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Preroll: The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.

Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. Bashar Qumseya. He's an associate professor of medicine and the chief of endoscopy at UF Health Shands Hospital. He's also the Chair of Standards of Practice Committee of the American Society of Gastrointestinal Endoscopy. He's here to high. Endoscopic sleeve gastroplasty, a non-surgical approach to the management of obesity. Dr. Qumseya it's a pleasure to have you with us as we get started with this topic. Can you define obesity for us just a little bit? Speak about the prevalence and what you've been seeing in the trends. We know this is an ongoing and increasing epidemic in our country. Speak about that for just a minute.

Dr Bashar Qumseya: Thank you so much, Melanie, for the introduction and yes, obesity is defined as body mass index, or bmi of more than 30, which is a calculation based on, someone's weight and height. So basically how much you weigh compared to your height. So body mass Index over 30 is defined as obesity and unfortunately, as you mentioned, obesity rates have been increasing throughout our, community, and in Florida and nationally as well. In fact, we looked at the state of Florida through one of our databases called the One Florida Database.

And we found that among adults, the rates of obesity have continued to increase, reaching about 40 or 42% of, the overall adult population in the United States and in the state of Florida, which is a very alarming rate. And it does appear to be, going up still more so we have not reached the peak of this, epidemic of obesity. And it is a disease that have far-reaching effects on our population, on its health and, on, the economics of the country as well.

Melanie Cole (Host): One of the things, I'm an exercise physiologist, Dr. Qumseya and one of the things that I've noticed is when you say far-reaching effects, and we're gonna talk about the sequela of untreated obesity as we look at our children that are starting with obesity very, very young. Now, when we talk about sequela, we're seeing young children with type two diabetes and high blood pressure and heart issues all the way up into their older years. Speak a little bit about what you have seen doing what you do for a living as far as kids all the way up through to adults because of this epidemic that we are seeing.

Dr Bashar Qumseya: Exactly. So the rates of increase of obesity, do start at a young age. And in fact, we used the One Florida database and we looked at this and we found that the rates of obesity was increasing at younger ages more than middle-aged and more than older aged patients. And so we think that the younger patients and the younger individuals who are getting obesity now, 10, 15, 20 years later, we do find sequela of that in terms of, acid reflux disease, Barrett esophagus, which is a condition that predisposes patients to esophageal cancer and other forms of cancer.

So obesity at early ages does seem to set up patients to have chronic diseases. Also, coronary artery disease, diabetes, fat, liver, and many kinds of cancer. And so the effect of obesity take many years to show and it starts in children. And usually when they are in their thirties and forties, you're seeing a lot of these downstream effects. They can start having, diabetes and fat liver at a much younger age, but a lot of the chronic diseases appear to develop many decades later, which is why it's really important to try to treat obesity as, early as possible to prevent the sequela from happening many years later.

Melanie Cole (Host): I agree with you completely. So I'd like you to speak a little bit about endoscopic sleeve gastroplasty, outline some of those recent advances to management of patients with obesity and tell us about that and how it differs from what we've been hearing about for years, which is bypass and gastrectomy. Tell us a little bit about this procedure.

Dr Bashar Qumseya: So we're very excited about being able to offer this procedure here at UF Health Shands Hospital. And so let me just tell you about the treatment of obesity to set the stage. So obesity, as we said, is very prevalent nowadays and most people know about lifestyle changes. These are changing your diet, going on many diets, trying to exercise more. Those are really good interventions to do, but unfortunately, they do not work very well. Most patients who try these do not, in fact, lose a lot of weight, and if they lose weight, they seem to gain it. The next option, for people who want to do something else is obviously medication. So there are a lot of medications and now more medications coming on the market that treat obesity.

And those can be effective when taken appropriately. But they also do have some side effects and they can be costly and many patients don't have a lot of success long term with these medications. And the third option that traditionally has been available is the surgical option, which is the gastric bypass, the sleeve gastrectomy. And other interventions. And these are, very good interventions in the sense that they can result in a lot of weight gain, but only about 3% of patients who qualify to have these kind of procedures ever have them. And the reason being is these are obviously, are invasive procedures. They involve you having to undergo a surgery.

And alter your anatomy. And this is not appealing to the vast majority of patients with obesity who would like to avoid invasive procedures. So in these three things that I said, lifestyle, medical management, and surgical. Now we have a fourth option, which is endoscopic management, which is, a very exciting option. The reason it's exciting is that it is non-invasive. It does not involve any kind of surgery. There is no cutting on the patient. There's no real change in the anatomy. It is also reversible. Meaning, we're not cutting part of your stomach. We're not bypassing your stomach. Rather, we are using an endoscopic device that fits on the tip of the scope.

We pass the scope into the stomach and then we use a suturing device, basically a needle to suture the stomach to make it smaller, so we'll reduce the size of the stomach. In doing so, when you eat, you cannot eat as much, and also you have delayed gastric emptying, so the food sits in your stomach for a longer time, so you feel full for a longer. And therefore you eat less and you lose weight. So this is a very exciting option because like I said, it is a non-invasive, it is endoscopic, it is reversible. These sutures can be cut and it is very, very well tolerated.

We have now randomized control trial that was published in last August showing that only 2% of patients have any, serious adverse events. So the vast majority of patients have no adverse events, and in our practice, we have not experienced any severe adverse events. The most common adverse event being nausea and vomiting, but those can be very well controlled with medications. And most of our patients are able to go back to work within a few days from having this procedure and being on a diet. So it is very exciting era for us to be in because now we have another option, which is really efficacious.

Patients can lose 15 to 20% of their total body weight and, not have, an invasive procedure. And finally, Get to the stage where they can improve their comorbidities, they can decrease their insulin dependence. They can improve their hyperlipidemia. They can have improvement in hypertension, fat liver disease improvement. and generally patients who lose weight and have been through our program feel a lot better than they did before. They can walk more they can travel more, they can exercise, they can hike, they can do a lot of activities that they were limited from when they had obesity.

Melanie Cole (Host): Wow, what an exciting time in your field and you're right about how many people don't want to do the big major surgeries of bariatrics, bypass, and gastrectomy, because as you said, they are major surgeries now, is this contraindicated for anyone? Can you speak about patient selection? Are there any endoscopic or esophageal issues that would preclude somebody from having this type of surgery? Even something like gerd? Would any of these things preclude somebody? Are there contraindications?

Dr Bashar Qumseya: Yes. So there are obviously some contraindications to having any procedure. So for example, you cannot have this procedure if you've had major abdominal surgery, you've had altered anatomy, in your stomach, then you cannot have that. Although, this is still an option, although it's not called endoscopic sleeve, but we can still do redo procedures for patients who had existing gastric bypass or had a sleeve gastrectomy surgically, but have regained some of the weight so that it is still an option to do endoscopic suturing for them and they lose a lot of weight.

But other contraindications could be, for example, pregnancy, really old age, somebody with cirrhosis of the liver, somebody with, recent heart attacks. So a lot of things that would prevent you normally from undergoing a medical procedure would be contraindicated. As far as esophageal reflux is not a contraindication, in fact there's a plethora of data now, which I have also personally published about that the surgical counterpart of this, which is the surgical sleeve, that patients have really bad acid reflux after that. There is a lot of data about that now.

And we looked at this in the randomized control trials and the data does not show that that is the case with, endoscopic sleeve because we do not do the same thing, even though it is called a sleeve. It does not resemble a lot the surgical sleeve. In that sense that we leave the fundus, which is part of the stomach that stays intact in our procedure. And this is where a lot of the accommodation of the stomach exists. And this is where, a lot of the acid prevention mechanism of the stomach is. And so we leave that intact.

So we believe that our patients do not have worsening reflux, after this, although we are also looking at this in our center prospectively, where acid pH testing and esophagus before the procedure and six months after. And then hopefully we'll get this data published. But that having acid reflux is not a contraindication, to having this procedure. So really, if somebody is medically fit to have a procedure, doesn't have any contraindications or comorbidities in general to have anesthesia and undergo procedure, they can be good candidates.

We also test patients for esophageal dysmotility. And make sure that their esophagus contraction is fine. If somebody already has a lot of abdominal symptoms, like have existing nausea and vomiting, this may not be a good, procedure for them because, if your stomach is smaller and you have delayed gastric emptying already, this may be a problem. So patients who have something called gastroparesis, I'm not also a good candidate for this, but we have a good screening process in which we have our patients go through the screening process.

We also look for psychological contraindications, and so we have them sees psychologist, for clearance. We have them see anesthesia for clearance, and then we have them work with the dietician. Part of our program, we have to work with the dietician, before the procedure, and then for six months, at least after the procedure, to continue to have counseling on calorie counting. And exercise and diet because any procedure that you can have for obesity if patients do go back to a lifestyle that they used to before, they can gain the weight back even if you do a gastric bypass.

So what I tell my patients is, I'm gonna do 20% of the work for you. You are gonna lose weight, but I'm not gonna be home with you. But we're gonna give you the resources so that when you are at home, you continue to make the right choices. You continue to eat a healthy diet, you continue to be more active and burn more calories than you take in. And that's how you lose weight. And we've had great success with that. And we are convinced that patients who follow the process do very.

Melanie Cole (Host): Well, thank you so much Dr. Qumseya. As we wrap up, I'd like you to let other providers know about endoscopic suturing and this endoscopic sleeve gastroplasty that you're doing at UF Health Shands hospital and really how your outcomes have been. What have you've been seeing with your patients and when do you feel is the right time for them to refer their patients to you for counseling?

Dr Bashar Qumseya: If you have a patient who has obesity, BMI more than 30, or the patient want to do something about it. Frequently, since many of our patients are obese, they come to us for other reasons. They come to us for acid reflux. They come to us for abdominal pain. They come to us for screening colonoscopy. They come for a lot of other things because people have gotten used to obesity. So anytime you have a patient encounter, I would encourage you to look at the patient's BMI and to have a discussion with them. Saying, you know, I've noticed that your weight is above what's recommended for your, age and, your height.

And would you be interested in finding out, about how to help you lose weight? And nine out of 10 times the patients, do wanna talk about it and, do wanna do something about it. For our procedure, they don't have to have failed other stuff, although most patients have tried diet and exercise most of their life. And, part of our program, we can refer them to a program to get medications for this. So our goal is not to, bring the patient and do the procedure for them. We really are hoping to provide them with the best answers.

Some patients are more suitable for surgery and for these patients, we refer them to surgeons and we have an excellent bariatric program here. And some are more suitable for medications. And we have, an endocrine program for obesity that, we, collaborate with in our program. And so we work together with all of these providers. And our goal is to provide the patient with the best care that is suitable for them. I think endoscopic sleeve is an important consideration. It's a lot less invasive and a lot of patients. Would be really excited to know about it. So if you have anybody who's dealing with obesity, I encourage you to to have this discussion with them.

We, as physicians know that when we improve obesity, we can decrease risk for coronary artery disease. We can improve diabetes, we can improve hypertension, obstructive sleep apnea, fat liver disease, cirrhosis, resulting from fatty liver, and decreased risk of many cancers. And our patients deserve to know about these options. These options are, many patients are not aware of them. So talking to your patients about weight loss is key, and if they are interested in having something done, we see them for a clinic consult. We explain the procedure for them.

We offer them the option, the surgical option, the medical options, the lifestyle options, and sometimes it's more than once. Many, many patients are obviously on medical management and have an endoscopic. and continue to have lifestyle changes. So attacking this problem from, multiple, points of view can help us achieve the best results for our patients. We encourage you to refer your patients and also to give us a call or send me an email and I'll be more than happy to have a discussion with you about what our program is and, how we can serve you and your patient.

Melanie Cole (Host): Thank you so much, Dr. Qumseya what an interest. C and thank you for all of this information. To learn more about this in other healthcare topics at UF Health Shands Hospital, please visit innovation.Ufhealth.org and to refer your patient or to listen to more podcasts from our experts, you can always visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole.