Twins: A special 'gastroscopy' helps you lose weight by suppressing hunger.

For several years, gastric mucosal ablation (GMA), the thermal removal of the gastric mucosa, rich in cells that produce ghrelin, the hunger hormone, has been combined with endoscopic vertical gastroplasty (Endosleeve), which reduces stomach volume and allows for a 14-20% weight loss. A few days ago, for the first time in the world, a next-generation probe (Moviva®) was used at the Fondazione Policlinico Gemelli in Rome, allowing for a faster "burning" of a larger portion of the gastric mucosa. The results of these two combined minimally invasive procedures, according to the Gemelli Hospital, are similar to those of bariatric surgery, with a reduction in initial weight of up to a third after a year and a half.

Obesity is a global problem—experts point out—so much so that, according to the World Obesity Federation, by 2035, over half the world's population will be overweight or obese. Today, there is no shortage of treatment options, from pharmacological therapies (GLP-1 and GLP-1/GIP receptor analogues) to bariatric surgery. But there is also a third option, bariatric endoscopy, which is gaining increasing ground both in terms of accessibility (including in terms of NHS resources) and efficacy. "Endoscopic vertical gastroplasty," explains Ivo Boskoski, associate professor of Gastroenterology at the Catholic University of the Sacred Heart and medical director of the Digestive and Surgical Endoscopy Unit at the Fondazione Policlinico Gemelli IRCCS, "is a minimally invasive procedure developed to endoscopically treat obesity. The procedure reduces the volume of the stomach (it is 'narrowed' by performing an endoscopic 'stitching') and slows gastric emptying, which gives a feeling of fullness. The Gemelli Hospital has been offering this procedure since 2013. We were the first in Europe and second in the world (only the USA was ahead of us)."

For now, the procedure is indicated for patients with obesity (from pediatric to geriatric age), meaning a body mass index (BMI) greater than 30, according to a statement from Gemelli Hospital. The latest edition of the guidelines from the Italian Society of Surgery for Obesity and Metabolic Diseases (SICOB) recommends the use of bariatric endoscopy in patients with class I obesity (BMI between 30 and 34.9 kg/m2) and at least one associated comorbidity, and in patients with class II obesity (BMI ≥ 35), regardless of the presence or absence of comorbidities. The guidelines, however, do not recommend either for or against the use of bariatric endoscopy in overweight patients (BMI between 27 and 29.9 kg/m2) and at least one associated comorbidity, not controlled by medical therapy. This indication is discussed on a case-by-case basis by the multidisciplinary obesity treatment team. The joint ASGE/ESGE (American and European Society of Gastrointestinal Endoscopy) guidelines instead recommend endoscopic gastroplasty (Endosleeve) for people with a BMI of 27-29.9 and comorbidities. Boskoski is co-author of both documents.

"At our hospital," adds Cristiano Spada, full professor of Gastroenterology at the Catholic University and director of the Surgical Digestive Endoscopy Unit at the Fondazione Policlinico Gemelli IRCCS, "the indication for endoscopic vertical gastroplasty is made by the multidisciplinary 'obesity pathway' team, which individually assigns the best treatment for each patient."

"The endoscopic procedure, which lasts 25-30 minutes," Boskoski explains, "is performed under general anesthesia or deep sedation. A stapler is mounted on a standard gastroscope, which is used to 'sew' a portion of the stomach from the inside, excluding it. The narrowing affects the antrum and body of the stomach, while sparing the gastric fundus (because distention of the gastric fundus with food produces a feeling of satiety). In recent years, combining this procedure with GLP-1 agonist therapy, even at low doses (and even with periods of withdrawal), has been very successful." However, this procedure achieves a weight reduction no greater than 14-20% of the initial BMI. "More recently," the specialist continues, "therefore, it has been thought possible to enhance the weight loss effects by combining endoscopic vertical gastroplasty with thermal ablation of the gastric fundus mucosa." At this level, in fact, are the enteroendocrine cells that produce ghrelin, which tend to be overactive in obese people. Once the gastric mucosa is destroyed with argon plasma, the regenerated mucosa in patients undergoing endoscopic vertical gastroplasty is healthy and enhances the weight loss effects, reaching a 28% reduction in initial BMI at 12 months and a 32% reduction in initial BMI at 18 months. These are the preliminary results of an ongoing study at the Gemelli Hospital, conducted on over 20 patients, which will be published by the end of the year.

But in the meantime, research and technological improvements continue. "A few days ago," Spada remarks, "we were the first in the world to use the updated version of this laser probe (called Moviva and awarded the CE mark) for mucosal ablation, which allows for faster treatment of a larger surface area of gastric mucosa. The procedure was performed on a 40-year-old woman with a BMI of 38. The combination of these two techniques (the bariatric endoscopy procedure and the ablation of the gastric fundus mucosa) allows us to achieve weight loss results comparable to those of traditional bariatric surgery, but with a minimally invasive technique."