Systematic Reviews and Meta-analyses
Effect of Endoscopic Bariatric and Metabolic Therapies on Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis

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Background & Aims

Weight loss via lifestyle intervention remains the mainstay of treatment for nonalcoholic fatty liver disease (NAFLD). Endoscopic bariatric and metabolic therapies (EBMTs) have recently been developed as an alternative treatment option for obesity. This study aimed to assess the effect of FDA-approved EBMTs on NAFLD.

Methods

We searched MEDLINE, EMBASE, Web of Science and Cochrane Central through December 2020 for studies that assessed changes in liver outcomes following EBMT. Primary Outcomes: Liver fibrosis. Secondary Outcomes: Liver biochemistry, steatosis, NAFLD histological changes and insulin sensitivity. The Grading of Recommendations, Assessment, Development, and Evidence (GRADE) approach was conducted to assess quality of evidence.

Results

Of 4994 potential studies, 18 studies with 863 patients were included. Average weight loss was 14.5% of initial weight at a 6-month follow-up. Primary outcomes: Following EBMT, liver fibrosis significantly reduced by standardized mean difference (SMD) of 0.7 (95% CI, 0.1, 1.3; P = .02). Secondary outcomes: There were significant improvements in other NAFLD surrogates including alanine aminotransferase (-9.0 U/L; 95% CI, -11.6, -6.4; P < .0001), hepatic steatosis (SMD: -1.0; 95% CI, -1.2, -0.8; P < .0001) and histologic NAFLD activity score (-2.50; 95% CI, -3.5, -1.5; P < .0001). Other metabolic parameters including insulin resistance and waist circumference also significantly improved. The overall quality of the evidence for primary outcomes was low to very low.

Conclusions

EBMTs appear effective at treating NAFLD with significant improvement in liver fibrosis. Given the worsening NAFLD pandemic and limitations of currently available therapies, EBMTs should be further investigated as a potential treatment option for this patient population.

Section snippets

Data Sources and Search Strategy

The search strategy, study eligibility criteria, selection process, data collection process, primary and secondary outcomes, and analyses were defined a priori and are described below. We searched 4 databases, MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials, from inception to December 2020 without language or study design restrictions. The search was designed and conducted by a medical librarian with input from study investigators. An extensive search

Search Results

A total of 4994 potential studies were identified, 501 of which were duplicates. After title and abstract review, 4122 studies were excluded, leaving 371 articles for full-text review. Full-text review resulted in 18 articles that satisfied all criteria and were therefore included in the systematic review and meta-analysis (Figure 1).

All 18 studies with a total of 863 patients reported at least one liver-related outcome after EBMT. Of these, 3 studies (17%) were RCTs (1 study comparing IGB vs

Discussion

This comprehensive systematic review and meta-analysis investigates the effect of the currently FDA-approved EBMTs on liver outcomes. Our study demonstrates that EBMTs are associated with significant improvement in all major NAFLD surrogates including liver fibrosis. In addition, all surrogate markers of insulin resistance including HOMA-IR, fasting glucose, and fasting insulin significantly improve, suggesting possible mechanisms of how EBMTs affect NAFLD improvement. On meta-regression, age,

CRediT Authorship Contributions

Pichamol Jirapinyo (Conceptualization: Lead; Data curation: Lead; Formal analysis: Lead; Methodology: Lead; Project administration: Lead; Software: Lead; Supervision: Equal; Writing – original draft: Lead; Writing – review & editing: Lead)

Thomas R. McCarty (Data curation: Supporting; Methodology: Supporting; Writing – review & editing: Supporting)

Russell D. Dolan (Data curation: Supporting)

Raj Shah (Methodology: Supporting; Writing – review & editing: Supporting)

Christopher C. Thompson, MD, MS

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      However, only five have been approved by the FDA based on randomized controlled trials. They include gastric and duodenal devices and techniques such as: intragastric balloons (IGB), endoscopic sleeve gastroplasty (ESG), primary obesity surgery endoluminal (POSE), aspiration therapy and transpyloric shuttle [39]. In a recent systematic review and metanalysis of 18 studies with 863 patients treated with these BET techniques, it was reported weight reduction of 14.5% at a 6 month follow- up.

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    Conflicts of interest These authors disclose the following: P. Jirapinyo: Apollo Endosurgery– research support; Fractyl - research support; GI Dynamics – research support, consultant (consulting fees); Endogastric Solutions – consultant; ERBE - consultant (consulting fees). C. C. Thompson: Apollo Endosurgery – consultant/research support (consulting fees/institutional research grants); Aspire Bariatrics – research support (institutional research grant); BlueFlame Healthcare Venture Fund – general partner; Boston Scientific – consultant (consulting fees); Covidien/Medtronic – consultant (consulting fees); EnVision Endoscopy (board member); Fractyl – consultant/advisory board member (consulting fees); GI Dynamics – consultant (consulting fees)/research support (institutional research grant); GI Windows – ownership interest; Olympus/Spiration – consultant (consulting fees)/research support (equipment loans); Spatz – research support (institutional research grant); USGI Medical – consultant (consulting fees)/advisory board member (consulting fees)/research support (research grant). The remaining authors disclose no conflicts.

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