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Inside Tract - Endoscopy's Growing Arsenal Against Obesity

InsideTract Fall 2009

Endoscopy's Growing Arsenal Against Obesity

Date: December 15, 2009

Patrick Okolo, chief of gastrointestinal endoscopy
Patrick Okolo, chief of gastrointestinal endoscopy

Traditional bariatric approaches may be the procedures most likely to spring to mind in discussions about surgical treatments for obesity, but Patrick Okolo can quickly expand the list.

A decade ago, for example, gastroenterologists at Johns Hopkins pioneered natural orifice translumenal endoscopic surgery—or NOTES—and today, they’re leading the way in applying NOTES to obesity surgery.

Part of the goal is to restrict the space within the stomach and digestive system. Using a technique called transoral gastroplasty (TOGA), says Okolo, “we’re able to create a small pouch that changes the shape of the stomach.” Food accumulates in the pouch, making the patient feel full faster. Although TOGA is not yet FDA approved, preliminary results are good, with patients losing between 15 percent and 30 percent of excess weight.

Another endoscopic option is the duodenal-jejunal bypass sleeve, which creates a long sheath across the duodenum where pancreatic and bile secretions pass into the jejunum. Rather than trying to affect the stomach structure or size, and thus the volume of food passing through, DJBS attacks one of the co-morbidities of obesity: diabetes.

“Actual weight loss is modest,” Okolo says. “But since we’re filtering how food is mixing with digestive juices, we’re able to improve blood-sugar control and the patient’s glycemic profile.” Plus, the sleeve is easily removable when it’s no longer needed.

The most obvious and significant benefits to endoscopic procedures, says Okolo, are that they don’t require incisions and patients recover faster. Besides offering an alternative to traditional bariatric surgery, endoscopic procedures may also make bariatric ones less risky, particularly for morbidly obese patients. “If we can achieve some weight loss first via an endoscopic procedure,” Okolo says, “then our patient is a better candidate for bariatric surgery.”

Another minimally invasive possibility in which Okolo has had a longstanding interest is botulinum toxin A. Although open-label trials produced divergent results, he’s encouraged by recent evidence indicating that the neuromuscular-blocking agent may help facilitate weight loss in some obese patients. It slows gastric emptying time and thus improves satiation,  resulting in a decrease in ingested calories.

What’s most clear to Okolo, however, is that no single method aimed at inducing weight loss can stand alone. “Every obesity management program that’s worked is a complex balance of many factors,” he says. “It’s got to be multidisciplinary and it needs to address lifestyle and behavior.”