experiencing improvement in one or more metabolic co-morbidities at 52 weeks. Furthermore, serious adverse events related to ESG were limited, occurring in only 2% of participants, with no mortality or need for intensive care or surgery reported.

The reduction in arterial hypertension (AHT), type 2 diabetes (T2DM), gastroesophageal reflux disease (GERD), obstructive sleep apnea syndrome (OSAS), and dyslipidemia correlated significantly with weight loss at six months, stabilizing at one year. A total weight loss exceeding 10% led to a substantial reduction in obesity-related co-morbidities [16]. Studies by Alqahtani et al. and Sharaiha et al. further support the efficacy of ESG. Alqahtani reported significant remission rates, including 76.5% for T2D, 100% for hypertension, and 56.3% for dyslipidemia at 12 months post-ESG. Sharaiha’s findings indicated sustained weight loss after ESG over five years, reinforcing the long-term metabolic effects of the intervention. The correlation between weight loss and improvements in biological parameters underscores the metabolic efficacy of ESG, a trend consistent with studies in the surgical literature. In light of these findings, ESG emerges as a viable treatment for obesity-related co-morbidities, especially for patients who may not be candidates for surgery or prefer non-surgical interventions. Proposing ESG in such cases holds promise for reducing long-term morbidity and mortality associated with obesity and its myriad pathologies [17-19].

The endoscopic approach to bariatric surgery offers a compelling alternative by avoiding incisions and scarring, introducing reversibility, and demonstrating a low incidence of serious complications.

Endoscopic Sleeve Gastroplasty (ESG), when combined with comprehensive multidisciplinary management, targeted dietary interventions, and physical activity, proves to be a potent strategy for achieving substantial weight loss and mitigating associated co-morbidities. At the one-year mark, ESG demonstrates a noteworthy total weight loss of 16.6%, showcasing its effectiveness as a minimally invasive intervention. Importantly, this weight loss is accompanied by a significant reduction in co-morbidities, including hypertension, type 2 diabetes (T2DM), obstructive sleep apnea syndrome (OSAS), dyslipidemia, and gastroesophageal reflux disease (GERD). ESG’s impact extends beyond weight loss, as it also brings about a marked improvement in various biological parameters linked to weight, encompassing reductions in AST, ALT, triglycerides, total cholesterol, and fasting blood sugar levels. The findings underscore the multifaceted benefits of the endoscopic approach to bariatric surgery, positioning ESG as a comprehensive and effective solution for patients seeking weight loss with a minimized risk of complications. The reversibility of the procedure enhances its appeal, providing flexibility in the event of evolving patient needs or preferences. In conclusion, the promising outcomes of ESG, coupled with its advantageous features, suggest that it holds significant potential as a valuable tool in the comprehensive management of obesity and its associated health challenges [16-20].

The authors declare that they have no conflicts of interest. No funding declared. All authors critically reviewed the manuscript and approved the final version submitted for publication.

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