Endoscopic sleeve gastrectomy may lead to long-lasting weight loss in patients with class III obesity, according to a new retrospective analysis.
In the study, patients with class III obesity who underwent ESG achieved an average total body weight loss (TBWL) of 21% at one year, which was sustained out to 36 months of follow-up.
“At one year, this cohort doubled what we would consider a clinically meaningful weight loss, which is over 10% TBWL. That’s a really meaningful benchmark, because that’s the inflection point beyond which we see dramatic improvement in weight-related medical problems like type 2 diabetes, cholesterol, high blood pressure and sleep apnea,” said lead investigator Daniel Maselli, MD, an endobariatric physician at True You Weight Loss, in Cary, N.C.
There had been concerns that those with class III obesity (body mass index, =40 kg/m2)—who have higher rates of morbidity and mortality than those with class I and II obesity—are better served by surgical weight loss rather than endobariatric therapy. Although the FDA approved ESG in July 2022 for patients with a BMI up to 50 kg/m2, nearly all published literature on ESG has been conducted in patients with BMIs between 30 and 40 kg/m2.
The study included 404 consecutive patients with class III obesity who underwent ESG between May 2018 and March 2022 with a mean age of 42.9 years, 78.5% of whom were female (World J Gastrointest Endosc 2023;15[6]:469-479). The mean BMI at the time of ESG was 44.8 kg/m2. The TBWL was 20.9% at 12 months, 20.5% at 24 months and 20.3% at 36 months. At 12 months, nearly all the patients (96.7%) had at least a 10% TBWL, and more than half (55.6%) had 20% or higher TBWL. In patients with comorbidities, 66.1% patients saw improvement in hypertension, 61.7% in type 2 diabetes and 45.1% in hyperlipidemia.
Dr. Maselli acknowledged important limitations to the study, including its retrospective design, and the fact that treating physicians were highly experienced in the procedure. Participants also received nutritional support, which could limit generalizability to other practices.
“They show nicely that their patients with the endoscopic sleeve are having excellent weight loss, and it’s maintained,” said Avlin Imaeda, MD, PhD, an associate professor of medicine at Yale School of Medicine and a gastroenterologist in the metabolic health and weight loss program at Yale New Haven Hospital, in New Haven, Conn., who was asked to comment on the study.
The study showed a higher percentage of weight loss in class III obesity than participants in the randomized MERIT trial, which found that class I and II obese patients lost a mean 13.6% of total body weight with ESG. There are several possible explanations for the difference, according to Dr. Imaeda. Although there is a possibility that people with class III obesity respond better to ESG, “I don’t necessarily think that that’s the case,” she said. Instead, she suspects that the effect may be due to the high level of experience of the two surgeons involved in the study compared with more heterogeneity in the multiple practitioners in the MERIT trial, or the fact that patients in the new study received lots of nutritional support and were likely of a higher socioeconomic status. “These patients had very frequent follow-up with nutrition,” Dr. Imaeda said, “and likely had much more knowledge and access to resources with regards to healthy food and exercise.”
To Dr. Imaeda, the study suggests that the endoscopic procedure is a reasonable option for patients who are wary of surgery and medication. “I do try to encourage bariatric surgery because I do think it is the most effective option that we have. But it is good to have options, so I think this is an important study that shows [ESG] is effective in people with class III obesity. It would be great if this helps get to a point where insurance companies would start to pay for this,” she said. “It may even be more cost-effective than GLP-1 [glucagon-like peptide-1] agonist medications like semaglutide and tirzepatide [Mounjaro, Eli Lilly].”
—Jim Kling
Dr. Imaeda reported no relevant financial disclosures. Dr. Maselli reported a financial relationship with Apollo Endosurgery.
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