Obesity and bariatrics for the endoscopist: new techniques

Abstract

Obesity and its associated conditions, including type 2 diabetes and cardiovascular disease, have reached epidemic proportions. Gastrointestinal weight loss surgery (GIWLS) shows the most promise in achieving significant and sustained weight loss and diabetes resolution. However, a large mismatch exists between the magnitude of the obesity epidemic and the number of surgical procedures performed to produce a significant shift in the distribution of obesity on a population level. This mismatch is fueled by high surgical costs, morbidity and mortality associated with surgical interventions, and the fact that the greatest public health burden of obesity comes from those around the center of the population body mass index distribution with mild to moderate obesity, rather than those at the distribution tail with severe obesity that GIWLS targets. New endoscopic methods, capitalizing on advances in our understanding of the physiological mechanisms by which GIWLS works, are developing to provide viable alternatives in the treatment of bariatric surgical complications, and for the primary treatment of obesity. These methods may have the added advantage of reduced invasiveness, reversibility, cost-effectiveness, and applicability to a larger segment of the population with moderate obesity.

Keywords: endoscopy; obesity; surgical complications; weight loss surgery.

Figure 1.

Endoscopic vertical gastroplasty technique using the EndoCinch endoscopic suturing device: (a) the EndoCinch device; (b) endoscopic suturing pattern for the creation of a vertical gastroplasty by the EndoCinch device; (c) and (d) endoscopic views before and after the creation of the endoscopic vertical gastroplasty. (Reprinted with permission from Fogel et al. [2008].)

Figure 2.

Transoral endoscopically guided stapling system (TOGA) for the creation of an endoscopic vertical gastroplasty, (a) The TOGA sleeve stapler that is used to create a gastric sleeve with a luminal diameter of approximately 20 mm parallel to the lesser curvature of the stomach, and the TOGA restrictor used to staple gastric folds together and restrict the distal end of the sleeve to approximately 12 mm. (b) The TOGA sleeve stapler with the extendable wire fully deployed for optimal alignment of the stapler, and a diagram showing the TOGA restrictor in place. (c) Radiographic and endoscopic views of the vertical gastroplasty created by the TOGA system. (Reprinted with permission from Deviere et al. [2008].)

Figure 3.

TERIS showing an endoscopically placed restrictive silicone device with a 10 mm orifice anchored by five silicone anchors through five transmural plications at the gastric side of the gastroesophageal junction. (Reprinted with permission from De Jong et al. [2010].) TERIS, transoral endoscopic restrictive system.

Figure 4.

A duodenal-jejunal bypass sleeve (EndoBarrier) made from a Teflon liner and delivered endoscopically to the duodenal bulb. (Reprinted with permission from Coté and Edmundowicz [2009].)