Bariatric and metabolic therapies targeting the small intestine

Abstract

The global prevalence of obesity and type 2 diabetes (T2DM) necessitates an increased reliance on effective and safe endoscopic therapies. While surgery is highly effective, endoscopic therapies may be able to reach a greater number of affected individuals and help to reduce the burden of disease worldwide. Although current endoscopic treatments entail space occupying gastric devices as well as suturing or plication, innovative, non-Food and Drug Administration (FDA)-approved small bowel-specific endoscopic bariatric and metabolic therapies have been developed within the last several years. Small intestine therapies include endoluminal bypass liners, duodenal mucosal resurfacing, endoscopic anastomosis systems, and restricted duodenal flow treatments. These endoscopic bariatric and metabolic therapies rely upon foregut and hindgut mechanisms to achieve weight loss and improve glucose homeostasis. This review will detail these important small bowel mechanisms and evaluate current small bowel endoscopic treatments.

Incorporating Bariatric Endoscopy Into Clinical Practice

“…EBMTs include both gastric and small bowel interventions (8). While most of the experience to date has involved gastric-targeted approaches designed to promote weight loss, emerging data suggest that small bowel therapies play a greater role in targeting metabolic parameters (9,10). Future implementation of combination therapy including both gastric and small bowel interventions may offer an exciting option to further augment weight loss and help alleviate metabolic disease.…”

Advanced endoscopic gastrointestinal techniques for the bariatric patient: implications for the anesthesia provider

“…The DJBL (Endobarrier Gastrointestinal Liner; GI Dynamics Inc, Lexington, MA, USA) is a sleeve-like implant placed from the duodenum to jejunum allowing chyme to be deposited at its distal end similar to the bypass portion of a RYGB. These patients develop a malabsorptive state with vitamin D, iron, B12, and magnesium deficiencies that may warrant complete blood counts and electrolyte testing prior to anesthesia [29].…”

Efeitos metabólicos da reepitelização mucosa duodenal endoscópica em pacientes diabéticos não insulinodependentes: revisão sistemática com metanálise

“…Dada a fisiopatologia compartilhada, estratégias como cirurgias bariátricas, desenvolvidas com o objetivo de proporcionar perda ponderal, também demonstraram grandes benefícios no metabolismo da insulina e no tratamento de doenças metabólicas [8][9][10][11] . Duas teorias (Foregut e Hindgut) envolvendo o efeito incretina e anti-incretina ajudam na compreensão da resposta metabólica e neuro-hormonal relacionada à obesidade e suas comorbidades associadas.…”

“…A teoria do intestino anterior (Foregut) presume que o intestino delgado desempenha um papel central na homeostase energética e o DM2 seria consequência de um estímulo anti-incretina exacerbado 14 . O entendimento disso é fundamental, pois essa teoria pressupõe que a exclusão ou ablação do duodeno da absorção de nutrientes reduz a sinalização anti-incretina melhorando a regulação glicêmica 10,11 . Já a teoria do intestino posterior (Hindgut), parte do racional que a transferência direta de nutrientes para o intestino delgado distal estimula a secreção de incretinas, aumentando a produção de insulina.…”