Outcomes of Anti-Obesity Glucagon-Like Peptide 1 Agonists vs Revisional Endoscopic Sleeve Gastroplasty for Weight Regain After Laparoscopic Sleeve Gastrectomy: A Case-Control Real World Experience

Introduction: Weight regain following laparoscopic sleeve gastrectomy (LSG) is a common and challenging scenario. Minimally invasive options include anti-obesity glucagon-like peptide 1 (GLP1) agonists or revisional endoscopic sleeve gastroplasty (R-ESG). While GLP1 agonists are popular, their efficacy in LSG patients compared with R-ESG or controls with intact stomach is unclear. We share a real-world experience with GLP1 agonists & R-ESG for weight regain after LSG. Methods: This is a retrospective study of all adult patients with a history of LSG who were treated with Sub-Q Semaglutide or Tirzepatide or underwent R-ESG for weight regain at UCLA Health from Jan 2019 till Jan 2023. A propensity-matched control group of obese patients on GLP1 agonists with no prior bariatric surgery was identified. Primary outcomes included total body weight loss (TBWL%), excess weight loss (EWL%) and adverse events (AE) on follow-up. Secondary outcomes included changes in A1c and lipid panel. Results: The study groups included 68 (LSG+ GLP1), 20 (LSG + R-ESG), and 87 control patients. Results are presented [Table 1]. R-ESG patients were significantly younger than LSG+ GLP1 or control groups (45.2 vs 52.9 vs 51.6 yrs, P=0.03), respectively. There was no significant difference in patients baseline BMI, diabetes prevalence, %weight loss and regain after LSG, or medication dosage between groups. Difficulty with GLP1 refills was encountered in 31 LSG (45.6%) and 33 controls (37.9%). Regarding outcomes, R-ESG offered a significantly higher TBWL% than GLP1 agonists at three (10% vs 4.3%,P=0.0001) and six months (11.5% vs 6.8%, P=0.03) in LSG patients. GLP1 agonists achieved significantly lower TBWL% in LSG patients than controls at three (4.3% vs 5.7%,P=0.02), six (6.8% vs 9.2%,P=0.02), and twelve months (9.2% vs 12.7%, P=0.03). While LSG + R-ESG patients had significantly higher post-op abdominal pain than LSG+ GLP1 (10% vs 0%,P=0.04), there was no significant difference in other AE. No significant difference in the change of A1c (0.05 vs 0.6, P=0.06), LDL (-8 vs -1.1, P=0.56) or triglyceride levels (15.2 vs 27.6, P=0.59) was seen at 12 months in LSG+ R-ESG vs LSG+ GLP1, respectively. Conclusion: In a real-world experience, anti-obesity GLP1 agonists achieved significantly lower weight loss in LSG patients than those with intact stomach. R-ESG offered significantly higher weight loss than GLP1 agonists in LSG patients with weight regain while also avoiding the difficulties of GLP1 refills, making it an attractive option. Table 1. - Study Results LSG + GLP-1 agonists LSG + R-ESG Controls on GLP-1 Agonists (N= 68) (N= 20) (N=87) P value Baseline characteristics Age (years) 52.9 ± 11.9 45.2 ± 12.2 51.6 ± 11.5 0.03 Gender: Male 17 (25%) 6 (30%) 15 (17.2%) Female 51 (75%) 14 (70%) 72 (82.8%) 0.25 Ethnicity Caucasian 38 (55.9%) 9 (45%) 37 (42.5%) 0.13 Hispanic 18 (26.9%) 5 (25%) 18 (20.7%) 0.66 African American 8 (11.8%) 3 (15%) 11 (12.6%) 0.94 Asian 2 (2.9%) 0 (0%) 10 (11.5%) 0.05 Others 2 (2.9%) 3 (15%) 11 (12.6%) 0.07 Baseline BMI (Kg/m2) 43.9 ± 7 37.4 ± 6.1 39.3 ± 6.1 0.11 Obesity-related comorbidities: Essential hypertension 47 (69.1%) 12 (60%) 58 (66.7%) 0.75 GERD 40 (58.8%) 11 (55%) 27 (31%) < 0.01 Diabetes mellitus 30 (44.1%) 4 (20%) 39 (44.8%) 0.11 Hyperlipidemia 48 (70.6%) 8 (40%) 47 (54%) 0.02 Obstructive sleep apnea 48 (70.6%) 8 (40%) 30 (34.5%) < 0.001 Fatty liver disease 10 (14.7%) 2 (10%) 10 (11.5%) 0.78 Coronary artery disease 8 (11.8%) 2 (10%) 4 (4.6%) 0.25 Baseline hemoglobin A1c (%) 6.1 ± 1 5.7 ± 0.5 6.5 ± 1.4 0.04 Baseline LDL cholesterol (mg/dl) 102 ± 38 108 ± 31.2 101.1 ± 37.8 0.8 Baseline triglyceride (mg/dl) 121 ± 61 122.2 ± 96.6 158 ± 92 0.03 LSG data LSG + GLP-1 agonists (N=68) LSG + R-ESG (N=20) Controls on GLP-1 agonists (N=87) P value TBWL by LSG (%) 14.6 ± 9.1 14.6 ± 11.5 N/A 0.9 EWL by LSG (%) 30.4 ± 19 28.8 ± 25.1 N/A 0.7 Regained weight after LSG (%) 40.3 ± 40.3 53 ± 33.5 N/A 0.2 Months from LSG to intervention 52.4 ± 33.8 76 ± 39.4 N/A 0.003 Pharmacotherapy data LSG + GLP-1 agonists (N=68) LSG + R-ESG (N=20) Controls on GLP-1 agonists (N=87) P value Medication used: Semaglutide 59 (86.6%) N/A 78 (89.7%) 0.57 Tirzepatide 7 (10.3%) N/A 9 (10.3%) 0.99 Both alternated 2 (2.9%) N/A 0 (0%) 0.19 Weekly semaglutide dose (mg) 1.25 ± 0.6 N/A 1.19 ± 0.6 0.61 Weekly tirzepatide dose (mg) 7.5 ± 3.1 N/A 7.2 ± 2.9 0.85 Difficulties with refills 31 (45.6%) N/A 33 (37.9%) 0.33 Months on medication 9.3 ± 5.9 N/A 8.6 ± 4.8 0.67 Medication discontinuation 12 (17.6%) N/A 7 (8%) 0.07 Months to discontinuation 11.3 ± 10.9 12.4 ± 8.9 Outcomes LSG + GLP-1 agonists (N=68) LSG + R-ESG (N=20) P value Controls on GLP-1 agonists (N=87) P value TBWL% 3 months 4.3 ± 4 10 ± 5.8 0.0001 5.7 ± 3.6 0.02 6 months 6.8 ± 5.6 11.5 ± 6.5 0.03 9.2 ± 5.8 0.02 12 months 9.2 ± 7 10.8 ± 7.8 0.5 12.7 ± 6.8 0.03 EWL% 3 months 12.7 ± 12.9 27.5 ± 18.6 0.001 14.9 ± 10.6 0.25 6 months 18.5 ± 17.4 36 ± 20.4 0.001 22.8 ± 15.9 0.003 12 months 25.4 ± 20.7 32.1 ± 22.4 0.38 32.9 ± 20.1 0.12 Adverse events Nausea ± vomiting 14 (20.6%) 2 (10%) 0.28 9 (10.3%) 0.07 Constipation 0 (0%) 0 (0%) 1 3 (3.4%) 0.25 Abdominal pain 0 (0%) 2 (10%) 0.049 0 (0%) 1 Intra-op bleeding. N/A 0 (0%) N/A N/A N/A Intra-op perforation N/A 0 (0%) N/A N/A N/A Post-op admission N/A 1 (10%) N/A N/A N/A A1c% change 3 months 0.3 ± 0.5 0.07 ± 0.1 0.21 0.8 ± 1.2 0.07 6 months 0.2 ± 0.5 -0.08 ± 0.2 0.23 0.7 ± 0.8 0.009 12 months 0.6 ± 0.8 0.05 ± 0.3 0.06 0.6 ± 0.9 0.89 LDL change at 12 months -1.1 ± 28.7 -8 ± 23 0.56 15.6 ± 36 0.09 Triglyceride change at 12 months 27.6 ± 58.3 15.2 ± 43.1 0.59 30.3 ± 73.2 0.07 Statistics presented as mean (±SD) or frequency (%). P was calculated using chi-square test for categorical data & one-way ANOVA for numerical data. P < 0.05 was considered statistically significant. LSG: laparoscopic sleeve gastrectomy, GLP-1: glucagon-like peptide 1, R-ESG: revisional endoscopic sleeve gastroplasty, BMI: body mass index, GERD: gastroesophageal reflux disease, TBWL: total body weight loss, EWL: excess weight loss.