1. Endoscopic therapies for obesity
Christen Klochan Dilly, MD, MEHP
Roudebush VA Medical Center
Indiana University School of Medicine

2. Objectives Define overweight and obese
List available therapies for obesity
Discuss factors considered when selecting a therapy for a patient
Understand the role of endoscopic therapies in the management of obesity
Recommend appropriate therapy to a patient

3. Disclosures
I attended FDA-mandated training paid for by Apollo Endosurgery
Videos may be produced by companies or physicians paid by companies
Showing them for demonstration of procedure only

4. Obesity
“Obesity is defined as a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.”
Obesity Medicine Association, Obesity Algorithm

5. >=40 Class III obesity
Body mass index
Ratio of weight to height (kg/m2)
<18.5 Under-weight
Normal weight
Over-weight 
Class I obesity
Class II obesity
>=40 Class III obesity
BMI Categories: 

6. Prevalence of self-reported obesity in the US, 2017

7. Obesity is a multifactorial disease
Environment (sociocultural factors)
Immune/ microbiota/ infections
Lack of physical activity
Genetics/ epigenetics
Suboptimal nutrition
Medical factors
Sleep disruption
Stress
Environment – geographic location, home environment, cultural practices
Medical factors – adverse effects of medications, physical limitations
Obesity Medicine Association

8. Clinical manifestations of obesity
Cardio-vascular
CHF
HTN
Clots
Pulmo-nary
OSA
OHS
Asthma
Neuro-psych
Pseudo-tumor cerebri
Depres-sion
Musculo-skeletal OA
Low back pain
Gout
Endo-crine
Insulin resistance, DM2
Dys-lipidemia
Infertility
Gastro-intestinal
GERD
NAFLD
Hernias
Gallstones
Renal
Stones
CKD

9. How much weight loss is needed?
Excess body weight = total body weight – lean body weight
=fat mass
Ideal body weight (within 20%)
5-10% decrease in total body weight provides meaningful health benefits
Unrealistic expectations about weight loss
Reasonable goal is 10% in first six months
Numeracy issues
Hamwi method for IBW
M = 106 lb for the first 5 ft + 6 lb for each additional inch. M = 48 kg for the first cm kg for each additional cm. F = 100 lb for the first 5 ft + 5 lb for each additional inch. F = 45 kg for the first cm kg for each additional cm.

10. Exercise, Diet, Behavioral Modification Endoscopic Procedures
Obesity Treatment
BMI
kg/m2
Exercise, Diet, Behavioral Modification
Medication
Bariatric Surgery
Endoscopic Procedures 25 X 27 X* 30 35 40
* With comorbidity
Ashley Gilmore, IUSM UDOS course

11. Weight loss options Intensive lifestyle modification Pharmacotherapy
Nutrition counselling
Exercise
Behavioral therapy
Pharmacotherapy
Endobariatric interventions
Surgical options

12. Intensive lifestyle modification
Heymsfield & Wadden, NEJM 2017

13. Pharmacotherapy Drug MOA Side effects Phentermine Stimulant
Hypertension, palpitations
Orlistat
Impairs fat absorption
Oily discharge, fat-solube vitamin deficiencies
Lorcaserin (Belviq)
SSRI – affects areas of brain involved with cognition, mood, appetite
minimal
Liraglutide
Slows gastric emptying
Nausea/vomiting, fullness
Naltrexone/buproprion (Contrave)
Blunts pleasurable response to eating, reduces food intake
Nausea/vomiting, diarrhea, risk of suicide in young adults
Phentermine/topiramate (Qsymia)
Adds anticonvulsant – increased energy expenditure & appetite suppression
Some psychiatric side effects, risk of birth defects

14. Weight loss with drugs is similar to intensive lifestyle modification
Heymsfield & Wadden, NEJM 2017

15. Surgical options Restrictive Malabsorptive Gastric band
Sleeve gastrectomy
Roux-en-y gastric bypass
Malabsorptive
Duodenal switch/biliopancreatic diversion

16. Laparoscopic adjustable gastric band
Excess weight loss 33-64%
15-20% of total body weight
250-lb person may lose 50 lbs
DeMaria, NEJM 2007

17. Endoscopy after lap band
Erosion of band
Food impactions
Galvo Neto et al, Surgery for Obesity and Related Diseases, 2010

18. Vertical sleeve gastrectomy
Excess weight loss 19-97% (mean 57%)
25% of total body weight at one year
250-lb person may lose lbs

19. Roux-en-Y gastric bypass
Excess weight loss 70-92%
Total body weight 30% at one year
250-lb person may lose 75 lbs
Dumping syndrome
Vitamin deficiencies

20. Endoscopy after bypass
Anastomotic ulcers
Bleeding in the excluded stomach
Need for ERCP
Endoscopic reduction of gastric pouch
video

21. Biliopancreatic diversion with duodenal switch
More weight loss
Many more complications
Rare

22. Issues with surgery Invasive Risk of complications
Marginal ulcers
Anastomotic strictures or leaks
Bleeding – 0.5%
Wound infections – 1.8%
Blood clots – 0.8%
Anesthesia complications – 6.1%
Incisional/internal hernias
Death – %
Risk of weight regain

23. Intragastric balloon BMI 30-40 ~25% excess weight loss
5.9% total body weight loss
About 20 lbs

24. Intragastric balloon
video

25. Intragastric balloon - contraindications
Prior GI or bariatric surgery
Large hiatal hernia
Severe or uncontrolled GERD
Anatomic abnormalities of the GI tract
Inflammation or ulcers of the GI tract
Potential for GI bleed (AVM, varices)
Coagulopathy
Use of NSAIDs
Serious or uncontrolled psychiatric illness
Binge eating disorder
Alcoholism or drug addiction
Unwilling to participate in diet & behavior modification program
Pregnancy or breastfeeding
Cirrhosis
Gastric or esophageal motility disorder

26. Intragastric balloon - risks
Early intolerance
Endoscopy-related complications
Migration
Hyperinflation
Acute gastric distention
Ulcerations
Pancreatitis
Death – 2/10,000

27. Roudebush VA process 3-6 months GI clinic Balloon placed 6 months
MOVE program
psych eval
GI clinic
Explain options
Balloon placed
Daily nurse call
6 months
MOVE
Monthly GI
Balloon out
Every other month GI

28. Endoscopic sleeve gastroplasty
video
Abu Dayyeh, CGH 2017

29. Endoscopic sleeve gastroplasty
BMI 30-40
About 50% excess weight loss at 1 year
Similar to lap band
Off-label use of the Overstitch device

30. AspireAssist
video
Thompson et al, AJG 2016

31. AspireAssist BMI 35-55 14.2% total body weight loss
45-60% excess weight loss
Must chew food thoroughly
Thompson et al, AJG 2016

32. Case 1 60-year-old man with hypertension and hyperlipidemia BMI 34
Well-controlled GERD
No prior abdominal surgeries
Lost 30 lbs with intensive lifestyle modification
What weight loss therapies would you recommend?

34. Case 2
30-year-old man with hypertension, obstructive sleep apnea, non- alcoholic fatty liver
BMI 38
No success with several weight loss methods
No physical activity
Forgets diet records at every visit
Possible binge eating disorder
What weight loss therapies would you recommend?

36. Case 3 55-year-old woman with obesity BMI 43
No prior abdominal surgeries
Well-controlled depression
What weight loss therapies would you recommend?

38. Case 4 45-year-old woman with type 2 diabetes BMI 35
On insulin and metformin
History of deep vein thrombosis
What weight loss therapies would you recommend?

40. Take-home messages Obesity is a major public health issue
Losing 5-10% of body weight can be enough to provide health benefits
Intensive lifestyle modification is a life-long commitment that requires a team approach
Registered (bariatric) dietitian, behavioral psychologist, physician
Pharmacotherapy can be helpful alone or in combination with other therapies
Bariatric surgery is recommended for BMI >40
Endoscopic bariatric therapies can help “boost” weight loss for BMI 30-40