Endoscopic sleeve gastroplasty plus liraglutide versus endoscopic sleeve gastroplasty alone for weight loss.

BACKGROUND AND AIMS: Endoscopic sleeve gastroplasty (ESG) has been shown to be effective for inducing weight loss. The efficacy of liraglutide, a glucagon-like peptide-1 agonist, to augment weight loss after ESG is unknown. This study aims to evaluate the efficacy of ESG and liraglutide (ESG-L) compared with ESG alone. METHODS: This was a retrospective study of prospectively collected data from patients undergoing ESG at 3 outpatient clinics in Brazil between November 2017 and July 2018. Liraglutide was offered to all patients 5 months after ESG. Patients who opted to take liraglutide (ESG-L) were matched 1:1 to patients who declined it (ESG). The primary outcome was percent total body weight loss (%TBWL), and percent excess weight loss (%EWL) 7 months after initiation of liraglutide (12 months after ESG). The secondary outcome was change in percent body fat 12 months after ESG. ESG technique and postprocedure follow-up were identical at all 3 sites. RESULTS: Propensity score matching yielded 26 matched pairs. Adjusted comparisons between the 2 groups showed that patients who opted to take liraglutide had a superior mean %TBWL 7 months after initiation of liraglutide (ESG-L) compared with those who declined it (ESG) (24.72% ± 2.12% vs 20.51% ± 1.68%, respectively; P < .001). ESG-L had a statistically greater reduction in percent body fat compared with ESG (7.85% ± 1.26% vs 10.54% ± 1.88%, respectively; P < .001) at 12 months. CONCLUSIONS: Addition of liraglutide at 5 months results in superior weight loss and improved efficacy as demonstrated by decreased body fat 12 months after ESG. Further studies are imperative to determine optimal dose, timing, and duration of liraglutide.

Endoscopic sleeve gastroplasty in the management of weight regain after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy is a well-standardized surgical treatment for obesity. However, rates of weight regain after sleeve gastrectomy in long-term follow-up are relatively high. This multicenter study is the first to evaluate the use of an endoscopic sleeve gastroplasty (ESG) technique for the management of this population. METHODS: This was a multicenter retrospective study, including patients with weight regain following sleeve gastrectomy who underwent ESG for weight loss. Primary outcomes included absolute weight loss, percent total weight loss (%TWL), change in body mass index (BMI), percent excess weight loss (%EWL) at 6 and 12 months, and safety profile. Clinical success was defined as achieving ≥ 25 % EWL at 1 year, ≤ 5 % serious adverse event (SAE) rate following society-recommended thresholds, and %TWL ≥ 10 %. RESULTS: 34 patients underwent ESG after sleeve gastrectomy. Technical success was 100 %. At 1 year, 82.4 % and 100 % of patients achieved ≥ 10 %TWL and ≥ 25 % EWL, respectively. Mean (SD) %TWL was 13.2 % (3.9) and 18.3 % (5.5), and %EWL was 51.9 % (19.1) and 69.9 % (29.9) at 6 months and 1 year, respectively. Mean (SD) %TWL was 14.2 % (12.5), 19.3 % (5.3), 17.5 % (5.2), and 20.4 % (3.3), and %EWL was 88.5 % (52.8), 84.4 % (22.4), 55.4 % (14.8), and 47.8 % (11.2) for BMI categories of overweight and obesity class I, II, and III, respectively, at 1 year. No predictors of success were identified in the multivariable regression analysis. No SAEs were reported. CONCLUSION: ESG appears to be safe and effective in the management of weight regain following sleeve gastrectomy.

Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study.

BACKGROUND AND AIMS: Obesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform "U" stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. This also uniquely assessed outcomes in all body mass index (BMI) categories and changes in metabolic rate, lean body mass, and adipose tissue composition. METHODS: This is a multicenter analysis of prospectively collected data from 7 centers including patients with overweight and obesity who underwent ESG. Primary outcomes included absolute weight loss, percent total body weight loss (%TWL), change in BMI, and percent excess weight loss (%EWL) at 6 and 12 months in overweight and obese classes I, II, and III. Secondary outcomes included adipose tissue, lean body mass reduction, and metabolic rate analyzed by bioimpedance. Additionally, immediate or delayed adverse events (AEs) were analyzed. Clinical success was defined as achieving ≥25% EWL at 1 year with ≤5% serious AE (SAE) rate following the American Society for Gastrointestinal Endoscopy (ASGE)/American Society for Metabolic and Bariatric Surgery (ASMBS) threshold. RESULTS: A total of 193 patients underwent ESG during the study period. All groups had >10% TWL and >25% EWL at 6 months of follow-up. On average, %TWL was 14.25% ± 5.26% and 15.06% ± 5.22% and the %EWL 56.15% ± 22.93% and 59.41% ± 25.69% at 6 months and 1 year of follow-up, respectively. %TWL was 8.91% ± .3%, 13.92% ± 5.76%, 16.22% ± 7.69%, and 19.01% ± .95% and %EWL 56.21% ± 2.0%, 62.03% ± 27.63%, 54.13% ± 23.46%, and 46.78% ± 2.43% for overweight and obesity classes I, II, and III, respectively, at 1 year. Male sex, age <41 years, and higher BMI were predictors of achieving a TWL ≥10% at 1-year follow-up. There was a significant reduction in adipose tissue from baseline. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery. CONCLUSIONS: ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds.

Gastric Emptying and Its Correlation With Weight Loss and Body Mass Index in Patients With an Intragastric Balloon: A Prospective Study With Six Years of Follow-Up.

Background Obesity is the most well-established and prolonged pandemic in modern society. Having a better understanding of the available tools is important to improve weight loss and make the strategies more productive. This study aims to evaluate the effect of intragastric balloon (IGB) on gastric emptying time, its relationship with weight loss after IGB removal, and weight maintenance after six years. Methodology This prospective study analyzed data from patients undergoing IGB placement. A six-years follow-up was performed and data about weight maintenance were collected. We analyzed the impact of the IGB on gastrointestinal motility and its correlation with weight loss. Results Of the 20 patients included in the study, 52.4% were diagnosed with class I obesity and 47.6% with class II obesity. The mean weight of the patients was 96.5 ± 11.9 kg at baseline, 79.6 ± 11.4 kg at the time of IGB removal, 81.8 ± 9.1 kg at six months, and 93.2 ± 14.3 kg six years after IGB removal. The mean difference between the initial weight and that measured immediately after IGB removal was 16.68 ± 5.71 kg. Regarding gastric emptying time, there was a difference in retention on comparing the measurement before balloon placement to that after the balloon was in place (72.9% vs. 86.8%) after one hour of food intake. Comparing two hours after food intake, patients before IGB placement had a 30.6% food retention, while patients with IGB in place had a 69.2% retention. Conclusions In patients with class I or II obesity, the use of an IGB delayed gastric emptying of foods but showed no direct correlation with weight loss. Weight loss achieved after IGB placement was maintained in half of the patients at a six-year follow-up.

Efficacy of Liraglutide to Prevent Weight Regain After Retrieval of an Adjustable Intra-gastric Balloon-a Case-Matched Study.

PURPOSE: Weight regain after balloon retrieval is a concern with all intra-gastric balloons (IGBs). The aim of this study was to evaluate the efficacy of liraglutide, a glucagon-like peptide-1 (GLP-1) agonist, to prevent weight regain following IGB retrieval. MATERIALS AND METHODS: This was a case-matched study of patients undergoing Spatz3 adjustable IGB (Spatz FGIA, Inc. NY, USA) at three outpatient clinics in Brazil between November 2015 and January 2019. Seventy-seven patients that opted to take liraglutide following IGB retrieval (IGB-L) were matched 1:1 to 198 patients that declined the medication-IGB-Alone (IGB-A). Propensity score adjustment was performed at the time of balloon retrieval on factors known to influence the choice of liraglutide. Weight and percent body fat (%BF) was measured at baseline and 9 months after IGB retrieval. % BF is defined as the total mass of fat divided by total body mass, multiplied by 100. The primary outcome was weight regain, and the secondary outcome was change in %BF 9 months after IGB retrieval. RESULTS: Propensity score matching yielded 53 matched pairs. Weight regain to the starting point was not observed in either group. There was significantly less weight regain in IGB-L compared to IGB-A, - 1.15 ± 0.94 kg versus - 0.66 ± 0.99 kg (p = 0.010) 9 months after balloon retrieval. Additionally, %BF decline in IGB-L was superior to IGB-A - 10.83 ± 1.50 versus - 7.94 ± 2.02 (p < 0.01). There was no difference in weight regain or decline in %BF based on liraglutide dose. CONCLUSION: Liraglutide has an additive benefit with respect to efficacy and a reduction in body fat when commenced after IGB retrieval. Future randomized control studies will be needed to determine the optimal dose and duration of liraglutide to achieve superior outcomes.

Gallbladder perforation due to endoscopic sleeve gastroplasty: A case report and review of literature.

BACKGROUND: The healthcare impact of obesity is enormous, and there have been calls for new approaches to containing the epidemic worldwide. Minimally invasive procedures have become more popular, with one of the most widely used being endoscopic sleeve gastroplasty (ESG). Although major adverse events after ESG are rare, some can cause considerable mortality. To our knowledge, there has been no previous report of biliary ascites after ESG. CASE SUMMARY: A 48-year-old female with obesity refractory to lifestyle changes and prior gastric balloon placement underwent uncomplicated ESG and was discharged on the following day. On postoperative day 3, she developed abdominal pain, which led to an emergency department visit the following day. She was readmitted to the hospital, with poor general health status and signs of peritoneal irritation. Computed tomography imaging showed fluid in the abdominal cavity. Laparoscopy revealed biliary ascites and showed that the gallbladder was sutured to the gastric wall. The patient underwent cholecystectomy and lavage of the abdominal cavity and was admitted to the intensive care unit post-operatively. After 7 d of antibiotic therapy and 20 d of hospitalization, she was discharged. Fortunately, 6 mo later, she presented in excellent general condition and with a 20.2% weight loss. CONCLUSION: ESG is a safe procedure. However, adverse events can still occur, and precautions should be taken by the endoscopist. In general, patient position, depth of tissue acquisition, location of stitch placement, and endoscopist experience are all important factors to consider to mitigate procedural risk.

The Effect of the Intra-gastric Balloon on Gastric Emptying and the DeMeester Score.

BACKGROUND AND AIMS: The mechanism of weight loss with the intra-gastric balloon (IGB) is thought to be a decrease in gastric emptying (GE); however the evidence is conflicting. Nausea, abdominal pain, and gastroesophageal reflux disease (GERD) can cause intolerance resulting in early removal. This is demoralizing for the patient and costly for the healthcare system. The ability to predict which patients will have superior weight loss and tolerance is invaluable. We sought to investigate if the IGB induced weight loss by reducing GE and the effect of the IGB on the DeMeester score. METHODS: We retrospectively reviewed prospectively collected data for patients undergoing IGB placement at a single hospital. Manometry and pH studies were performed before and with the IGB in place. Weight was measured at baseline, at removal, and 6 months later. Adverse events leading to early removal were recorded. RESULTS: Twenty-four patients were evaluated. There was a statistically significant decrease in GE for solids with the IGB (117.92 ± 150.23 vs 281.48 ± 206.49 min; p = 0.0048), but not for liquids (54.44 ± 17.97 vs 56.08 ± 43.96 min; p = 0.7228). The lower esophageal sphincter (LES) pressure did not change significantly with placement of the IGB (17.76 ± 7.39 vs 14.74 ± 7.24 mmHg; p = 0.09). On multivariate analysis, increase in DeMeester score was associated with total body weight loss (p = 0.0125) and change in GE (p = 0.038) independently. CONCLUSION: The IGB delays GE for solids, but not for liquids, and increases the DeMeester score by a mechanism other than a loss of LES pressure.

Increased Gastric Retention Capacity, Assessed by Scintigraphy, after APC Treatment of Dilated Gastrojejunal Anastomosis.

BACKGROUND: Weight regain occurs in about 20% of patients after Roux-en-Y gastric bypass (RYGB). Studies have reported that in most cases this regain is associated with dilatation of the gastrojejunal anastomosis. To correct this dilatation, one of the methods used is the application of argon plasma coagulation (APC). CASE: The authors report the case of a 39-year-old woman submitted to RYGB who had weight regain. In the endoscopic evaluation, the patient presented with dilatation of the gastrojejunal anastomosis, for which treatment with APC and an adjusted diet was proposed. After 3 sessions of APC, the patient presented with a reduction of the anastomosis diameter, weight loss, and increased satiety to food, with an increased gastric emptying time evidenced by scintigraphy. CONCLUSION: APC proved to be a safe and efficacious method.

INTRODUÇÃO: O reganho de peso após bypass gástrico em Y de Roux (RYGB) ocorre em cerca de 20% dos doentes. Estudos relatam que na maioria dos casos este reganho está associado a dilatação da anastomose gastrojejunal. Para corrigir esta dilatação um dos métodos utilizados é a apli-cação de árgon plasma (APC). CASO: Os autores relatam o caso de uma mulher de 39 anos de idade, submetida a RYGB, que apresentou reganho de peso. Na avaliação en-doscópica a doente apresentava dilatação da anastomose gastrojejunal sendo proposta a realização de APC e dieta ajustada. Após 3 sessões de APC, a doente apresentou redução do diâmetro da anastomose associada a perda de peso, aumento da saciedade alimentar e aumento do tempo de esvaziamento gástrico documentado em cintigrafia. CONCLUSÃO: O tratamento com APC mostrou ser um méto-do seguro e eficaz.

Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy Treatments for Obesity: Systematic Review and Meta-Analysis of Short- and Mid-Term Results.

BACKGROUND: Laparoscopic greater curvature plication (LGP) has recently emerged as a new bariatric procedure. This surgery provides gastric restriction without resection, which could potentially provide a lower risk alternative, with fewer complications. The real benefit of this technique in the short and long term is unknown. This systematic review aims to compare laparoscopic gastric plication and laparoscopic sleeve gastrectomy for obesity treatment. METHODS: Clinical trials were identified in MEDLINE, Embase, Cochrane, LILACS, BVS, SCOPUS, and CINAHL databases. Comparison of LGP and laparoscopic sleeve gastrectomy (SG) included hospital stay, operative time, loss of hunger feeling, body mass index loss (BMIL), percentage of excess weight loss (%EWL), complications, symptoms in the postoperative period, and comorbidity remission or improvement. RESULTS: This systematic review search included 17,423 records. Eight studies were selected for meta-analysis. There is no difference in operative time, hospital stay, and complications. Patients in the SG group had improved loss of hunger feeling. BMIL was better in the SG group at 12 and 24 months [mean difference (MD) - 2.19, 95% confidence interval (CI) - 3.10 to - 1.28, and MD - 4.59, 95% CI - 5.55 to - 3.63, respectively]. SG showed improved %EWL compared with gastric plication in 3, 6, 12, and 24 months. However, no difference was found in %EWL long-term results (24 and 36 months). Patients who underwent LGP had more sialorrhea. SG showed better results in diabetes remission. CONCLUSIONS: SG showed improved weight loss when compared with LGP, with better satiety, fewer symptoms in the postoperative period, and improved diabetes remission.

Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study.

BACKGROUND: Endoscopic approaches exist for targeting weight regain after Roux-en-Y gastric bypass (RYGB), including endoscopic suturing, clipping, and sclerotherapy. Argon plasma coagulation (APC) is a noncontact electrocoagulation method, and when used in RYGB patients, it has shown reduction in the diameter of the gastrojejunal anastomosis. OBJECTIVES: To study the effectiveness of APC for weight regain in terms of weight loss for RYGB patients, from eight bariatric centers. METHODS: A retrospective chart review was performed for 558 patients at eight bariatric centers in the USA (1) and Brazil (7) who underwent APC procedure between 31st July 2009 and 29th March 2017. APC was performed on patients who regained weight after RYGB procedure. RESULTS: Upon exploratory analysis of the individual BMI data, the mean BMI decreased slightly during the first 24 months and increased slightly afterwards following the APC intervention. The mean weight was 94.5 ± 18.6 kg and the mean BMI was 34.0 kg/m2 at APC. Where data were available, the mean of lowest weight was 67.0 ± 23.0 kg and the mean of lowest BMI was 24.1 kg/m2 following gastric bypass. The mean weight loss was 6.5, 7.7, and 8.3 kg at 6, 12, and 24 months, respectively, and the changes in weight over time was statistically significant (p < 0.0001). Multi-level for change model showed the low body mass index (BMI) group (BMI < 30 kg/m2) to have greater TWL than the high BMI (BMI ≥ 30 kg/m2) group at 6, 12, and 24 months. In the low BMI group, the mean TWL was 4.7, 6.1, 6.9, and 2.4%, at 6, 12, and 24 months, respectively. In the high BMI group, the mean TWL was 7.5, 10.4, 13.4, and 3.7%, at 6, 12, 24, and 36 months, respectively. Of the 333 patients in four centers who provided complication information, complications after APC included stenosis (n = 9), GJ ulcer (n = 3), vomiting (n = 3), GJ leakage (n = 2), and melena (n = 1). CONCLUSION: APC can be useful in reducing the regained weight after RYGB, and patients showed 6-10% total weight loss at 12 months. Randomized trials would be needed to validate the findings.