Vivek Kaul, MD
Obesity along with its associated comorbidities has emerged as a worldwide public health problem. Medical therapy endoscopic therapy and surgical interventions for obesity have evolved rapidly over the last several years. Several multidisciplinary programs have been developed internationally to deal with this problem. The most rapid and dramatic evolution has occurred within endoscopic therapies for obesity which offer relatively minimally invasive solutions for patients with obesity and metabolic syndrome.
In this issue of e-WGN, Drs. Linares and Thompson review the current state-of-the-art for endoscopic approaches to obesity management and reflect upon aspects related to training, clinical care, program development and future areas of research. I had the opportunity to discuss several aspects of endoscopic obesity management and program development with Dr. Linares. In this accompanying Q&A where he sheds some light on his own personal journey along this paradigm, the key principles for successful program development as well as helpful suggestions for colleagues around the world who may be considering choosing this as a career pathway and or interested in developing endoscopic bariatric programs going forward. We hope that the pearls and caveats discussed in this conversation will be helpful for our readers and membership around the world.
Vivek Kaul (VK): Dr. Thompson, how did you get involved with this niche area of endobariatrics? Tell us a little about how your interest developed, your training and your pathway to specialization in this area.
Christopher Thompson (CT): There was no real concept of bariatric endoscopy when I was in training. When I joined as faculty, our bariatric surgeons were requesting better organized and more streamlined gastroenterology care for their patients. I quickly became responsible for preoperative evaluation and postoperative complication management for all of their patients. Also, I had an interest in NOTES at the time, had an active research lab, and was clinically performing a good number of advanced endoscopic procedures, including Zenker’s septotomy and pancreatic necrosectomy. During an advanced endoscopy fellowship, I had also learned how to suture using the Bard EndoCinch device to treat GERD, which, as it turns out, would be very relevant to my future practice. One afternoon I was performing an endoscopy on a patient with a Roux-en-Y gastric bypass (RYGB) and a history of refractory GERD with weight regain. There was an obvious gastro-gastric fistula between the pouch and the remnant stomach – and this is where it all came together for me. All I needed to do was use the same EndoCinch I was using to treat GERD, a few centimeters lower, to close that fistula! This had never been reported before, however, the surgeons were very supportive as it could potentially avoid a rather complicated surgical revision which carried significant morbidity at the time. The procedure required using the device in some novel ways, but it was successful. The GERD resolved and the patient began to lose weight. To me, this was the beginning of bariatric endoscopy. We subsequently began to study the gastrojejunal anastomosis and its relationship to weight regain after RYGB, and shortly after developed the Transoral Outlet Reduction (TORe) procedure using the same EndoCinch. The hospital then provided me with funding to build out these programs and gave me the title, Director of Bariatric Endoscopy.
VK: Dr. Simons-Linares, you entered this field when it was well established. Please elaborate on your journey, as in: how did your interest develop for this field and your training pathway?
Roberto Simons-Linares (RSL): Since very early in my medical career, specifically medical school, I developed a strong interest for gastrointestinal endoscopy and I noticed that endoscopy is the missing link between clinical medicine and surgery. Then, I fell in love with everything endoscopy! While doing medical school rotations at the IRCAD center, University of Strasbourg Hospitals in France, I was exposed to the most novel endoscopic treatments in GI. I was lucky to be trained in gastroenterology and interventional endoscopy at the Cleveland Clinic under an extremely talented group of mentors that I’m now honored to call my partners. I was also very fortunate to do my bariatric and metabolic endoscopy fellowship at the Brigham and Women’s Hospital of Harvard Medical School under Prof. Christopher Thompson and his team. I developed a passion for the field of endoscopic treatments for obesity and metabolic comorbidities, which affects more than one billion people worldwide – and with endoscopic therapies we can impact so many lives from a non-surgical approach.
VK: Dr. Simons-Linares, given that bariatrics has been in the surgical realm for so long, tell us the importance and value of collaboration with our surgical colleagues. How critical is it and how does one go about establishing that partnership? What is the recipe for developing that successful relationship?
RSL: The simple answer is that there is not “one size fits all;” the reality is that obesity is a chronic relapsing multi-organ disease that requires teamwork across multiple specialties. Teamwork between gastroenterologists (GI), bariatric endoscopists and bariatric surgeons is key to improve outcomes for patients suffering from obesity. This partnership should be transparent, dynamic, innovative and open to discussions on how to best help patients in need of bariatric procedures or surgeries. I’m very fortunate to work with a fantastic team of surgeons. On a daily basis we share patients, camaraderie, innovation and we continually strive for excellence in patient care and aim to advance the science through research. GI bariatric endoscopists should always be there for surgical partners and take care of all endoscopy or GI clinical needs of our bariatric patients. I believe this is key to building relationships with surgeons, as well as other important specialties involved in the multidisciplinary team approach. To be more specific, in my case I’m not there only to do the cool bariatric cases and I do not have a policy that says “ESG referrals only” for example; but rather, I’m there for all my partners (surgeons and non-surgeons) that think I can be of help with my medical/GI background as well as with my interventional and bariatric endoscopic skills. I strongly believe this sincere, transparent multidisciplinary approach and collaboration ultimately benefits patients, providers, institutions and improves outcomes.
VK: Dr. Thompson, in terms of training, especially for endoscopists from low-medium resource environments, what advice do you have regarding training and achieving competence in these procedures? Please elaborate on the feasibility of hands-on workshops, sabbaticals, on site proctorships etc. in this realm.
CT: There are many different ways to develop the skills necessary to start an endobariatric practice. Each physician or surgeon has a different set of base skills and goals. There are several different starting points and individualized curricula that would be ideal. Nevertheless, a basic cognitive and technical foundation must be assured. Cognitive elements of endobariatrics are critical to good patient care. They include developing an understanding of obesity and its comorbidities, medical management of obesity, indications and risk profiles of the various procedures, patient selection, and complication management among other content. The technical performance of procedures is also critical to a safe and effective practice. Procedures are typically categorized into Level 1 and 2 based on the level of skill required and length of learning curve to achieve competence. Level 1 procedures can typically be learned at a hands-on course with a modest level of clinical proctoring during initial clinical cases. Intragastric balloons are an example of Level 1 procedures. Level 2 procedures require a higher level of skill and experience to attain competency. These typically cannot be learned adequately at a hands-on workshop and often require training in the context of an advanced endoscopy program, or a sabbatical/clinical mentorship program with hands-on clinical training. Not everyone will be able to start their practice with advanced endoscopic suturing techniques such as ESG or TORe. They may start with medical therapy and intragastric balloons and need to build the more advanced skills over time in a mentoring program. More advanced endoscopy fellowship programs are including bariatric endoscopy in their curricula, and specialized bariatric endoscopy fellowships are also starting to appear. Simulators and longitudinal training programs are also being designed to help address some of the hurdles in training practicing clinicians. Additionally, new technology and simplification of procedural technique should help to shorten the learning curve for these procedures in the future. I am confident we will get there. We just have to grow the field safely and methodically.
VK: Dr Simons-Linares, any additional perspectives you would like to add as a recent trainee?
RSL: In 2020, the ASGE/ABE released a position statement on training and privileges for bariatric endoscopy. The statement described three essential principles for provision of quality endoscopic bariatric therapy (EBT): 1) broad and in-depth understanding of the management of patients with obesity, 2) mastery of GI endoscopic skills, and 3) procedure and device-specific knowledge necessary to provide specific EBTs and manage potential associated adverse events. Outside of formal training, these skills can be acquired through obesity medicine society courses and or during residency/fellowship electives, rotations, as well as proctorships with existing bariatric endoscopy programs. I always recommend to reaching out to the GI endoscopy societies, and to the lead endoscopist in existing bariatric endoscopy programs, to ask for upcoming courses. There is also some data on competency for bariatric endoscopy: a study by Sharaiha et al. showed that endoscopic sleeve gastroplasty (ESG) efficiency was attained after 38 ESGs, and mastery after 55 procedures. We definitely need to improve access to training in bariatric endoscopy at all levels but, as a trainee, be proactive, ask, ask and ask for opportunities and follow through!
VK: Dr. Simons-Linares, please elaborate on the importance of medical therapy in this realm. Where and how does medical therapy fit in with endoscopic and surgical bariatric interventions?
RSL: Anti-obesity medications (AOM) continue to develop nicely, with some AOM reaching >15% total body weight loss. AOM are safe, effective and non-invasive. However, to my earlier point, there is not “one size fits all” since we are dealing with a chronic relapsing disease of obesity, we need all hands on deck. Moreover, we live in a world of personalized medicine, innovation and evolving technologies, where patients should have access to all available therapies to help manage obesity, including lifestyle modification, surgery, AOM, and Bariatric Metabolic Endoscopy. One interesting phenomenon I see happening more and more is the use of so-called “combination therapy” (AOM + bariatric endoscopy) and this appears very promising. As more combination therapy studies get published, we will see more indications and improved efficacy, and I suspect outcomes will be better for selected patients when combining AOM with bariatric endoscopy.
VK: Dr. Thompson, based on your experience, if one wants to setup an endobariatrics program, how do you recommend one go about it? What are some of the typical challenges and difficulties one should expect to encounter?
CT: There are many different ways to structure an endobariatric program. It is important to be flexible and shape the program around your assets. You can do this in an academic center, a private hospital, a group practice, or as a solo venture. I have seen all models be successful, and any of them can fail. No matter what the model, for it to be successful and deliver good patient care, you must adopt a multidisciplinary approach. You need a team that includes dieticians, psychologists, exercise physiologists or physical therapists, patient navigators and social workers. You also need to collaborate closely with surgeons, obesity medicine physicians, endocrinologists, hepatologists, cardiologists, and sleep medicine physicians. You can incorporate much of this as part of a unified service line with a shared front office, or you can be independent with a virtual multidisciplinary structure. The independent model is in some ways easier if you can attract the financial resources and are willing to take the risk. Marketing is expensive yet critical to the success of such models. When attempting to build this in a traditional academic model, there are several hurdles. Care is soloed in the traditional model with separate cost centers, compensation plans, budgets and goals. Departments and divisions can behave in a tribal fashion, unwilling to truly cooperate at a service line level. This can be extremely difficult to overcome and requires buy in and support from the highest levels of the hospital if it is to be truly successful. Programs that have accomplished this have seen impressive results and been able to push the field forward and change practice with novel research initiatives. In the end, there are many different pathways to offer excellent care.
VK: Dr. Simons-Linares, how can we best partner with industry to further the goals of bariatric medicine going forward?
RSL: Industry is a key player in the field, as they continue to develop more devices and technology for bariatric endoscopy – it is important to partner with them to continue to support research, device development, and increase access to education, hands-on courses, proctorships, and fellowships. I would encourage industry partners to keep investing in research and education in the field of bariatric endoscopy, as well as supporting GI societies in different strategic collaboration initiatives. I would also suggest creating a “bariatric endoscopy program development summit” with experts that have had diverse experiences in developing successful bariatric endoscopy programs across all types of practices (private, academic, hybrid, etc.). This summit can offer not only clinical knowledge and hands-on training, but most importantly how to set up a successful bariatric endoscopy program (logistics, referral network, insurance/payers, billing, multidisciplinary clinics, etc.) and even offer a long-term mentorship program to develop these programs across the globe.
VK: Dr. Simons-Linares, how can national and international societies help move the needle forward?
RSL: GI societies should invest heavily in bariatric endoscopy training and education (clinical-cognitive, hands-on endoscopic skills, and program development). It is important to realize that obesity is a chronic relapsing disease and the aim to develop solid high-quality bariatric endoscopy programs with excellent outcomes within GI should be a priority. The obesity pandemic is only worsening – for example, by 2030, half of the US population will have obesity, and currently more than one billion people worldwide have obesity. However, this is a unique opportunity for gastroenterologists and GI societies to step up and help lead the treatment of obesity.
VK: Drs. Thompson & Simons-Linares, what are the areas of future research and innovation that you are most excited about?
CT: There is a lot of opportunity to help this field grow with new procedures and new technology. As we better understand the pathophysiology of obesity, or just how to better manipulate normal physiology to get the desired treatment effects, we will achieve better outcomes and hopefully make procedures easier to perform. I have been exploring third space endoscopy as a path to more consistent and durable results, but there are many other ways to achieve this. Small bowel therapies are just starting to enter pivotal trials in the US and they are showing promise. This means we may be on the verge of personalized endobariatric or metabolic therapies, and even combination therapies that could deliver even better results than we have seen until now. Additionally, evolution in technology is making procedures easier to perform. Whether it is new plication devices or patterns, improved balloons, endoscopic robotics or endoscopically delivered gene therapy, technology will no doubt continue to help this field develop.
RSL: As an endoscopist, I am incredibly excited of the future of device development and integration of robotics, artificial intelligence and newer technologies in the space of bariatric endoscopy (can’t wait to see what devices I have in my hands in ten years from now!). However, I’m also very excited about the roles of the microbiome and combining AOMs with endoscopy to treat obesity. What if I could tell that we now have a pill that has an effective microbiome that will help you lose weight? Or keep the weight off along with the other established interventions? I think we are heading towards that direction where bariatric endoscopy has a bright future, and it’s a great opportunity for gastroenterologists to help lead the treatment of a very widely prevalent chronic disease such as obesity and its associated metabolic comorbidities.