Dr. Yang Chih-Wei and Dr. Wang Chih-Hsuan from the Gastroenterology Division
Endoscopic bariatric treatment is an emerging field for obesity management that has gradually developed in the United States over the past decade. It serves as a middle ground between conventional lifestyle, diet, and medication-based therapies and surgical weight-loss procedures.
Endoscopic bariatric treatment is not surgery; instead, it employs a standard endoscope used for stomach examinations, commonly known as a "gastroscope," to perform various weight-loss procedures. This approach is non-invasive, does not damage organs, and is reversible, making it a unique internal medicine treatment.
The entire process is performed under anesthesia, eliminating the discomfort typically associated with undergoing a gastroscopy while awake. Most patients do not require hospitalization, making it a truly minimally invasive method without visible scars for obesity management.
One such procedure, endoscopic sleeve gastroplasty, is also known as a "scar-free gastric lift." Below is an introduction to the treatment methods:
Main Indications for Endoscopic Bariatric Treatment
1. Obesity-Related Indicators
● Body Mass Index (BMI):
Suitable for patients with a BMI between 30 and 40 (moderate to severe obesity) who do not qualify for or are unwilling to undergo more invasive weight-loss surgeries.
● Obesity-Related Comorbidities:
Applicable for patients with a BMI ≥27.5 accompanied by obesity-related conditions, such as type 2 diabetes, hypertension, sleep apnea, fatty liver disease, or metabolic syndrome.
2. Patients Unsuitable for Traditional Bariatric Surgery
● Patients who prefer not to undergo traditional weight-loss surgeries such as laparoscopic sleeve gastrectomy or gastric bypass.
● Patients with medical conditions or high surgical risks that make traditional bariatric surgery unsuitable.
3. Pre-Surgical Weight Control
Used as a transitional measure for patients with severe obesity (BMI >40) to achieve weight control before undergoing higher-risk procedures, such as gastric bypass surgery.
Common Types of Endoscopic Bariatric Procedures
1. Botulinum Toxin Injection:
Using an endoscope, botulinum toxin is injected into the gastric wall muscles, reducing their contraction ability. This slows gastric motility and delays stomach emptying, leading to a quicker sensation of fullness and reduced food intake, which may aid in weight loss. However, international research studies have shown limited evidence of significant weight-loss effects.
2. Intragastric Balloon Placement:
A balloon filled with 400-700 mL of liquid is placed inside the stomach, reducing its volume and lowering food intake while promoting a sense of fullness. Due to the highly acidic gastric environment, the balloon must be removed after six months to a year. This approach can lead to weight regain once the balloon is removed.
3. Endoscopic Sleeve Gastroplasty (ESG):
Using an endoscopic suturing system inserted through the mouth, the stomach is folded and stitched to resemble a pouch. This reduces the stomach's volume without removing or damaging any gastric tissue or glands. The procedure mimics the effects of surgical sleeve gastrectomy by decreasing stomach capacity and caloric intake, but it is less invasive and organ-sparing.
What Are the Risks of Endoscopic Sleeve Gastroplasty (ESG)?
Common post-procedure discomforts after ESG include mild to moderate abdominal pain, slight cramping, nausea, and a bloated sensation. These symptoms typically resolve within 1 to 3 days. Rare serious complications occur in approximately 0.5% of cases, such as post-procedure bleeding or fluid accumulation around the stomach.
To date, no fatalities directly attributable to ESG have been reported in the medical literature. Compared to the 3-5% risk associated with surgical bariatric procedures, ESG is considered a relatively safe option.
What Is the Difference Between Endoscopic Sleeve Gastroplasty (ESG) and Surgical Gastric Sleeve?
ESG does not leave any visible external scars, as it is performed entirely via endoscopy without incisions. Patients typically only require one day of hospitalization and experience minimal post-procedure pain, allowing for a rapid return to normal activities. This makes it an attractive option for individuals who are concerned about visible scars or longer recovery times. Additionally, patients can wear lighter clothing without worrying about surgical marks.
However, the primary limitation of ESG compared to traditional surgery is that it does not forcibly reduce the stomach size or alter its path as the surgical approach does. As a result, the weight loss achieved with ESG is typically less than that of traditional surgery, with weight loss typically around 20%, compared to 30-40% seen with surgical methods. Another factor is that ESG does not remove the part of the stomach responsible for secreting ghrelin, the hunger hormone, meaning patients may still feel hunger, even though their food intake is significantly reduced. Consequently, weight loss is slower compared to surgical gastric sleeve.
Advantages of ESG:
• No visible scars
• Shorter recovery period
• Lower risk of complications
• Less likelihood of developing new-onset gastroesophageal reflux disease (GERD)
• Reduced risk of nutrient or trace element deficiencies
Disadvantages of ESG:
• Smaller weight loss (20% vs. 30-40%)
• Slower weight loss
• Persistent hunger sensation compared to surgery
Conclusion
Endoscopic Sleeve Gastroplasty (ESG) is a minimally invasive, reversible weight-loss procedure suitable for obese patients. It effectively reduces body weight and improves metabolic comorbidities with low risks and fast recovery, making it a promising treatment option with broad clinical applications.
At Tri-Service General Hospital's Gastroenterology Department, the internationally certified and widely used OverStitch endoscopic suturing system is employed for performing ESG (also known as scar-free gastric lift). When combined with a multidisciplinary team approach and dietary control, ESG can effectively achieve significant weight loss outcomes.
For those interested, you can consult Dr. Yang Chih-Wei's team at the outpatient clinic or call (02) 8792-3311, extension 16668 for inquiries.Outpatient hours: Tuesday afternoon (Neihu), Wednesday afternoon (Neihu), Friday afternoon (Tingzhou).
References
1. Dayyeh BKA, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. The Lancet 2022;400(10350):441-51.
2. Elshakh H, El-Ejji K, Taheri S. The role of endoscopic intra-gastric botulinum toxin-A for obesity treatment. Obesity surgery 2017;27(9):2471-78.
3. Brunaldi VO, Neto MG, Sharaiha RZ, et al. Endoscopic sleeve gastroplasty as an early tool against obesity: a multicenter international study on an overweight population. Gastrointestinal Endoscopy 2024;99(3):371-76.
4. Hedjoudje A, Dayyeh BKA, Cheskin LJ, et al. Efficacy and safety of endoscopic sleeve gastroplasty: a systematic review and meta-analysis. Clinical gastroenterology and hepatology 2020;18(5):1043-53. e4.
5. Sharaiha RZ, Hajifathalian K, Kumar R, et al. Five-year outcomes of endoscopic sleeve gastroplasty for the treatment of obesity. Clinical Gastroenterology and Hepatology 2021;19(5):1051-57. e2.
6. Boston Scientific Corporation