Exploring Endoscopic Bariatric Therapies

As a less invasive treatment for weight loss, compared to other bariatric procedures, endoscopic bariatric therapies (EBT) have continued to gain acceptance, especially for patients with obesity who are unable to lose weight or maintain it solely through lifestyle interventions or other methods. EBTs also may be considered prior to bariatric surgery and can facilitate weight loss in preparation for other surgical procedures. EBTs approved by the U.S. Food and Drug Administration for weight loss include intragastric balloons (IGB), endoscopic sleeve gastroplasty (ESG), aspiration therapy and revision procedures (which may be performed following Roux-en-Y gastric bypass).

Intragastric balloons are space-occupying devices, which may be filled with either saline or gas and are recommended to be removed after six months. Both types require an endoscopic procedure for removal; however, only the single fluid-filled balloon system is placed endoscopically. The three gas-filled balloons system involves swallowing a capsule that is attached to a catheter. In addition to reducing preprandial hunger, IGBs delay gastric emptying and may alter hormones thereby inducing satiety.

Patients may experience nausea, vomiting and reflux but, with medical management, these symptoms generally do not persist past the first few weeks. Preventing dehydration and achieving adequate protein intake shortly after the balloons are placed are the main nutritional concerns. Abdominal discomfort, such as bloating, constipation or gas can result if patients consume a high amount of fat or dietary fiber. More serious adverse events are uncommon but have been reported, such as bowel obstruction and perforation.

For patients who undergo ESG, it involves a drastic reduction in gastric volume through the use of sutures. Many of the same responses are experienced following this procedure (i.e., decreased hunger prior to meals, delayed gastric emptying, increased feeling of fullness), all of which have been shown to influence weight loss and metabolic health. ESG is considered a suitable option for patients who are not candidates for a laproscopic sleeve gastrectomy, and its safety and effectiveness have been evaluated for children and adolescents.

With aspiration therapy, a percutaneous gastrostomy tube is placed, along with a device that allows patients to remove digested contents 20 minutes after eating, thereby preventing about one-third of the calories from being absorbed. Compared to other types of EBT, aspiration therapy may be considered for longer term use and should include guidance regarding chewing to achieve a consistency similar to applesauce in order to reduce the risk of the tube clogging.

Although diet progression will vary due to individual tolerances, registered dietitian nutritionists can support patients undergoing EBT by personalizing the nutrition intervention and addressing any adverse symptoms that affect food or fluid intake. Additionally, RDNs can serve as a critical link by helping patients establish behaviors that promote a healthy lifestyle to aid in weight loss and maintenance.

Since this area of practice continues to evolve, RDNs should stay abreast of EBTs that are pending FDA approval and continue to collaborate with members of the interdisciplinary team.

References:

• Isom K A, Majumdar MC. Chapter 9: Endoscopic Bariatric Therapies. In: Academy of Nutrition and Dietetics: Pocket Guide to Bariatric Surgery. Third Edition. Chicago, IL: Academy of Nutrition and Dietetics; 2022:205-218.
• Abu Dayyeh BK, Edmundowicz S, Thompson CC. Clinical Practice Update: Expert Review on Endoscopic Bariatric Therapies. Gastroenterology. 2017;152(4):716-729.
• Reja D, Zhang C, Sarkar A. Endoscopic bariatrics: current therapies and future directions. Transl Gastroenterol Hepatol. 2022 Apr 25;7:21.
• Ali MR, Moustarah F, Kim JJ, American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. American Society for Metabolic and Bariatric Surgery position statement on intragastric balloon therapy endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Obes Relat Dis. 2016 Mar-Apr;12(3):462-7.