Metabolic endoscopy: Today's science-tomorrow's treatment

Abstract

Obesity, type 2 diabetes mellitus (T2DM) and nonalcoholic steatohepatitis are increasing pandemic metabolic disorders. Lifestyle intervention (LSI) is the cornerstone treatment for these but is successful as standard care alone in only a few patients, given the modest weight loss at mid and long term. Conversely, bariatric surgery is the only proven effective treatment for these metabolic disorders, albeit offered only in a small percentage of cases because of its invasiveness and cost. The so-called endoscopic bariatric and metabolic therapies (EBMTs) include new, less-invasive technologies such as intragastric balloons, aspiration therapy, endoscopic sleeve gastroplasty, diversion devices, and duodenal mucosal resurfacing, currently at various stages of development. EBMTs, as an add-on to LSI, might represent an effective treatment filling the gap between medical and surgical management, taking into account, however, that obesity and its associated comorbidities constitute a chronic disease that needs lifelong therapy. In this review we describe the current scientific evidence surrounding EBMTs as well as future opportunities for such treatments in managing obesity and metabolic disorders.

Keywords: Obesity; endoscopic bariatric and metabolic therapy; metabolic disorders; nonalcoholic steatohepatitis; type 2 diabetes.

Figure 1.

Research priorities and unmet needs in endoscopic and bariatric therapies (EBMTs).

Figure 2.

Potential weight-independent mechanisms of action of endoscopic and bariatric therapies (EBMTs) at the level of the gut. (a) Microbiome, opportunity to modify the microbiome through fecal microbiota transplant. (b) Production of gut peptides: orexigen peptides (PYY, peptide YY; cholecystokinin), incretins (GLP-1, glucagon-like peptide-1; GIP, gastric inhibitory peptide). (c) Modification of bile acids affect glucose metabolism and insulin sensitivity. (d) Enteric nervous system. The regulation of blood glucose is complex and necessitates crosstalk between the liver, the endocrine pancreas, the adipose tissue, the central nervous system and the intestine. FMT: fecal microbiota transplant. This figure was created with BioRender (www.biorender.com).