Chapters Transcript Video The Spectrum of Obesity Management: The Role of Bariatric Endoscopic Therapies to Fill the Gap Between the Medical and Surgical Extremes I'm ali Abbas. I'm the director of endoscopic bariatric intervention at USF in Tampa General Hospital. And I would like to present this very normal uh field. And and I titled my presentation the spectrum of obesity management through bariatric endoscopy. To fill the gap between medical and surgical extremes. Um The first I have nothing to disclose related to this topic. The objective of this presentation is to overview basically the path of physiology of obesity as chronic disease. And also briefly review the available options for the city management and also touch on the bariatric endoscopic options that are available right now. And I also give brief Um review of the two techniques that are very promising and will be available hopefully in the next 1-2 years um for clinical news and within the field of biotic and catastrophe. Um Little introduction as we all know, what we see is a big problem. This map is getting darker every year. I can't find them Um on the CDC website and it's estimated more than 1/3 of the population Of the United States. Every body mass index of above 30 technically obvious. Yet very interesting observation is only 1% of those who are eligible for obesity surgery actually getting that surgery. And there's a lot of barriers for for patients to what religion before surgery to get the surgery, including the cost of mobility, adverse traits and most importantly, the patient's preference in terms of going through surgical intervention. Um So briefly the path of physiology of obesity is when the energy and take is more than extent energy expenditure plus finance successive storage on the metabolism side. And nowadays we we have an abundance of uh palatable food with high calorie um and increased per capita food consumption has been um you know, documented over the last 100 years in addition to decrease the physical activity and growing use of medication that is created with weight gain in addition to an adequate sleep due to the lifestyle that we are living. Um and also the medical innovation that basically belonged our lives to the degree that infectious disease now is not an issue. And the chronic conditions now is becoming more um uh main health issues and that contributed to a predisposition evolutionary process between predisposition to retain of the calories and weight gain all the way. So the terms of genetic mutation, there's a lot of genetic mutations that has been associated with um obesity that are non syndrome IQ It means that these are every like usual normal individual. And they happen just to have these mutations. It is beyond the spectrum of this presentation to go through all the details. But just to show that there's multiple genetic factors associated with obesity and predisposition to energy storage. In addition to that there is so many drug classes that we are routinely using, including better blockers, antidepressants and anti diabetics. All of them are weight again promoting agents and all contraceptives has been a controversial topic in terms of its effect For way too attention. But just to show the uh list of the most common corporate of uh in terms of medication and I can safely get more than 50% of um everyone's patients has been on on currently on one of these medications. So understanding of obesity and appetite and hunger regulation of the body has been evolving but also and it is not as simple as this diagram which is leptin and Ghrelin leptin is the hormone that is uh created by adipose tissue and its signal into the brain that there's enough calorie or enough energy storage and promote society. And Guerin is produced by the stomach and its signal to the brain that uh there's energy deficiency and promote hunger. Um this was a very primitive understanding of hunger and state regulation. Now we know that there is more than 50 got hormones enter ties. Um there are reliefs through various parts of the G. I. system uh are responsible for regulating society, metabolism, energy storage uh and energy expenditure. And only a few of them are actually extensively studied and probably a handful of them are currently used as a medication or under development most prominently the GLP hormone which I'm gonna touch based on later on this presentation. So these factors coming from various tissue types, mainly from the G. I. System, all signaling to the brain mostly promoting society and growing promoting hunger. But again there's a lot of interconnected signaling between these organs when the nutrients are movement between the stomach to the small bowel to getting absorbed to deliver all of that is constant signalling and to regulate the metabolism and energy storage and energy expenditure. Now um fans here now adipose tissue is not merely a storage issue. It is has been, it is we're very well known that is by itself as pro inflammatory tissue. There's a lot of edible kinds that are promised excreted by the adipose tissue that are promoting various tissue damage that causes insulin resistance that cause fatty deposition and damage. For the hypotheses that could cause state hepatitis and subsequently cirrhosis that has been linked to you know, release of the free fatty acids that has been promote that has been shown to be like a toxic to the blood vessel that produce atherosclerosis and subsequent disease. And there is all of that is through the toxicity and and the decide to activity of these cells that are primarily used for to store fat and energy. But they have other influence on the body. In addition to that the mechanical stress that that you know very self explanatory, it's caused degenerative joint disease and also obstructive sleep apnea. Good heartburn parody esophagus as as far as adenocarcinoma. Um So adding to all of that uh the psychological impact and social stigmatization of of being obvious. That increases the stress level and has been shown to be by itself a predictor of poor health outcomes. So there's a lot of there's a wealth of information about how and it goes to show how fatty should can produce um uh medical problems and and the fact that it is a chronic condition, it is um not something that is related to the power of well or a few if I die it it I will be able to control my way. No, this is much more complex. There is environmental and genetic predisposition Among most of the people. Now, if 1/3 of the population has Bmi above. Thirdly, it means that most of the people have tendency to store fat um in this environmental and dietary. Incidentally uh like that we're living. So now how can we address this chronic condition, how how can we address this chronic evolutionary tendency um to store fat um diet, you know there's a lot of diets out there. All of them are promising um to induce plates and there's different kinds of categories. All these diets, some of them are focusing on low fat, some of them focusing on low carbohydrates and some of them are focusing on low um but all of them has some sort of calorie deficit to introduce weight loss but some of them are balanced basically just like weight watchers for example. Um pretty much all of them has similar efficacy and when weight loss induction between Probably eight and 10% and they are very effective in witnessing production. Probably the low carbohydrate diets are more um are faster and reducing way to Los but associated with more muscle uh mass reduction. Um But eventually they are very poor options for weight maintenance. Which is the problem. I mean it's it's sometimes most people will say it's easy for me to wait to lose weight, but it's impossible for me to maintain it. They will go through the soil pendulum um zigzag pattern just like global warming basically the trend is up but it goes up and down. So that's why diet alone is never good strategy for weight loss maintenance. And there are biological reasons why it is not a good strategy. Uh It is more stimulated to leptin when there is fat to chew deficiency. When people lose weight rapidly, their fat mass get reduced significantly and that will reduce the leptin level. And that will signal to the brain that there is energy deficiency. There's a starvation that's happening. And this is probably an evolutionary protective mechanism. Um So what the brain will do is we'll shut down the, you know, the expenditure, it will lower the metabolism which will lower the tyros creation. It will uh inhibit their productive hormone and also lowered the immunity and it will signal craving and overfeeding where possible. And that is very documented and people would like or destroyed when they have zero fat cells. They have all these changes in their body including the lack of reproductive ability but wants to give them leptin. He will be able to reverse all of that. So it's all about signaling that is left in deficiency or left in excess. Even obesity by itself. Some people I mean, there's a lot of it's what you're saying that this is actually leptin resistance. Just like diabetes is insulin resistance. So that basically illustrates why there is in the modern environment tendency towards um uh, storing calories and storing energy. Um Now exercise, uh, exercise is a good strategy for weight loss maintenance, not for induction. And there's a reason why is that because our bodies. So the question that, you know, I I believe the most common answer when I ask patients or do you exercise say I walk I walk my dog. I walk around the block. Okay, that's good for you. But how much walking can induce weight loss. There's a simple calculation. If you are able to, if you want to Lose weight by walking, you will have to walk five miles per day, seven days per week To induce £1 weight loss over a week timeframe. So that is unrealistic and most people will not be able to do that. So, um, eventually to, I mean, definitely there is a higher level of expenditure with resistance exercise with, with swimming, basketball, competitive activities, but eventually exercise alone is unable to induce weight loss. The most common combination is inducing weight loss by diet followed by balanced diet plus exercise as a maintenance. And that's that's combined caused lifestyle modifications. No, the next line of treatment of obesity, I transitioned gradually to the topic of what are the available options to treatment of obesity. And I started with lux with diet and exercise. Now we have medication to induce weight loss and most of them are essentially acting appetite suppressants. Um, you know, previously we have Velvet which has been withdrawn from the market last year because of the concern for cancer list. But well, it's currently available is five medication all the stats and uh, see MIA and contrary and six. And uh, and most recently in this year, why go, which is the same. A group of low tide which is the awesome pick for diabetes. And when they change the indication to change the dosage, they become aware the class medication, the last two uh medications are injectable and they are looking on like tight and and they are Focusing on the fact that I showed you the long list and these two has been shown to be the most effective and most promising in terms of the side effect profile in terms of the efficacy and efficacy is around 8% of everybody where it was. Um, this in combination with the lifestyle and diet and exercise can produce about 10%. Uh, some people are able to achieve more than 10% by weight loss. But on average that's what we expect in terms of the efficacy of lifestyle lifestyle and medication. Um Now the currently the next step after lifestyle and medication to surgery. Uh this has been the situation for the last, you know, decade. It's the last few decades. Until recently we don't have a good middle ground to offer locations. So anyone who is a Bmi above 35 With comorbidities or b. m. I. above 40 or equal or above 40 um should undergo surgical interventions. These are the standard of care and they are the most effective for this patient population. Now, the options, these are the most common options that we had until recently. The lap band of the bypass and sleeve gastrectomy and duodenal switch. Um now the lap band is out of practice because of a lot of problems with erosions and slippage. So now what we're doing is removal of the lap band that has been placed uh you know, probably in the early 2000s, The bypass has been very common in the early 2000s and I will stay up until Around 8-10 years. This was the most common surgery performed. But then the gastric sleeve took over. And right now the sleeve gastrectomy is is the most common surgery performed for weight loss. Nobody knows switches rarely performed because it's associated with a lot of metabolic problems. And although it is very effective to reduce weight loss. But right now, um the most common two surgeries that we do is gastric sleeve and bypass. And and to select between them and depends on their commerce ability. What's the D. M. I. They're super obese uh you know be a mile above 60 maybe they will they will need bypass which is a little bit more effective and they're still destructive um In addition to the diabetes and heart burn all of these taken into consideration and the patient preference also. Um and deciding where surgery to offer the patient. But these are the gold standard. These are the standard of care now um between uh let's talk about the mechanism of action of these surgeons. Initially the third process was these surgeries are mad. Absorptive the inducement absorption and uh they induce restriction in terms of portion control and and that's true to a certain extent but the most effective the most prominent effect of these surgeries is altering the got hormones and and that will signal that has the strongest signal to the brain about appetite and about society feeling you know after bypass two bites is enough to make to make people feel like they're full. And that's not because the approach is small. That's actually because of the GLP signaling to the brain that there is calories really changed the distal end of the small bowel. That means that everything about this full. It means that we don't need any more food and that is the strongest effect. And in addition to all the restrictive and to a lesser extent they might absorb because people are they are having significant absorption. They will be they will have poor outcomes, but mostly for the bypass and the sleeve gastrectomy. Um There is no significant malabsorption, you know, micronutrients, vitamins has to be uh taken but they don't have a significant fat or protein, not obstruction. Um the no The obesity care continuum. This concept has been evolving for the last I will say 5-10 years um with colonial disease, we have better blockers and statins. We have cabbage and in between there is cardiac stents and this is the continuum of care depending on the severity, depending on the presentation and obesity. Now by the attic endoscopy is proposed to fill that gap between the surgical effective, higher risk intervention and the lifestyle modification. Less effective. The safest in terms of the safety profile. Um Endoscopy is less invasive, has its own complication, but usually that's severe and less frequent than surgical complication and can offer a little bit more effective uh intervention as lifestyle modification and uh medication. So a little bit of uh equations when you look at the obesity literature you will see free via B. M. I. We're all familiar with it. Uh There's something called total value weight loss which is basically the delta and the weight after the intervention divided by the starting weight. This is a person. How much How much is the person who is that? This intervention is expected to cause weight loss. And then there's excess weight loss which is the delta after the intervention. And the delta from the over the delta from the ideal by the way. Which is basically how much Is the person to the reduction from the excess weight from the ideal by the weight. So if if I have an intervention that will produce 100% reduction in the excess weight, then I would go back to the ideal weight, which is almost impossible. Um so all the interventions are measured by these uh blocks to uh parameters. Now the american society of gastro intestinal endoscopy and the american society of um Metabolic and bariatric surgery met together in 2011 and decided to uh place a framework for endoscopic interventions. And and they said that Basically for the endoscopic intervention to be useful and clinically uh implementing double, it has to produce 25% excess weight loss. So 25 um to to be considered as useful and worthwhile. And this uh weight loss has to be 15% above the placebo which is the control group Or whatever you want to use as a control group but it has to be statistically significant and 15% absolute excess weight loss above the control group. And the side effects should be less than 5%. And the for those who are provisional intervention has to be more than 5%. So these are like overall guidelines of how to judge these endoscopic interventions. So now we will move and move on to the primary into this topic and therapies. And this has been evolving for the last 10 years. And now we have a lot of options. Few of them are approved and and even fewer has been proven to be um clinically effective and useful. And our practice uh the balloons is the longest, has the longest history uh since the eighties has been around but then pulled out of the market because of the quality of the premature eruption migration. But now they're back if they approved, I believe in 2000 and 14. And now they are commercially available. And they are simple in terms of the concept there space occupying object delaying and gas like emptying inducing about 25%. Um uh total body weight loss. I'm sorry, excessive weight loss, 25% excessive weight loss in about 11%. Total body way lots. And that is uh 12 months when we put place them for six months and then we remove them at six months and we measure their efficacy at 12 months. Now a lot of cities has been following these patients beyond the 12 months uh benchmark. And and they saw that people will regain their weight. And that is expected because this is just a reversal moving. And in terms of side effects, nothing serious but accommodation phase which is the first week Or two after placement can be harsh with pain and nausea and gert. Uh and a small percentage of alteration And earlier removal can be expected about 7%. So overall at least 1/3 of people will have some sort of side effects and the accommodation of face. But then eventually they can adapt to it now. Uh in april of this year, a g american gastroenterology association should their practice guideline and and mentioned uh for the balloons as as a therapeutic option. So it shows that there is um acceptance and adaptation for the major societies for these interventions. And now we have a cpt code that's gonna be coming next year replacement and removal and hopefully that will be paving the way for Medicare and other instruments approval. And so the balloons are effective but they are reversible because once you remove them you have to depend they're they're good induction strategy for weight loss because they help the patients losing significant amount of weight. They would have been able to lose this weight on their own. But once you remove them they are on their own. They have to maintain it with exercise with the change of the dietary habits. So they are good induction but there are bad and maintenance of we're close now in discovered sleep gas, stop plastic which is basically a concept that has been under development for the last I'll say about 12, 13 years. Um it's just basically trying to replicate the sleeve gastrectomy or Steve Gas application that has that has been done from outside during laparoscopy. If we're able to future the stomach from inside we might induce reduction in the size without the need for surgical intervention. And This device has been tried in 2008 and faded away because it was ineffective because of the tissue capture was only because it was full thickness fighting. But the paradigm shifted significantly when this device came to the market. And This device enabled full thickness in this topic featuring it's it'll be approved for tissue approximation and endoscopic structuring. And the first human case was done I believe in 2012 Christopher Thompson from Brigham and Women's Hospital and Harvard Medical School. Uh it was done and showed very promising results. Since then a lot of uh change and a lot of development has been introduced to the technique. The initial technique was simply putting three bites or across the greater curvature to the lesser curvature and tighten it to induce folding of the gastric greater curvature on its own. That was the original technique. Eventually they would several development. The current acceptable pattern is using U shaped suturing which is basically folding with multiple bites trying to do like just like an accordion and and and and basically shrink the greater curvature. And currently there is a trial is finished. It's finished. It's called the marriage trial and this is going to provide level one evidence for uh the efficacy compared to the control group. So this is a video of a procedure that I performed and interpreted general. First I start by marking, they go to curvature. I spare the Fund us in case revision or conversion to bypass was there uh down the road? And then this device is basically just like a corkscrew. It drills inside the gastric ball and then pull it and create a fault and then the future basically goes from one side to the other side. And um the pattern is the U. Shape starting from the greater curvature going to the lesser curvature and back to the greater curvature. And then once it is tightened you'll see in a few seconds the how what's the difference between the original lumen and the the afternoon. Now this procedure is going to be involved basically multiple new shape starting from the end of the stomach filers towards the upper side towards the fund us and usually is being able to be achieved in in about an hour to an hour and a half. So this is basically when it suits your you can see the new shape right now the fold is basically with the usual pattern of the of the of the switch up and then after uh performing multiple of these shapes. This is what's going to happen to the gastric lumen. Um It is very uh tight, very small. Eventually it is Now I'm gonna skip to the next slide. Um So this trial is is basically has been uh published its preliminary results and it showed that it it showed the its primary target in terms of the efficacy. Um It's still not yet fully published but it's expected to come out hopefully either end of this year or early next year to pave the way for FDA approval as an obesity device. And also hopefully the having a listed CBD God. Now, um this is other pictures of the stomach. After three months, it retains a lot of restrictions and uh in terms of um efficacy, how it compares to the surgical option. Um since then production thousands of these procedures have been done in the in europe Middle East. And also to let's extend the United States. And also brazil is is a big center for the for for this procedure. And um this analysis pulling about a couple of 1000 of each side. And and we have to make a big understanding that these patients who undergo endoscopic interventions are mostly not eligible to the surgical intervention. So they are uh the B. M. I. Of less than the subject of counterparts. So we're not comparing Apple to Apple. This is apple's to oranges here. Um So the B. M. I arranged for the endoscopic option between 33 38. The BMR. Range between the surgical option is 38 to 48. So definitely there's more excess weight for the surgical site. And at 12 months, the total body weight loss for the endoscopic is 17% Compared to the sleeve. The surgical sleeve is about 30%. But when you look at the excess weight loss in the second count, uh it's about 60%. And on both sides, 60% for the endoscopic, 70% for the surgical. And the B. M. I. Event is around 30. So, the surgical group has more weight to lose. And and the surgical option is more effective. That's why the surgical options should be reserved for people who are eligible for it. Because it is definitely more effective. Now, In terms of five peer outcomes. The longest cohort is from Cornell. And then they showed sustained results of about 15%. Total body were lost at five here. And that is um opposite to the balloon. The balloon is not a good long term outcomes. Now, the as I mentioned, the endoscopic sleeve should be reserved for those who are not eligible. Are unable to go through a surgical options because of multiple scars earning it. There's a lot of uh adhesions in their abdomen. They become a very poor surgical candidates. So now, for the first time, we have an option that we can offer for those who are unable to undergo surgery. Now, what's coming next is um uh video probably is not working. But it is a new device that is going to make uh the in the stocks, the gas capacity more efficient and in terms of it's going to be done and probably less than an hour. And and and it's basically application which is folding the gastric wall and applying uh this um structure with two retention uh snowshoe pattern and that will create fibrosis and adhesion and the gastric wall and make it less compliant and smaller. Um and that's hopefully coming in the next couple of years. It's it's there's a trial that's going right now. No aspiration therapy is another idea, approved intervention and and it's basically attacking to that is designed to evacuate the gastric contents. Now this is for understandable reasons or not, is not very popular but there's certain group of patients that will ask for it and especially those for very bothered or very, I will say um affected by the community related to obesity. And there's no other options for them. And and they will say this is better than the one with the community of the obesity. So it is basically a character that has approached that kind of flush the stomach and then evacuated as simple as that. Uh there is a trial that has been published and led to the FDA approval that showed about 30% excess weight loss, very very good results and there is no evidence of an increased food intake or abnormal eating behavior that was a concern when the original design was proposed and and they analyze them psychologically and there is no evidence that they are having binging and purging behavior in terms of efficacy. Um There is um After two years it can induce about 50% of the vote everyone. So it's very efficacious if the patients uh was using it. And definitely it has its own problems including the leakage and to you know, uh sticking out. So there's there's a lot of problems that comes with it. But it can be a reasonable option for uh for certain group of patients. So now for the primary intervention, we cover the balloons and stop extinguish capacity and the aspiration therapy and interpersonal we have the and discovers the gas of plastic and the balloons and the aspiration is coming very soon. The revision of the Starbucks copies. Now that is something that I realized that a lot of primary care providers and also health care provider in general have no awareness of it. But people who already had uh bariatric surgery, it doesn't mean, you know, that's that's part of the obesity and chronic disease because it's a metabolism tendency to retain colors. So even if you have surgery at some point with time after 10 years after 15 years the metabolism will find its way around that signaling change. That happened when the when the bypass over the steep got second. So what happens is people will start regain weight. And uh that happens usually around your 5 to 10. Uh with with some people begin all their lost weight and some people will regain some of their lost weight. At least 30 of them will regain uh you know, about 10% of their lost with it. So there will be associated with recurrence of their comorbidities. That has been improved after the surgery. So now, what to do with these patient populations? Uh, endoscopic interventions has emerged to provide an outlet for this because having a surgical revision is very um I'll say high risk and cumbersome intervention on the patient and also on the provider side. Um So in this topic interventions, if the sleeve got stretched, we can make it tighter the pouch and the anastomosis, which is the gastrointestinal stomach got stretched and that will allow more carries to go in and less restrictive feeling. We can make it tighter within this complex featuring so we're addressing only the restrictive component of these interventions. So we're not expecting to be as effective as as the original one. But at least there will provide a reasonable option in a safe option for people who regained weight uh to go back and flatten the curve, so to speak, to prevent further deterioration and further recurrence of their com abilities that has been originally improved with the with the surgery. Um I'm gonna skip On that video, but that's basically how it looks with the anastomosis before and after and after the structuring device. And this is how it looks after three months, the patient and the top is actually walks about £40 uh in a in a matter of three months. And and this is how her anastomosis looked after. We revised it increases the the uh the stiffness reduces the compliance of the anastomosis and also reduce its size and provide a lot of restriction feeling in the pouch. And In terms of efficacy. And this intervention is expected to cause about 10%, 10% total body weight loss. Um and there's a long term data, five years and seven years coming out that shows a persistent results. Um Same thing with the sleep gas to a gastrectomy with time it gets stretched and then discovered. Surgery can offer um an alternative to conversion to bypass or or do the switch which can be a very um complex in the setting of Prior for good surgery. The This is also very promising with about 17% total body was lost at one year and it's fairly recent. So the papers are still coming out, but very good results compared to the amount of risk that is being taken by the patient within the skull picks or joint? Uh No. All right. We have a quick question regarding the endoscopic interventions. Do you see any complications associated with those? Very good question? So, overall the complications are mild uh kind of skipped through a few slides that mentioned the complication rate. Uh usually it's about 1% 1-2% moderate complications which are um structure sometimes it can happen, bleeding can happen. Most of these can be add realized with further and discovered intervention with structure. We stretch it out a little bit with bleeding, we clip or cauterizing and everything stops. Uh So far there is zero fatality. The in terms of uh the discovered featuring um there is very rare case report of gold bladder injury within this complex featuring where the future went outside the stomach and and and and and and hit the globe letter. That was in the early cases when we when we were learning what's the proper positioning of placing these futures and placing the patient. So overall Right now it is very safe. It's expected to pose this than 1% problems and usually it's mild to moderate. Okay all right so um moving on to the metabolic endoscopy, this is a new concept that is also evolving over the last few years and it is focusing on these growth hormones and primarily two types of them, the G. I. P. Which is glucose dependent instead of tropic uptight G. I. P. Is created by the approximate small ball which is the duodenum and and the proximity Jonah. Ngl people collect the just created by the disk of small bomb which is the Elliott. Both of them have a very important role in uh incident homeostasis and sugar control. So now it is being gradually understood that diabetes is actually starts in the small bowel. It doesn't start in the pancreas although still in evolution of all the of the concept of insulin resistance. But we we understand that the fact to shoot the small bowel is playing a lot of rule in the path of physiology and also the propagation of of internal resistance um through this menu through these two hormones. Uh Now this is a very interesting concept here. It's called Gi Windows which is basically a magnet that is formed in a circle. And it's promote formation of anastomosis between small bubbles. And the whole idea is to connect the proximus mobile with the distal small bowel uh to bypass the calories away from the approximate small bowel that's produced. That that that has a diseased G. I. P. For producing and parasites to the distal small battle to promote the GOP's creation and that will promote insulin uh christian and also improve uh glucose control for the american patients. So this intervention is actually has been developed by regular Women's Hospital and Harvard Medical School. And it is very interesting concept. And and it's self assembled magnet that using the same snake called earth magnet is very strong magnets and apply it into alumina lee and that will cause compression anastomosis between these foul ups. Um Now this is very early in development right now and this is how it looks from endoscopic viewpoint when when the magnet is deployed. This is the first human trial that has been done. And about 10 patients. And uh it was done in 2016 and it showed the reduction of a one c. Um you know impressive from from like By about 1- two on average, 1- 2% on average. Um and not much total body weight loss. This this is just focusing on insulin resistance and and and insulin promotion of insulin secretion to help with the A. One C. So that was the original design which is basically both magnets are applied with endoscopy done simultaneously. One from the rectum, one from the um from the stomach. So and then this is the laproscopic view to confirm how how it looks to make sure that the couple have accord. Um but that then eventually that that approach has developed uh to combine laparoscopic and endoscopic approach. And this is when they are basically testing how robust this than estimates exist by applying pressure and preliminarily through surgical examination, there's anastomosis can offer a very unique opportunity to uh provide these anastomosis without searchers without adhesions without excessive dissection to the to the bowel. And that can be applied for them for the new uh surgical um intervention that's called socialist uh new diameter anastomosis procedure snap. This has been recently published in 2021. Uh and the obesity surgery. And it's the first trial I believe that it had age patients that they applied this anastomosis. And again the same group of researcher from uh from breaking women's and Harvard Medical School school leading this technology. And uh the this uh series. They applied the elio um magnets laparoscopically through a small incision. Uh and the ilium followed by the injection of this magnet inside the lumen. And then they switched to the small incision. Very very simple technique followed by in this car pick uh introduction of the gas success over the duodenal side uh through the mouth. And then they come up with a couple them with simple laproscopic adjustment of the bowel loop. And then they confirmed the coupling by X ray. And eventually this magnets. After they do the compression anastomosis. They disassemble and following they go out with this tool after a month leaving a very nice anastomosis basically side to side move anastomosis. Now they found out that this improved the A. N. C. This small magnet improved the A. One C. Um From being in the high 7-9 range to below seven and most people a 20 year. Um And so it's very promising technology and also can be applied for what we call Sadie procedure which is single honest. I want to do within within a elio bypass which is a new surgical oxygen. Uh There has been proposed and associated with less metabolic problem or absorptive problem than the duodenal switch. But it's definitely challenging because it evolves the exception of the duodenum which is electrically Antonio organ. And and involves working in close proximity to the portal trial, very sensitive area. And so that magnet can offer uh performing this anastomosis in addition to a sleeve which is very standard intervention and that will give the restrictive and the observer and the uh neuro hormonal which is basically the diverse, you know the bypass effect of the of the state procedure with because of the flow is maintained and there is no diversion to the duodenum. The complications are way less in terms of leakage in terms of uh protections in terms of malabsorption. Um So this is uh very new and uh and actually expected to be approved very soon. Um In terms of the F. D. A. The other breakthrough as they do it, you know because there is surfacing rather than diverting the calories. Why not focusing on regenerating these and parasites by destroying them with ablation and allowing them to regenerate. Maybe just like the barrett esophagus constant when we a blade and allow them to regenerate. This is special balloon that has been developed recently and being tried right now and it's basically uh introduced over wire to the duodenum uh create uh lifting uh so it's gonna inject underneath the mucosa to lift it from its wall. And then the heat is applied through the balloon to a blade, the mucosa. And that has been shown to be effective in inducing about one About actually 2% reduction in anyone see at three months and um one on average at six months. And if you did longer segment of ablation you get more a one c reduction. So it's very promising. There is a meta analysis and currently a multi center international trial that's being done to test this device, this endoscopic intervention on diabetic patients. And right now The efficacy that we were expecting is about one at six months after single session, 1% reduction of violence, not much production. And wait. This is not a weight loss intervention. Now, When you think about 1%, maybe it's not that dramatic. But when you look at the efficacy of all oral anti diabetic agents, you will see they are between one and two. Mid foreman has an average of 20.9 a one C reduction. So when you take these people and I blamed them once a year or Once every couple of years and induce 1% production. That's not a bad deal for our diabetic patients who want on multiple interventions. So, very promising metabolic intervention may be the gastroenterologist will have some rules in the endocrine world. Who knows. Um now duodenal mucosal resurfacing now gains the FADA breakthrough device approval. And this is just recently in May of 28, All of these are being right now tried and hopefully in the next 1-2 years become commercially available. Yeah. Now conclusions the what I wanted to show in this topic in this lecture, the obesity is a chronic metabolic disease and should be treated as such. We're treating hypertension as chronic disease, which treating diabetes chronic disease. But we're not treating obesity as chronic disease, which is the origin of all of these comorbidities that we're dealing with. There is a tendency in your metabolism and the lifestyle that we're doing to attain calories. This is not an issue with the will power. This is not an issue with the um, you know, if if you diet more exercise more, this is a metabolic problem that has to be treated as such with sequential and multidisciplinary approach with as many options as possible. The old school thinking of surgery is one and done deal for obesity is probably not correct. Um, as evidence of wait for again after surgery, that requires further intervention with the medication or in the skull. Because the efficacy of the discovery interventions that I revealed or the Overall obesity interventions that I reviewed is core diet and lifestyle modification is about 6-8%. If you added medication to them, you can reach to around 10%,, Then this cosmic intervention that I showed is expected to cause about 10-20%. Total body weight loss. Surgical intervention is definitely the most effective and it is causing about 25-50 or 60% of my boss in some cases. So, um, that's why the more weight patient has to lose the more effective the treatment has to be. We do not offer a. b. m. i. of 50 lifestyle modification or in this context because it's not going to cut it. Um And then lastly but not least the the metabolic interventions are very promising as and I jumped therapy for treatment of diabetes. Um thank you very much for the attending and I'm happy to answer any questions. Yeah sure. I just want to say um I have one question in the Q. And to the audience. If you have any other comments or questions, please use this time to type them into the chat box. So for dr office um how do you select patients for medical endoscopic and surgical interventions? What is that based on? Yeah, it's a very good question actually. This is based on a multidisciplinary approach in our program. So when a patient comment uh with obesity depends on his B. M. I. He will be tried to see the surgeon of the qualifies. And if he doesn't he will be tried to see either me or the medical weight management provider and and then we will will present them in the multidisciplinary team. If we think that initially for example if the patient is not ready or not eligible, we will try an intervention with lifestyle modification and medication and then once they achieve some success or we will uh you know discuss with them the other options to be able to achieve more and then we will, you know, put them back again to the surgical or then discuss intervention abroad. So it is a dynamic fluid movement of patients between these options. Ultimately, the goal is to induce and maintain weight loss. People who had endoscopic or surgical intervention and they're experiencing stalls and their weight loss. We will ask the medical bariatric providers to help with that. We will put them through a program of diet and exercise in addition to medication to help moving the trend more. So it is that's why I'm uh probably the most important point I want to make. It is a chronic disease. It requires sequential and multiple intervention to provide success. Otherwise, if you just put a diet and exercise and then forget about the patient, it's probably going to have no good long term. Thank you. And can you advise the referral process for patients that are in need of weight management. Yeah. So our program in U. S. A. T. G. H. Is basically um open for for any referrals from the community or from within our system. Um you don't have to overthink basically what this patient needs. We will be able to try agent effectively and switching between these pathways throughout the follow up. So all what the providers have to do is to to refer them to our center and our front this will be able to track them and and verify their benefits and and make sure that they are uh paired with the right provider. Great, thank you. And I guess that's top of the hours. So I'd like to close out by thanking everyone for joining us and thank you doctor office for your time this evening. Just a reminder. I'll email you all with directions on how to claim your credits within the next couple of days. So closing out. Thank you from everyone at T. G. H. And have a good rest of your night. Published Created by
