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    Interventional procedure overview of endoscopic sleeve gastroplasty for obesity

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    Indications and current treatment

    Obesity is defined as a BMI of 30 kg/m2 or over. The degree of obesity is classified as obesity class 1 (BMI 30 kg/m2 to 34.9 kg/m2), obesity class 2 (BMI 35 kg/m2 to 39.9 kg/m2) and obesity class 3 (BMI 40 kg/m2 or more). The NICE guideline on obesity recognises that people with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean origin are prone to central adiposity and their cardiometabolic risk occurs at a lower BMI. So a lower BMI of 27.5 kg/m2 or above is recommended as the threshold for obesity in these groups.

    Obesity is directly linked to a number of other illnesses including type 2 diabetes, hypertension, gallstones and gastro-oesophageal reflux disease, as well as psychological and psychiatric morbidities. Weight loss reduces the risk of other significant disease worsening and improves long-term survival.

    The NICE guideline on obesity recommends a multicomponent approach involving dietary advice, exercise, lifestyle changes and medication. Bariatric surgery is recommended as a treatment option in some people who have a BMI of 40 kg/m2 or more (class 3 obesity), or between 35 kg/m2 and 39.9 kg/m2 (class 2 obesity) and other significant disease (such as type 2 diabetes) and have not lost enough weight using other methods. It is also considered at a lower BMI than in other populations in people of Asian family origin who have recent-onset type 2 diabetes.

    Surgical procedures for obesity aim to help people to lose weight and to maintain weight loss by restricting the size of the stomach, decreasing the capacity to absorb food or both. Procedures that reduce the size of the stomach (gastric volume) limit the capacity for food intake by producing a feeling of satiety with a smaller ingested volume of food. They include laparoscopic gastric banding and SG. Procedures aimed at decreasing the capacity to absorb food include biliopancreatic diversion and duodenal switch. People are also advised to modify their eating behaviour by adhering to an explicit postoperative diet.

    Clinical unmet need

    Data from the Health survey of England 2019 shows that in England 28% of adults are obese (BMI 30 kg/m2 or over) and a further 36% are overweight (BMI between 25 kg/m2 and 30 kg/m2). There is growing unmet need for treatment for obesity. ESG is an additional endoscopic treatment option and can be used at an earlier stage in the treatment pathway to reduce the risk of progression. There may be some subgroups of people in whom ESG is useful. These include people who:

    • are considered high-risk for bariatric surgery due to age or comorbidities

    • refuse bariatric surgery due to fear of the associated risks and complications

    • have had a previous surgical intervention in the abdomen, making bariatric surgery technically challenging and increasing the risk of surgical complications.

    • have a lower BMI (class 1: 30 kg/m2 to 34.9 kg/m2; class 2: 35 kg/m2 to 39.9 kg/m2), for whom ESG may be useful as an earlier intervention to prevent disease progression and associated comorbidities (type 2 diabetes, non-alcoholic steatohepatitis [NASH], hypertension, cardiovascular disease).