The report is a product of the VA/HSR&D Evidence Synthesis Program.
Endoscopic Bariatric Interventions versus Lifestyle Interventions or Surgery for Weight Loss in Patients with Obesity: A Systematic Review and Meta-analysis
According to the World Health Organization (WHO), more than 500 million adults are obese, including an estimated 78% of U.S. Veterans. Obesity contributes to a range of harmful comorbidities and economic burden approximates $150 billion dollars per year. Despite the prevalence of obesity and the proven efficacy of bariatric surgery – the gold standard for treating severe obesity – few who qualify ultimately receive this intervention. Surgery poses risks, and VA medical centers perform only 500 bariatric surgeries annually. Endoscopic bariatric therapy is an alternative offering a less invasive, possibly cost-effective approach for patients who otherwise would not qualify, or who are hesitant or do not have access to surgical bariatric therapy.
VA’s Evidence Synthesis Program (ESP) Center in Los Angeles, CA conducted this review to assess the impact of endoscopic bariatric therapies on weight loss, morbidity, mortality, and the resolution of comorbid conditions compared to surgery and lifestyle modification. Investigators searched the literature, including PubMed, Embase, and Cochrane databases from January 1, 2014 to July 2, 2021, as these therapies were approved by the U.S. FDA between 2015 and 2017. From 3,541 citations, 115 were give a full text review, with 36 publications meeting the criteria for this review, including four randomized controlled trials (RCTs).
Types of endoscopic therapies
This review examined evidence on several types of endoscopic bariatric therapies, including Intragastric Balloon (IGB), Endoscopic Sleeve Gastroplasty (ESG), and AspireAssist. Both IGB and ESG are intended to limit the stomach’s capacity for food and drink. In IGB, one or more balloons is inserted into the stomach and filled with saline or air to decrease stomach capacity, while ESG employs sutures to reduce the size of the stomach. AspireAssist uses a gastrostomy tube and external device that aspirates stomach contents and removes about one-third of ingested calories after a meal, and also incorporates lifestyle (diet and exercise) counseling.
Summary of Findings
IGB, ESG, and AspireAssist are associated with greater short- and intermediate-term weight loss in patients with obesity compared to lifestyle management alone. Various complications are more common in patients treated with endoscopic therapies than with lifestyle management. The degree of weight loss with endoscopic therapies is likely less than more invasive surgical interventions, but with fewer adverse events. Additional findings include:
- IGB achieves a greater percentage of total body weight loss than lifestyle therapy at 6 and 12 months.
- IGB also achieves a greater percentage of excess body weight loss than lifestyle therapy at 6 months.
- ESG achieves a greater percentage of total body weight loss than lifestyle therapy at 6 months.
- Across all therapies, the most common complications included nausea, vomiting, and abdominal discomfort.
Implications for VA
No studies were specific to VA populations. Therefore, the applicability of these results to VA populations may depend on both the similarity of the patients studied in the trials to VA patients, as well as the experience of the gastroenterologists performing endoscopic bariatric therapies compared to VA provider experience. Available studies were primarily in patients with obesity with BMI 30-40 kg/m2, which is applicable to the VA population.
Research Gaps/Future Research
Compared to the existing literature on bariatric surgeries, novel endoscopic therapies lack long-term data. Additionally, evidence on the effect of endoscopic therapies on obesity-related comorbidities (e.g., diabetes, hypertension, non-alcoholic fatty liver disease) was of moderate or low certainty because of limitations of existing studies or because only one relevant study was available. Future research should employ more robust randomized controlled trials or well-designed prospective studies with adequate power and follow-up to assess the durability of weight loss following endoscopic therapy and its effects on obesity-related comorbid conditions.
Maggard-Gibbons M, Shekelle PG, Girgis MD, et al. Endoscopic Bariatric Interventions versus Lifestyle Interventions or Surgery for Weight Loss in Patients with Obesity: A Systematic Review and Meta-analysis. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2022.
To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/endoscopic-bariatric.cfm (Intranet access only)
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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