Minimally invasive and scarless endoscopic procedures are expanding the range of treatment options available for patients with the complex, chronic disease of obesity, offering hope where other weight loss methods have failed or where surgery is not an option for medical or personal reasons, says an expert from Cleveland Clinic marking World Obesity Day today (March 4).

Whereas dietary and lifestyle modifications, medication and bariatric (weight loss) surgery were the traditional mainstays for treating obesity, the last decade saw the emergence of several procedures that use an endoscope – a flexible tube with a light and camera attached to it that is passed through the mouth – explainsDr Roberto Simons-Linares, director of Bariatric Endoscopy at Cleveland Clinic.

“Endoscopic procedures are bridging the gap between medication and surgery,” says Dr Simons-Linares. “As a rule of thumb, the more invasive the approach, the higher the weight loss. At the lowest end of the invasiveness scale, we have medication and lifestyle modifications, which may not work for many people. At the highest end, we have surgery, which is highly effective, but not everyone is eligible. In addition, we have found that only 1% of eligible patients actually undergo bariatric surgery – this could be for a multitude of reasons, from lack of access to personal choice. The less-invasive, same-day endoscopic procedures, therefore, provide important additional treatment options for obesity.”

Eligibility for bariatric surgery is determined by looking at patient’s body mass index (BMI) — their weight in kilograms divided by the square of their height in metres — and whether they have any weight-related comorbid conditions such as high blood pressure or diabetes. To be eligible for bariatric surgery, patients need a BMI of 40 or above, or a BMI of 35 and above if they have comorbidities.

“Considering that individuals are categorised as having obesity when their BMI is 30 or above, this leaves many patients ineligible for bariatric surgery, so endoscopic procedures offer a viable alternative,” says Dr Simons-Linares.

There are three primary endoscopic solutions for patients, with more on the horizon. The current procedures lead to a reduction in calories consumed and are done on an outpatient basis, but have different time frames.

The first solution, an endoscopic sleeve gastroplasty, is intended to be permanent and involves stitching the stomach to reduce its size to that of a banana, similar to the result achieved through a surgical sleeve gastroscopy. The second involves a space-occupying, satiety-inducing intragastric balloon used for six months, and which is endoscopically implanted and removed. The third is the endoscopic placement of a small tube for aspiration therapy, which enables a patient to remove as much as 30% of gastric contents after a meal, and can be removed after sufficient weight is lost.

Endoscopic methods are also useful as secondary weight loss procedures in instances where a patient has gained weight after bariatric surgery, Dr Simons-Linares says. If a patient’s stomach, gastric pouch or anastomosis have stretched after a previous operation, various revision endoscopic techniques ensure that the patient does not have to repeat the original surgery or undergo a more invasive surgical revision.

Dr Simons-Linares says he works closely with the patient and a multidisciplinary team of experts in the treatment of obesity to determine which treatment method – from pharmacotherapy through to surgery – is the best option. In addition, prior to undergoing any procedures, patients are fully evaluated by a multidisciplinary team to assess eligibility, as well as to determine the presence of comorbidities, such as diabetes or sleep apnea, and other factors, such as eating disorders, that also need to be treated. It is important to note that lifestyle modifications are the cornerstone of any therapy to treat obesity.

“Obesity is a complex disease with many different forms and causes, so no single treatment will work for everybody and sometimes combination therapy is needed. We know that multiple genetic, biological, developmental, behavioural and environmental factors contribute to weight gain and the development of obesity,” Dr Simons-Linares says.

“In addition, there is no quick fix to address obesity, and I explain to my patients that all methods will require hard work on their part. Rather than being seen as simple cures, these endoscopic procedures represent additional tools we have to address the obesity pandemic and its significant impact on population’s health.”

He adds: “To maintain weight loss, patients will need to modify their diets and lifestyles in the long-term. Having the support of a multidisciplinary team of physicians and other experts including dietitians and psychologists is very important. Obesity is a chronic condition, with the potential for relapse, so we encourage our patients to continue to check in with us regularly post-procedure so that we can address any issues as they arise. With digital consultations, our international patients can continue regular follow-ups with their care teams.”

According to the World Health Organization, around 650 million adults and a growing proportion of children worldwide have obesity. The disease is widely recognised as a pandemic and is associated with many cancers and metabolic conditions such as type 2 diabetes, cardiovascular diseases, hyperlipidemia, fatty liver, hypertension, and osteoporosis.