Metabolic function and weight loss after endoscopic sleeve gastroplasty: resistance is futile

The ongoing SARS-coronavirus–2 associated disease (COVID-19) pandemic is yet another on a growing list highlighting the negative impact of obesity on comorbid conditions and patient survival. Patients with obesity are known to have more-severe COVID-19 outcomes, including higher mortality than in age- and sex-matched individuals.¹ Furthermore, obesity-associated insulin resistance has been proposed as a key factor in COVID-19 severity.²

Weight loss is a lifelong battle for most patients, and an increasing repertoire of nonsurgical therapies is available, ranging from pharmaceutical to minimally invasive endoscopic procedures, including endoscopic sleeve gastroplasty (ESG), which has >3000 cases reported in the literature.^{3 , 4} Unfortunately, as with most weight loss interventions, widespread growth and adoption of these procedures and further development of transformative innovations are met by lack of insurance coverage, therapeutic nihilism, and stigmatization of patients with this deadly disease. Most previous arguments against ESG revolved around the lack of data on long-term outcomes and impact on obesity comorbidities.

In a prospectively enrolled registry at a single academic institution, Hajifathalian et al⁵ analyzed a subset of 118 patients who had both obesity and nonalcoholic fatty liver disease and were followed for as long as 2 years after undergoing ESG. Weight loss associated with ESG was consistent with prior reports, summarized as a 15.5% total body weight loss at 2 years.6, 7, 8 Because liver biopsy and/or elastography data were not available for the cohort, the authors relied on a surrogate calculation, the hepatic steatosis index, which was calculated for all patients on the basis of laboratory and clinical parameters and was used to rule in patients with nonalcoholic fatty liver disease (NAFLD).

Subsequently, the NAFLD fibrosis score, also using laboratory and clinical parameters, was calculated to categorize patients according to their risk for increasing degrees of fibrosis. As expected, based on the degree of total body weight loss reported, the calculated hepatic steatosis and fibrosis score was significantly improved. Improvements in NAFLD and fibrosis scores after an endoscopic bariatric procedure have been previously more directly described with the use of EUS-guided liver biopsy and magnetic resonance elastography before and after a fluid-filled intragastric balloon procedure.⁹

Finally, and perhaps most compelling, insulin resistance was estimated with the validated homeostasis model assessment of insulin resistance,¹⁰ which improved from 6.7 ± 1.1 to 3.0 ± 1.6 (P = .019) only 1 week after the procedure and to 2.9 ± 2.0 (P = .03) after 2 years of follow-up, suggesting a meaningful and surprisingly immediate effect of the procedure on insulin homeostasis, which had not previously been demonstrated with ESG. Also consistent with previous reports, no serious adverse events were reported with ESG, and only 1 moderate adverse event (0.8%) was reported, involving a perigastric leak after dietary indiscretion, which was successfully and conservatively managed.

There is a clear and present need to apply different tactics in the remissive strategy to control the obesity pandemic and its comorbidities. Too often, therapeutic nihilism stems from unrealistic expectations of a given therapy, expecting a “silver-bullet” effect while ignoring the chronic incurable nature of this disease. In a clinical trial of patients with obesity and type 2 diabetes, even weight loss achieved through diet alone was nonetheless sufficient to achieve the same metabolic benefits as in patients who underwent gastric bypass surgery.¹¹ This and the evolving literature on ESG support its role as an effective, safe, anatomy-preserving, repeatable, and combinable weight loss intervention capable of producing sufficient weight loss to place excess adiposity–related diseases in remission when coupled with a comprehensive multifaceted lifestyle and medical intervention program to maintain and enhance its durability. So, now more than ever, resistance is futile.

Disclosure

Dr Abu Dayyeh is a consultant for Boston Scientific, BFKW, USGI, DyaMx, Endo-TAGSS, and Metamodix; a speaker for Olympus, Medtronic, Johnson and Johnson, and Endogastric Solutions; and the recipient of grant/research support from Medtronic, USGI, Apollo Endosurgery, Cairn Diagnostics, Aspire, and Spatz. Dr Storm is a consultant for Apollo Endosurgery, GI Dynamics, Endo-TAGSS, ERBE, and Enterasense; and the recipient of grant/research support from Apollo Endosurgery, Endo-TAGSS, and Boston Scientific.