Gastroenterology & GI Surgery

Bariatric Endoscopy Program Expands Options for Patients Seeking Durable Weight Loss

Jan. 10, 2024 - Eden McCleskey

With an overweight and obesity rate currently at 70%, America is still struggling with its decades-long battle against dangerously excessive weight levels.

The good news is that proven, durable and achievable solutions do exist. The key is expanding access and awareness to ensure that the treatments are utilized by the people who need them most.

One important new arrow in the quiver that recently arrived at Houston Methodist is bariatric endoscopy, an ultra-minimally invasive technique analogous to bariatric surgery that has been proven to produce very effective weight-loss results.

Interventional gastroenterologist Dr. Thomas R. McCarty is one of a few physicians in the country to specialize in the approach. Triple board-certified in Internal Medicine, Obesity Medicine and Gastroenterology, Dr. McCarty joined Houston Methodist's Underwood Center for Digestive Disorders in 2022. He plays an active role in Houston Methodist's comprehensive weight management program, a multidisciplinary team of nutritionists, endocrinologists, psychologists, bariatric surgeons and now gastroenterologists dedicated to tackling one of America's most deeply entrenched health problems.

Dr. McCarty recently sat down with Leading Medicine to discuss the benefits of endoscopic bariatric procedures, how they complement other weight-loss options offered at Houston Methodist and his passion for treating obesity and helping patients avoid its downstream consequences.

Q: What is bariatric endoscopy?

Dr. McCarty: This is a specialized field that includes a variety of innovative weight-loss procedures designed to help patients achieve weight-loss goals when traditional measures like diet and exercise alone are unsuccessful. Unlike open or laparoscopic bariatric surgeries, including gastric bypass and gastric sleeve, endoscopic procedures don't go through the patient's abdomen — they are incisionless. A flexible tube, called a gastroscope, equipped with a camera and suturing tools navigates through the mouth, esophagus and stomach.

Endoscopic suturing procedures like endoscopic sleeve gastroplasty (ESG) work by folding the stomach on itself, reducing the volume by 80% of its original size. These types of procedures are associated with a 15%-20% total body weight loss, and when combined with newer drugs like Wegovy, Ozempic, or Mounjaro can even reach bariatric surgical weight loss numbers of 25%-30%. Most importantly, this is an outpatient procedure with little-to-no downtime for the patient.

Q: What other types of bariatric endoscopic procedures can you perform?

Dr. McCarty: For patients with a history of prior bariatric surgery with weight regain, endoscopic revision procedures are also available. Revisional techniques are associated with a 10-15% total body weight loss which is comparable to surgical revision, with few complications. Like the ESG procedure, there is no overnight stay and patients receive a same-day discharge from the hospital.

These techniques all induce a sense of fullness more quickly and alter gut hormones, promoting weight loss. The goal is to provide effective and durable weight loss outcomes similar to traditional bariatric surgery but with no external incisions, faster recovery time and even fewer complications than bariatric surgery — which already has an extremely low complication rate. Importantly, undergoing this ultra-minimally invasive technique does not preclude a surgical procedure like gastric sleeve or gastric bypass in the future.

Q: Are endoscopic bariatric procedures new?

Dr. McCarty: Endoscopic bariatric procedures have been around in various forms since the 1980s and include a variety of techniques ranging from gastric balloons to endoscopic suturing. However, it wasn't until 2022 that the FDA approved these two endoscopic suturing procedures that we now offer specifically for the purpose of weight loss.

Q: Why are endoscopic procedures needed when effective bariatric surgeries exist?

Dr. McCarty: Given the rising rates of obesity, there is a huge need for effective and safe treatment options. While bariatric surgery provides the most robust weight-loss option for patients, only about 1%-2% of eligible patients undergo surgery — leaving a large number of at-risk individuals with few options other than diet and exercise. More treatment options, including endoscopic interventions, simply means more eligible patients are able to access the care they need.

Q: How does the eligibility criteria differ from bariatric surgery?

Dr. McCarty: Traditionally, bariatric surgery candidates are patients with a body mass index (BMI) of 35-40 kg/m2 with obesity-associated conditions or people with a BMI >40 kg/m2 regardless of comorbidities. That means people with class I obesity (defined as those with a BMI 30-35 kg/m2) typically do not qualify for surgery. That leaves a large portion of the population in treatment limbo, sometimes waiting for obesity to become worse or develop more severe downstream conditions.

That is highly counterintuitive to me, especially since endoscopic procedures have been shown to be effective and are FDA approved for patients with a BMI of 30-50 kg/m2. These endoscopic suturing procedures should be offered to patients struggling with obesity and other conditions like high blood pressure, diabetes, high cholesterol and fatty liver disease, among others, who would otherwise not be surgical candidates. Our goal with the endoscopic procedure is to intervene early and to help patients before they develop serious conditions.

Endoscopic options are a valuable tool in the comprehensive management of obesity, offering an alternative for individuals who may not qualify for bariatric surgery or those who prefer to avoid more invasive surgical interventions. By adding bariatric endoscopy to Methodist's already stellar center for weight loss and bariatric surgery, we are able to offer a truly personalized, multidisciplinary approach and provide patients with comprehensive, holistic care.

Q: Any other benefits for patients?

Dr. McCarty: This is a powerful tool that is able to help individuals in ways beyond just weight loss. Outside of simply seeing a better number on the weight scale, patients can see improvements in other serious conditions, like blood sugar control, blood pressure, cholesterol and many others. This translates into patients reducing or eliminating many of the medications needed for these conditions after the procedure.

The procedure's adaptability and incisionless approach is also an important selling point, allowing patients to go home the same day and often return to work in one to two days. The ability to personalize the approach and combine it with weight-loss drugs is also key.

These endoscopic procedures may be utilized as an independent treatment, bridge to surgery or as part of a step-up approach to obesity. Patients may start with diet and exercise, then consider medications if not successful at achieving clinically significant weight loss results. If medication is not effective, an endoscopic bariatric procedure is a reasonable next-treatment option, with bariatric surgery like gastric sleeve and gastric bypass still viable options if the patient does not achieve their desired weight loss goals.

Q: Talk to us about patient outcomes. How do they stack up against other interventions?

Dr. McCarty: The endoscopic suturing procedures we offer at Houston Methodist are very effective weight-loss options for patients. Published literature on ESG has shown durable weight loss results with study follow-ups as long as 10 years.

Looking at other interventions, there is no doubt newer weight-loss drugs have seen a tremendous amount of attention in the past few years. These drugs are typically associated with a 10%-15% total body weight loss, though these new drugs may have side effects, can be expensive or not covered by all insurances, and are associated with weight regain once discontinued. For some individuals, these drugs can be combined with other treatments to produce even greater effects.

Then there is bariatric surgery. This is the most effective weight loss therapy available, though it may not be the best choice for all patients. While weight loss is the most significant with bariatric surgery achieving 20%-35% total body weight loss, endoscopic procedures are less invasive, associated with a lower rate of adverse events, and do not require an overnight admission.

Q: You are one of a select few physicians in the nation who can provide endoscopic weight-loss procedures. Why aren't there more people doing this?

Dr. McCarty: Being a gastroenterologist with specific training in obesity medicine and advanced endoscopic procedures is not common. Some of that is likely due to the newness factor and some of that is unfortunately due to a stigma around obesity. The field of bariatric endoscopy, while it has been around since the 1980s, is still relatively new. I was fortunate to train with a pioneer in the field, Dr. Christopher Thompson, in a specialized two-year fellowship dedicated to bariatric endoscopy and obesity management. It's a special skill set that very few places currently have. I think as we destigmatize the treatment of obesity, we will begin to see more individuals with training in the care and management of this disease.

Ultimately, there are very few places in the country that are able to truly provide a comprehensive approach to weight management, including medical, endoscopic and bariatric surgery therapies. I am thankful to work here at Houston Methodist, where we have experts across all fields and specialties. Everyone on the treatment team has unique skills they bring to ensure outstanding, high-quality patient care.

Q: Why did you want to get into this field?

Dr. McCarty: It's important for any physician working in this field to truly have a passion for treating obesity and understanding the mechanisms and challenges of treating such a complex disease. I'm comfortable managing these patients from a medical and endoscopic obesity standpoint, even if they don't undergo the procedure. Managing the medications, managing complications, managing post-bariatric patients who may have vitamin deficiencies and need care for that. I'm not just a proceduralist, I really am invested in helping people with obesity from a lifestyle standpoint, from a pharmacotherapy standpoint, from a bariatric surgery standpoint, and from an endoscopy standpoint.

I truly believe that any weight-loss therapy, whether it be medication, bariatric endoscopy or surgery, is most effective when integrated into a multidisciplinary setting that emphasizes diet and exercise as its foundation. That's what motivates me as a physician.

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Gastroenterology & GI Surgery