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Sleeve Endoscopic

ESG vs. Traditional Bariatric Surgery: Pros and Cons

Picture of BY DR THIERRY MANOS
BY DR THIERRY MANOS

Table of Contents

Introduction

Obesity, a health concern that has seen an alarming rise in recent decades, now affects a significant proportion of the global population [1]. This burgeoning epidemic not only compromises individual health but also burdens healthcare systems and economies at large. The need for practical, sustainable weight loss solutions has become paramount, especially for those where traditional diet and exercise regimens have fallen short. Consequently, the medical field has developed several surgical interventions to address severe obesity and its accompanying health complications [2].

One such intervention is the Endoscopic Sleeve Gastroplasty (ESG), a newer, less invasive procedure that has garnered attention for its promising results in weight loss surgery [3]. Contrasted against this is the realm of traditional bariatric surgeries, which includes procedures like gastric bypass and gastric sleeve, surgeries that have stood the test of time with established efficacy and results [4]. While ESG utilises an endoscopic approach to reduce stomach size, traditional bariatric surgeries involve more invasive methods, each with its own advantages and challenges.

The choice between ESG and traditional bariatric surgeries is multifaceted. It’s not just about the expected weight loss but also the potential risks, benefits, and long-term implications. As we delve deeper into this article, we will explore the specifics of ESG, compare it against traditional bariatric surgeries, and provide insights to help individuals make informed decisions about their health journey [5].

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ESG (Endoscopic Sleeve Gastroplasty)

Definition and Description

Endoscopic Sleeve Gastroplasty (ESG) represents one of the latest advancements in the field of bariatric interventions. Unlike traditional surgical weight loss methods, ESG is a minimally invasive procedure that does not require external incisions. Using an endoscope inserted via the mouth, the procedure primarily aims to reduce the stomach’s size and capacity [6].

How ESG Works

The fundamental operation of ESG revolves around using an endoscope fitted with a suturing device. Once the endoscope reaches the stomach, a series of sutures are strategically placed to cinch the stomach’s size, making it resemble a tubular structure. Reducing the stomach’s volume limits the amount of food intake, thus fostering weight loss [7]. Notably, this procedure does not involve any removal of stomach tissue, which differentiates it from some traditional bariatric surgeries like the gastric sleeve. The outpatient nature of the procedure, combined with the absence of abdominal incisions, leads to a faster recovery period and minimal post-operative pain for most patients [8].

The novelty of ESG and its less invasive approach has made it an appealing option for many seeking weight loss solutions. However, it’s essential to consider its relatively recent emergence in the medical field and the necessity for more long-term studies to ascertain its efficacy and potential side effects over extended periods [9].

Traditional Bariatric Surgery

Types of Traditional Bariatric Surgery

Traditional bariatric surgeries have been the cornerstone for surgically addressing severe obesity for decades. Several types fall under this umbrella, including:

  1. Gastric Bypass (Roux-en-Y): This procedure involves creating a small stomach pouch and bypassing a portion of the small intestine. This results in reduced food intake and decreased absorption of calories and nutrients [10].
  2. Gastric Sleeve (Sleeve Gastrectomy): This involves removing a significant portion of the stomach, leaving behind a tubular structure. It primarily reduces stomach volume, limiting food intake [11].
  3. Adjustable Gastric Banding: A band is placed around the top portion of the stomach, creating a small pouch. The band’s tightness can be adjusted, controlling the rate of food passing to the rest of the stomach [12].
  4. Biliopancreatic Diversion with Duodenal Switch (BPD/DS): One of the more complex procedures involves a combination of gastric sleeve and rerouting a significant portion of the small intestine [13].

How They Work

The primary objective of traditional bariatric surgeries is to either limit the amount of food the stomach can hold, reduce nutrient absorption, or both. Gastric bypass and BPD/DS are both restrictive and malabsorptive, as they limit food intake and reduce nutrient absorption. In contrast, the gastric sleeve and adjustable gastric banding mainly focus on food restriction [14].

These surgeries have seen continuous refinements over the years, enhancing safety profiles and improving outcomes. The established nature and longer track record of these procedures mean that their benefits, risks, and long-term effects are well-documented, helping patients make informed decisions.

Deciding Between ESG and Traditional Bariatric Surgery

Factors to Consider

Choosing between ESG and traditional bariatric surgeries requires a comprehensive understanding of one’s unique health needs and desired outcomes. Several crucial factors should be taken into account:

  1. Amount of Weight to Lose : ESG is generally recommended for those with a lower BMI, or those who might not qualify for traditional bariatric surgery but still need an intervention [15].
  2. Underlying Health Conditions : Some obesity-related health issues, such as type 2 diabetes, have been shown to resolve more consistently after specific traditional surgeries like gastric bypass [16].
  3. Age and General Health : The patient’s overall health can influence the surgery’s risk and the recovery process. Traditional bariatric surgeries might pose more significant risks for individuals with certain pre-existing conditions [17].
  4. Adaptation to New Dietary and Lifestyle Changes : Both ESG and traditional bariatric surgeries require long-term dietary adjustments. However, the malabsorptive nature of some traditional surgeries might require stricter adherence [18].
  5. Financial Considerations : While many insurance plans cover traditional bariatric surgeries due to their established nature, coverage for ESG might vary. Out-of-pocket costs and post-surgical care expenses should also be factored in [19].

Importance of Professional Consultation

Regardless of the factors mentioned, engaging in thorough consultations with healthcare professionals specialising in bariatric procedures is essential. A patient-specific approach ensures that the chosen procedure aligns with the individual’s health profile, goals, and lifestyle.

Conclusion

Addressing obesity requires a blend of precision, patience, and personalised care. Both ESG and traditional bariatric surgeries offer pathways to sustainable weight loss and improved health. While ESG provides a less invasive alternative with shorter recovery periods, traditional bariatric surgeries have stood the test of time, offering profound weight loss and potential resolution of associated comorbidities [20].

The decision between the two should be rooted in individual needs, health conditions, and desired outcomes. What remains clear is that surgery alone is not a magic bullet. Long-term success in managing obesity necessitates a holistic approach, combining surgical interventions with dedicated lifestyle, dietary, and behavioural changes [21].

Additionally, continued consultations with healthcare professionals ensure that patients remain on track and adapt to the evolving challenges post-surgery [22]. Ultimately, the journey toward a healthier life is a collaborative effort between patients, medical professionals, and support systems, all working in tandem to achieve the desired health outcomes [23].

Research

The importance of research in identifying effective interventions and strategies cannot be overstated. Community-based programs provide individuals and communities with the resources they need to adopt healthy behaviors, manage chronic conditions, and access appropriate healthcare services. Policy interventions can create environments that support healthy behaviors, increase access to care, and improve the affordability and availability of healthy foods. Collaboration and partnerships can ensure that interventions are evidence-based, responsive to the unique needs of different communities, and sustainable over time.

Moving forward, it will be critical to continue to prioritize efforts to address diabetes and obesity, through ongoing research, community-based programs, policy interventions, and collaboration and partnerships. By working together, we can ensure that interventions are effective, sustainable, and accessible to all individuals and communities who need them.

References

  1. World Health Organization. (2018). Obesity and overweight. *World Health Organization*.
  2. Sjöström, L. (2013). Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery. *Journal of Internal Medicine*, 273(3), 219-234.
  3. Abu Dayyeh, B. K., Kumar, N., & Edmundowicz, S. A. (2017). Endoscopic bariatric therapies. *Gastrointestinal Endoscopy Clinics*, 27(2), 267-285. 
  4. Angrisani, L., Santonicola, A., Iovino, P., Vitiello, A., Zundel, N., Buchwald, H., & Scopinaro, N. (2019). Bariatric Surgery Worldwide 2013. *Obesity Surgery*, 25(10), 1822-1832.
  5. Courcoulas, A. P., Belle, S. H., Neiberg, R. H., Pierson, S. K., Eagleton, J. K., Kalarchian, M. A., … & Jakicic, J. M. (2015). Three-year outcomes of bariatric surgery vs lifestyle intervention for type 2 diabetes mellitus treatment: a randomised clinical trial. *JAMA surgery*, 150(10), 931-940.
  6. Lopez-Nava, G., Galvão, M. P., Bautista-Castaño, I., Jimenez-Baños, A., & Fernandez-Corbelle, J. P. (2015). Endoscopic sleeve gastroplasty for the treatment of obesity. *Endoscopy*, 47(05), 449-452.
  7. Abu Dayyeh, B. K., Acosta, A., Camilleri, M., Mundi, M. S., Rajan, E., Topazian, M. D., … & Gostout, C. J. (2017). Endoscopic sleeve gastroplasty alters gastric physiology and induces body weight loss in obese individuals. *Clinical Gastroenterology and Hepatology*, 15(1), 37-43. 
  8. Sharaiha, R. Z., Kedia, P., Kumta, N., DeFilippis, E. M., Gaidhane, M., Shukla, A., … & Kahaleh, M. (2017). Initial experience with endoscopic sleeve gastroplasty: technical success and reproducibility in the bariatric population. *Endoscopy*, 49(02), 164-166.
  9. Khan, Z., Khan, M. A., Hajifathalian, K., & Kamal, S. (2018). Endoscopic sleeve gastroplasty: Where does it fit in the bariatric surgical landscape? *Obesity Surgery*, 28(9), 2852-2857.
  10. Adams, T. D., Davidson, L. E., & Litwin, S. E. (2017). Weight and metabolic outcomes 12 years after gastric bypass. *New England Journal of Medicine*, 377(12), 1143-1155. 
  11. Salminen, P., Helmio, M., Ovaska, J., Juuti, A., Leivonen, M., Peromaa-Haavisto, P., … & Victorzon, M. (2018). Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at five years among patients with morbid obesity: the SLEEVEPASS randomised clinical trial. *JAMA*, 319(3), 241-254.
  12. O’Brien, P. E., MacDonald, L., Anderson, M., Brennan, L., & Brown, W. A. (2013). Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. *Annals of Surgery*, 257(1), 87-94.
  13. Hess, D. S., Hess, D. W., & Oakley, R. S. (2005). The Biliopancreatic Diversion with the Duodenal Switch: Results Beyond 10 Years. *Obesity Surgery*, 15(3), 408-416.
  14. Courcoulas, A. P., King, W. C., Belle, S. H., Berk, P., Flum, D. R., Garcia, L., … & Pomp, A. (2018). Seven-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) study. *JAMA Surgery*, 153(5), 427-434.
  15. Kumar, N., & Sullivan, S. (2019). Candidate selection and considerations for endoscopic sleeve gastroplasty. *Gastroenterology Research and Practice*, 2019.
  16. Schauer, P. R., Bhatt, D. L., Kirwan, J. P., Wolski, K., Brethauer, S. A., Navaneethan, S. D., … & Nissen, S. E. (2017). Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. *New England Journal of Medicine*, 376(7), 641-651.
  17. Hutter, M. M., Schirmer, B. D., & Jones, D. B. (2011). First report from the American College of Surgeons Bariatric Surgery Center Network: Laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. *Annals of Surgery*, 254(3), 410-420.
  18. Karmali, S., Brar, B., Shi, X., Sharma, A. M., de Gara, C., & Birch, D. W. (2013). Weight recidivism post-bariatric surgery: a systematic review. *Obesity Surgery*, 23(11), 1922-1933.
  19. Martin, M., Beekley, A., Kjorstad, R., & Sebesta, J. (2010). Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis. *Surgery for Obesity and Related Diseases*, 6(1), 8-15.
  20. Maggard-Gibbons, M., Maglione, M., Livhits, M., Ewing, B., Maher, A. R., Hu, J., … & Shekelle, P. G. (2013). Bariatric surgery for weight loss and glycemic control in nonmorbidly obese adults with diabetes: a systematic review. *JAMA*, 309(21), 2250-2261.
  21. Cooper, T. C., Simmons, E. B., Webb, K., Burns, J. L., & Kushner, R. F. (2015). Trends in weight regain following Roux-en-Y gastric bypass (RYGB) bariatric surgery. *Obesity Surgery*, 25(8), 1474-1481.
  22. Beck, N. N., Johannsen, M., Støving, R. K., Mehlsen, M., & Zachariae, R. (2012). Do postoperative psychotherapeutic interventions and support groups influence weight loss following bariatric surgery? A systematic review and meta-analysis of randomised and nonrandomized trials. *Obesity Surgery*, 22(11), 1790-1797.
  23. Afshar, S., Kelly, S. B., Seymour, K., Woodcock, S., Werner, A. D., & Mathers, J. C. (2016). The effects of bariatric surgical procedures on the improvement of metabolic syndrome. *Surgery for Obesity and Related Diseases*, 12(8), 1516-1522.
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