Open label, prospective, randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve versus low calorie diet for pre-operative weight loss in bariatric surgery

Emerging Endoscopic Interventions in Bariatric Surgery

Various endoscopic tools and techniques have been developed to treat obesity and its associated weight-related medical conditions. However, many of these endoscopic treatments may be little known or utilized. This article examines the many endoscopic options that have been developed to treat obesity including gastric aspiration devices, incisionless magnetic anastomotic systems, endoluminal bypass barrier sleeves, primary obesity surgery endoluminal, endoscopic sleeve gastroplasty, and duodenal mucosal resurfacing. We review their development, application, efficacy, and the reported literature on their use and results.

The Effectiveness and Safety of the Duodenal-Jejunal Bypass Liner (DJBL) for the Management of Obesity and Glycaemic Control: a Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

The duodenal-jejunal bypass liner (DJBL) is a less-invasive treatment of obesity and type 2 diabetes mellitus (T2DM).

METHODS

This is a systematic review and meta-analysis including randomized clinical trials (RCTs) comparing DJBL versus sham or pharmacotherapies aiming to evaluate the effectiveness and safety of DJBL.

RESULTS

Ten RCTs (681 patients) were included. The DJBL group showed superior excess weight loss (+ 11.4% [+ 7.75 to + 15.03%], p < 0.00001) and higher decrease in HbA1c compared to the control group (- 2.73 ± 0.5 vs. - 1.73 ± 0.4, p = 0.0001). Severe adverse events (SAEs) occurred in 19.7%.

CONCLUSION

The DJBL did not reach the ASGE/ASMBS thresholds for the treatment of obesity. However, it is important to state that many SAEs were not really severe. Therefore, we believe this therapy plays an important role in the management obesity and T2DM.

Research Progress of Duodenal-Jejunal Bypass Liner in the Treatment of Obesity and Type 2 Diabetes Mellitus

With the development of economy and improvement of people's living standards, the incidence of obesity and type 2 diabetes mellitus (T2DM) has increased significantly and obesity has also become one of the most important risk factors of T2DM. In light of these trends, there have been many ways to take effect in losing weight. However, they also have corresponding deficiencies including inapparent curative effect, complex and incomplete reversible procedures and severe complications. Duodenal-Jejunal Bypass Liner (DJBL), which mimics Roux-en-Y gastric bypass (RYGB), is proved to play a key role in weight loss and control of T2DM. DJBL is reversible, less invasive and is more suitable for the treatment of obesity and T2DM, which is associated with multiple mechanisms, including incretin effect, gastric emptying mechanism, bile acid regulation, intestinal microbiota, inflammatory reaction mechanism and neural mechanism. In our review, we aimed to elaborate DJBL's clinical efficacy, safety and mechanisms in detail.

Emerging Endoscopic Interventions in Bariatric Surgery

Although obesity rates are growing across the world, endoscopic modalities to treat obesity and its metabolic consequences are advancing rapidly. Multiple devices and techniques dedicated to weight management are being developed and have either been approved for use or are undergoing clinical trial. This article reviews many of these endoscopic interventions in bariatric surgery, including gastric aspiration devices, incisionless magnetic anastomotic systems, endoluminal bypass barrier sleeves, primary surgery obesity endoluminal, endoscopic sleeve gastroplasty, and duodenal mucosal resurfacing. These effective techniques may serve either as a primary therapy or as a bridge to bariatric surgery.

The current state of bariatric endoscopy

A variety of endoscopic bariatric and metabolic treatments (EBMTs) have been developed in recent years to combat the growing prevalence of obesity in the United States (US) and worldwide. This manuscript reviews the current state of bariatric endoscopy, detailing all US Food and Drug Administration (FDA) approved EBMTs including space-occupying intragastric balloons (IGBs), aspiration therapy, and endoscopic tissue apposition devices. Additionally, this review describes non-FDA approved treatments including additional IGBs, endoluminal bypass liners, duodenal mucosal resurfacing, and endoscopically placed anastomosis devices.

Various Novel and Emerging Technologies in Endoscopic Bariatric and Metabolic Treatments

Obesity, along with its comorbidities, has become a significant public health concern worldwide. Bariatric surgery is considered the most effective treatment modality; however, only 2% of patients with obesity undergo bariatric surgery. Endoscopic bariatric and metabolic therapies (EBMTs) are emerging alternatives to traditional bariatric surgery for patients who are not eligible for or do not prefer surgical treatment. EBMTs are generally categorized as space-occupying, gastric restrictive, aspiration, and small bowel therapies. We aimed to review various non-balloon and non-gastroplasty devices with available clinical data and discuss the possible mechanisms of action, efficacy, and safety profile of these EMBTs.

The Role of duodenal jejunal bypass liner in obesity treatment

<abstract> <p>Endoscopic bariatric procedures including Duedenal Jejunal Bypass Liner (DJBL) have become widespread in obesity treatment in recent years. The aim of this systematic review was to assess the role of DJBL in obesity treatment. A comprehensive search of several databases, including Cochrane Library, PubMed, and Web of Science was conducted to December 2020. Twenty-four clinical studies were assessed. According to the results, it is clear that DJBL provides effective weight reduction at 6–12 months and significant improvements in parameters associated with metabolic syndrome and cardiovascular disease. This technique also has potential to reduce comedications in patients with obesity and type 2 diabetes. Although these positive effects of DJBL are clear, its effect on liver, pancreatic functions, and inflammation markers are not clear yet. In addition, the overall and serious complication (gastrointestinal bleeds, pancreatitis, hepatic abscess, obstruction of the sleeve, biliary colic without cholecystitis and cholangitis) rate causing from the DJBL is very high. DJBL has not been approved by the Food and Drug Administration due to the frequency and severity of complications it causes. While it is certain that DJBL has significant effects on obesity and obesity related comorbidities, the safety aspect needs to be improved.</p> </abstract>

Comparative efficacy of bariatric endoscopic procedures in the treatment of morbid obesity: a systematic review and network meta-analysis

BACKGROUND

The comparative efficacy of bariatric endoscopic procedures has not been completely elucidated. We aimed to comprehensively evaluate the efficacy of bariatric endoscopic procedures.

METHODS

We searched for randomized controlled trials investigating the efficacy of bariatric endoscopic procedures, including the use of an intragastric balloon, duodenal-jejunal bypass liner (DJBL), aspiration therapy, primary obesity surgery endoluminal (POSE) procedure, and botulinum toxin injection to the stomach. Network meta-analyses were performed to determine the percentage of weight loss (%weight loss) and percentage of excess weight loss (%EWL).

RESULTS

22 studies with 2141 patients were included in the meta-analysis. Most endoscopic procedures showed superior efficacy in terms of %weight loss compared with the control (mean difference [MD] [95 % confidence interval (CI)]: aspiration therapy 10.4 % [7.0 % to 13.7 %]; fluid-filled balloon 5.3 % [3.4 % to 7.2 %]; POSE 4.9 % [1.7 % to 8.2 %]; and DJBL 4.5 % [1.4 % to 7.7 %]). In terms of %EWL, aspiration therapy, fluid-filled balloon, POSE, and DJBL were superior to the control (MD [95 %CI]: 27.3 % [15.3 % to 39.3 %]; 22.4 % [15.4 % to 29.4 %]; 15.3 % [2.5 % to 28.0 %]; and 13.0 % [4.9 % to 21.2], respectively). The gas-filled balloon and botulinum toxin injection did not show a significant difference in %weight loss or %EWL compared with the control. For the fluid-filled balloon, the %EWL and %weight loss tended to decrease after balloon removal at 6 months after the procedure.

CONCLUSION

All bariatric endoscopic procedures, except for gas-filled balloon and botulinum toxin injection to the stomach, showed superior short-term efficacy in terms of %weight loss or %EWL compared with lifestyle modification.

Efficacy and Safety of the Duodeno-Jejunal Bypass Liner in Patients With Metabolic Syndrome: A Multicenter Randomized Controlled Trial (ENDOMETAB)

OBJECTIVE

The aim of this study was to compare the efficacy and safety of 12-month implantation of a duodeno-jejunal bypass liner (DJBL) with conventional medical care in patients with metabolic syndrome (MS).

SUMMARY BACKGROUND DATA

DJBL is an endoscopic device for treating obesity and related disorders. The persistence of favorable results after 6 months has not been tested in a controlled study.

METHODS

We conducted a multicenter randomized controlled trial, stratified by center and diabetes status. The primary endpoint was the remission of MS at 12 months. The secondary endpoints included body mass index (BMI), glucose control, blood pressure, and lipids, assessed at 12 months after implantation, and again, at 12 months after the removal of the DJBL. Up to 174 subjects were planned to be randomized into either the DJBL or the control arm at a 2:1 ratio, respectively. Study enrollment was discontinued by the Scientific Monitoring Committee due to the early termination of the ENDO trial (NCT01728116) by the US Food and Drug Administration. The study was terminated after withdrawal of the device's European Conformity marking by the European Medicines Agency, and an interim analysis was performed.

RESULTS

A total of 82 patients were enrolled (67.5% female, 48.8% with diabetes). At 12 months after randomization, the primary endpoint was met in 6 (12%) DJBL patients and 3 (10%) controls (P = 0.72). Patients in the DJBL group experienced greater BMI loss [mean adjusted difference (95% confidence interval, CI) -3.1 kg/m (-4.4 to -1.9) kg/m, P < 0.001] and HbA1c change [mean adjusted difference -0.5% (95% CI -0.9 to -0.2); P < 0.001] than those in the control group. No difference remained statistically significant at 12 months after the removal of the DJBL. In the DJBL group, 39% of patients experienced at least one device-related serious adverse event, which was classified as Grade III Dindo-Clavien in 22%, and required premature device explantation in 16%.

CONCLUSIONS

The present study showed a transient clinical benefit of DJBL, which was only apparent at 1 year, when the device was still in situ, and was obtained at the risk of serious device-related adverse events in 39% of patients. These results do not support the routine use of DJBL for weight loss and glucose control in patients with MS.

Bariatric and Metabolic Therapies Targeting the Small Intestine

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 evaluates current small bowel endoscopic treatments.

Procedures and devices for bariatric and metabolic endoscopy

Obesity is a leading cause of preventable death in developed countries, with a rising incidence over time. Lifestyle modification, pharmacotherapy, and bariatric surgery are the mainstays of bariatric therapy, even though burdened by several limitations in terms of efficacy or safety. Bariatric endoscopy has been developed in the last decades as a minimally invasive alternative, aimed to bridge the gap between conservative and interventional conventional therapies. This review aims to provide an updated overview of the bariatric and metabolic available endoscopic procedures and to drive the choice of the right procedure for the right patient.

Endobarrier as a Pre Bariatric Surgical Intervention in High-Risk Patients: a Feasibility Study

Background

Obesity surgery mortality risk scoring system (OS-MRS) classifies patients into high, intermediate and low risk, based on age, body mass index, sex and other comorbidities such as hypertension and history of pulmonary embolism. High-risk patients not only have a higher mortality but are more likely to develop post-operative complications necessitating intervention or prolonged hospital stay following bariatric surgery. Endoscopically placed duodenal-jejunal bypass sleeve (Endobarrier) has been designed to achieve weight loss and improve glycaemic control in morbidly obese patients with clinically proven effectiveness.

The aim of this study was to assess if pre-operative insertion of endobarrier in high-risk patients can decrease morbidity and length of stay after bariatric surgery.

Materials and Methods

Between 2012 and 2014, a cohort of 11 high-risk patients had an Endobarrier inserted (E&BS group) for 1 year prior to definitive bariatric surgery. These patients were compared against a similar group undergoing primary bariatric surgery (PBS group) during same duration. The two groups were matched for age, gender, body mass index, comorbidities, surgical procedure and OS-MRS using propensity score matching. Outcome measures included operative time, morbidity, length of stay, intensive therapy unit (ITU) stay, readmission rate, percentage excess weight loss (%EWL) and percentage total weight loss (%TWL).

Results

Patient characteristics and OS-MRS were similar in both groups (match tolerance 0.1). There was no significant difference in total length of stay, readmission rate, %EWL and %TWL. Operative time, ITU stay, post-operative complications and severity of complications were significantly less in the E&BS group (p < 0.05) with significant likelihood of planned ITU admissions in the PBS group (p < 0.05).

Conclusion

Endobarrier could be considered as a pre bariatric surgical intervention in high-risk patients. It may result in improved post-operative outcomes in high-risk bariatric patients.

The Effect of 6 and 12 months Duodenal-Jejunal Bypass Liner Treatment on Obesity and Type 2 Diabetes: a Crossover Cohort Study

OBJECTIVE

The aim of this research was to study the duodenal-jejunal bypass liner (DJBL) treatment for obesity and type 2 diabetes mellitus (T2DM) in patients after dietary treatment in a cross-over design.

BACKGROUND

DJBL treatment has been proven effective for treatment of obesity and T2DM. However, data on safety and efficacy of a 12-month DJBL treatment is limited.

METHODS

In 2014, our research group reported on a multicenter randomized clinical trial. Patients were randomized to DJBL or dietary treatment (control group). Twenty-eight patients crossed over after their dietary treatment and received up to 12 months of DJBL treatment. Patient visits were conducted at baseline, during DJBL treatment (1 week, 1-6, 9, 12 months) and 6 months after removal of the liner. Patients underwent a standard physical examination, blood sampling, assessment of adverse events, nutritional and diabetes counseling, and a standardized meal tolerance test.

RESULTS

Of the 28 patients included in this study, 24 patients completed 6 months of treatment. Eighteen patients were extended to 12 months of DJBL treatment; 13 patients completed this treatment period. After 6 months of DJBL treatment, a significant increase in excess weight loss (EWL) and decrease in weight, BMI, HbA1c, fasting glucose, cholesterol, HDL and LDL improved significantly. After 12 months of DJBL treatment, these parameters stabilized.

CONCLUSIONS

The DJBL is an effective, minimally invasive treatment option. Even after successful treatment with dietary restrictions, the DJBL is still capable of significantly reducing weight and improving cardiovascular and type 2 diabetes mellitus parameters in obese patients.

Trends in BMI, Glycemic Control and Obesity-Associated Comorbidities After Explantation of the Duodenal-Jejunal Bypass Liner (DJBL)

BACKGROUND

A novel-approach for treatment of obesity and diabetes mellitus type 2 (T2DM) is represented by the endoscopic duodenal-jejunal bypass liner (DJBL). Recent data from the German DJBL registry provide evidence for substantial efficacy of the DJBL during the implantation period in obese patients with T2DM. However, little is known about the trends of glycemic control, BMI, and comorbidities after explantation of the DJBL, which have been investigated in the registry in this report.

METHODS

Patients were selected from the registry if they had a dataset at implantation, explantation, and at least one time point after explantation of the DJBL (n = 77). We also investigated a subgroup of patients with available data at least 1 year (-2 weeks) after explantation of the DJBL (n = 32).

RESULTS

For a mean BMI at implantation and a mean follow-up period, an increase of BMI of 2.1 kg/m² (CI 0.8-3.2; p = 0.013) had to be expected (for HbA1c 0.3% (CI - 0.0-0.7; p = n.s.), respectively). In the subgroup analysis, HbA1c and BMI increased after explantation of the DJBL but stayed significantly below baseline levels. Meanwhile, the mean number of antidiabetic drugs slightly increased. There was deterioration seen for blood pressure and LDL cholesterol over the postexplantation period to approximately baseline levels (or higher).

CONCLUSION

With this data, we show that improvement of HbA1c and BMI can be partly maintained over a time of nearly 1-year postexplantation of the DJBL. However, for HbA1c, this may be biased by intensified medical treatment and effects deteriorated with time after explantation. These results suggest that implantation of the DJBL needs to be integrated in a long-term weight management program as most of other interventions in obese patients with T2DM.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02731859.

New Anchoring Mechanism and Design of an Endoluminal Duodeno-Jejunal Bypass Liner for Treatment of Obesity: a Pilot Animal Trial

OBJECTIVE

Complications of bleeding, liver abscess and movement have been associated with previous duodeno-jejunal bypass liner (DJBL) applications in the past. A new anchoring system and design of a DJBL is presented as a pilot study.

METHOD

A newly designed DJBL device was inserted in 2 pigs and observed over 2 months.

RESULTS

The newly designed device was anchored and monitored for 1 month in 1 of 2 pigs, the other being passed early. Effectiveness and safety have been shown.

CONCLUSION

The results of this pilot study warrant further investigation of the modified DJBL setup, which may help solve standing issues associated with the clinical use of a DJB liner.

Network meta-analysis of the relative efficacy of bariatric surgeries for diabetes remission

BACKGROUND

Bariatric surgery leads to a higher remission rate for type 2 diabetes mellitus than non-surgical treatment. However, it remains unsolved which surgical procedure is the most efficacious. This network meta-analysis aimed to rank surgical procedures in terms of diabetes remission.

METHODS AND FINDINGS

We electronically searched for randomized controlled trials in which at least one surgical treatment was included among multiple arms and the diabetes remission rate was included in study outcomes. A random-effects network meta-analysis was performed within a frequentist framework. The hierarchy of treatments was expressed as the surface under the cumulative ranking curve value. Results of the analysis of 25 eligible randomized controlled trials that covered non-surgical treatments and eight surgical procedures (biliopancreatic diversion [BPD], BPD with duodenal switch, Roux-en Y gastric bypass, mini gastric bypass [mini-GBP], laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, greater curvature plication and duodenal-jejunal bypass) showed that BPD and mini-GBP had the highest surface under the cumulative ranking curve values among the eight surgical treatments.

CONCLUSION

Current network meta-analysis indicated that BPD or mini-GBP achieved higher diabetes remission rates than the other procedures. However, the result needs to be interpreted with caution considering that these procedures were in the minority of bariatric surgeries.

Small Bowel Endoscopic Bariatric Therapies

Endoscopic bariatric therapies that emulate some of the principles of bariatric surgery have been developed as a less invasive option for the treatment of obesity and related comorbidities. Small bowel endoscopic bariatric therapies include bypass sleeves, incisionless anastomosis systems, and duodenal mucosal resurfacing. Clinical experience with small bowel devices suggests that endoscopic bariatric procedures can be safely implemented and that these devices are effective for both weight loss and metabolic improvement. Although the mechanisms behind these effects should be further elucidated, endoscopic bariatric therapies may be more effective and safer adjunctive interventions than lifestyle modifications and pharmacological regimens for patients with obesity or obesity-related comorbidities.

Comparative efficacy and safety of the duodenal-jejunal bypass liner in obese patients with type 2 diabetes mellitus: A case control study

AIMS

The duodenal-jejunal bypass liner (DJBL) is an endoscopic device mimicking surgical duodenal-jejunal bypass, and is indicated for the treatment of obesity-associated type 2 diabetes mellitus. This analysis was conducted to evaluate the efficacy and safety of the DJBL in comparison to lifestyle changes and antidiabetic drugs.

MATERIALS AND METHODS

To determine the efficacy and long-term safety of the DJBL, data concerning 235 obese patients with type 2 diabetes mellitus from the German DJBL registry were analysed. For comparison with standard treatment, propensity-score-matching with patients from the German DPV registry, including the matching parameters sex, age, diabetes duration, baseline BMI and baseline HbA1c, was applied. The final matched cohort consisted of 111 patients in the DJBL group and 222 matched control DPV patients.

RESULTS

Mean treatment time with the DJBL was 47.5 ± 12.2 weeks, mean BMI reduction was 5.0 kg/m² (P < .001) and mean HbA1c reduction was 1.3% (11.9 mmol/mol) (P < .001). Reduction of antidiabetic medications and improvements in other metabolic and cardiovascular risk parameters was observed. In comparison to the matched control group, mean reductions in HbA1c (-1.37% vs -0.51% [12.6 vs 3.2 mmol/mol]; P < .0001) and BMI (-3.02 kg/m² vs -0.39 kg/m² ; P < .0001) were significantly higher. Total cholesterol, LDL cholesterol and blood pressure were also significantly better.

CONCLUSION

This study provides the largest, so far, hypothesis-generating evidence for a putative positive risk/benefit ratio for treatment of obese patients with type 2 diabetes mellitus with the DJBL as an alternative treatment option for this patient population.

The EndoBarrier: Duodenal-Jejunal Bypass Liner for Diabetes and Weight Loss

The rapid rise of obesity and type 2 diabetes poses a global threat to healthcare and is a major cause of mortality and morbidity. Bariatric surgery has revolutionised the treatment of both these conditions but is invasive and associated with an increased risk of complications. The EndoBarrier is a device placed endoscopically in the duodenum, which is designed to mimic the effects of gastric bypass surgery with the aim of inducing weight loss and improving glycaemic control. This review outlines the current clinical evidence of the device, its efficacy, potential mechanisms of action, and utility in clinical practice.

Effect of the Duodenal-Jejunal Bypass Liner on Glycemic Control in Patients With Type 2 Diabetes With Obesity: A Meta-analysis With Secondary Analysis on Weight Loss and Hormonal Changes

OBJECTIVE

Duodenal-jejunal bypass liner (DJBL) is an endoscopic device that may mimic small bowel mechanisms of Roux-en-Y gastric bypass (RYGB). Previous studies have demonstrated the efficacy of DJBL at inducing weight loss. We assessed the effect of DJBL on glycemic control in patients with type 2 diabetes (T2D) with obesity.

RESEARCH DESIGN AND METHODS

Data sources included MEDLINE, EMBASE, and Web of Science through 1 July 2017. Included were published studies that assessed DJBL outcomes in obese T2D patients.

RESULTS

Primary outcomes were change in HbA_1c and HOMA of insulin resistance (HOMA-IR). Secondary outcomes were change in weight and gut hormones glucose-dependent insulinotropic peptide (GIP), glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and ghrelin. Seventeen studies were included. At explant, HbA_1c decreased by 1.3% [95% CI 1.0, 1.6] and HOMA-IR decreased by 4.6 [2.9, 6.3]. Compared with control subjects, DJBL subjects had greater HbA_1c reduction by 0.9% [0.5, 1.3]. Six months after explant, HbA_1c remained lower than baseline by 0.9% [0.6, 1.2]. At explant, patients lost 11.3 kg [10.3, 12.2], corresponding to a BMI reduction of 4.1 kg/m² [3.4, 4.9], total weight loss of 18.9% [7.2, 30.6], and excess weight loss of 36.9% [29.2, 44.6]. The amount of weight loss remained significant at 1 year postexplantation. After DJBL, GIP decreased, whereas GLP-1, PYY, and ghrelin increased.

CONCLUSIONS

DJBL improves glycemic control and insulin resistance in T2D patients with obesity. DJBL also appears to induce significant weight loss in this population. Additionally, changes in gut hormones suggest mechanisms similar to RYGB. Study limitations included heterogeneity among studies.

Safety and Effectiveness of an Endoscopically Placed Duodenal-Jejunal Bypass Device (EndoBarrier®): Outcomes in 114 Patients

BACKGROUND

The duodenal-jejunal bypass liner (DJBL) is an endoscopically placed device designed to achieve weight loss and improve glycemic control in obese patients. Previous studies report promising results but typically included small patient numbers and short follow-up. This study aims to determine the safety and effectiveness of the device.

METHODS

Study design: A series of all patients treated by the DJBL at our institutions.

OUTCOME MEASUREMENTS

Weight loss, biochemical measures, complications.

RESULTS

Between July 2012 and March 2015, 114 consecutive patients were treated for a mean 51.1 weeks (standard deviation (SD) 19.9 weeks). Mean total body weight change from baseline was 12.0 kg (SD 8.5 kg, p < 0.001). Mean percent total body weight loss (%TWL) was 10.5% (SD 7.3%). Mean HbA1c was not significantly improved, but of 10 patients on insulin, 4 ceased insulin and 4 reduced insulin dosages. There was a significant decrease in hemoglobin and total cholesterol and a significant increase in serum alkaline phosphatase. Seventy-four percent of patients experienced at least one adverse event, some of them serious including 6 device obstructions, 5 gastrointestinal hemorrhages, 2 liver abscesses, and 1 acute pancreatitis. Seventy-four percent of patients experienced weight gain after removal with a mean 4.5 ± 6.1 kg (p < 0.0001) within the first 6 months after explantation.

CONCLUSIONS

The DJBL provides significant but highly variable weight loss. Glycemic control was variable. Most insulin-requiring T2DM patients ceased or reduced insulin. Most patients experience an adverse event and most regain significant weight after device removal. Major adverse events can occur, including the potentially life-threatening complications of hepatic abscess and gastrointestinal hemorrhage.

Randomized sham-controlled trials in endoscopy: a systematic review and meta-analysis of adverse events

BACKGROUND AND AIMS

Sham procedures in endoscopy are used with the intention of controlling for placebo response, potentially allowing more precise evaluation of treatment effect. Nevertheless, this type of study may impose significant risk without potential benefit for those in the sham group. The aim of the current study was to systematically review and analyze the endoscopic literature to assess the safety of sham controls.

METHODS

MEDLINE and Embase databases were searched for endoscopic sham procedures for all dates to July 2017. Only randomized controlled trials comparing an endoscopic therapy with a sham were included. Primary outcome was adverse events (AEs) categorized as mild, moderate, or severe. Results were combined using a random-effects model. Heterogeneity was assessed with the I² statistic, and publication bias was assessed with the Egger test and funnel plots.

RESULTS

Data were extracted from 34 publications (1987-2017; 100% full text), with a total of 2492 procedures (1355 treatment/1137 sham). Sham procedures involved upper endoscopy (31 studies) and ERCP (3 studies). Treatment arms included procedures with the following indications: weight loss (38.2%), GI bleeding (26.5%), GERD (20.6%), sphincter of Oddi dysfunction (8.8%), and dysphagia (6.2%). Overall percentage of severe adverse events (SAEs) in the sham group was 1.7% (19/1137). Of these, the most common SAEs in the sham groups were need for surgery/intensive care unit stay (35.3%), post-ERCP pancreatitis (23.5%), and perforation (11.8%). There was no significant difference in the odds of developing an SAE between the treatment group and the sham group (odds ratio, 1.3; 95% confidence interval [CI], 0.7-2.3). The pooled additional risk incurred from being initially randomized to the sham arm and then receiving a cross-over intervention was significant (RR, 1.33; 95% CI, 1.14-1.56; P < .001), compared with patients initially randomized to the study intervention.

CONCLUSION

The frequency of AEs in endoscopic sham procedures is substantial, and patients are subjected to considerable morbidity. These results raise a serious ethical dilemma regarding the use of sham-controlled trials.

A randomised controlled trial of a duodenal-jejunal bypass sleeve device (EndoBarrier) compared with standard medical therapy for the management of obese subjects with type 2 diabetes mellitus

INTRODUCTION

The prevalence of obesity and obesity-related diseases, including type 2 diabetes mellitus (T2DM), is increasing. Exclusion of the foregut, as occurs in Roux-en-Y gastric bypass, has a key role in the metabolic improvements that occur following bariatric surgery, which are independent of weight loss. Endoscopically placed duodenal-jejunal bypass sleeve devices, such as the EndoBarrier (GI Dynamics, Lexington, Massachusetts, USA), have been designed to create an impermeable barrier between chyme exiting the stomach and the mucosa of the duodenum and proximal jejunum. The non-surgical and reversible nature of these devices represents an attractive therapeutic option for patients with obesity and T2DM by potentially improving glycaemic control and reducing their weight.

METHODS AND ANALYSIS

In this multicentre, randomised, controlled, non-blinded trial, male and female patients aged 18-65 years with a body mass index 30-50 kg/m² and inadequately controlled T2DM on oral antihyperglycaemic medications (glycosylated haemoglobin (HbA1c) 58-97 mmol/mol) will be randomised in a 1:1 ratio to receive either the EndoBarrier device (n=80) for 12 months or conventional medical therapy, diet and exercise (n=80). The primary outcome measure will be a reduction in HbA1c by 20% at 12 months. Secondary outcome measures will include percentage weight loss, change in cardiovascular risk factors and medications, quality of life, cost, quality-adjusted life years accrued and adverse events. Three additional subgroups will investigate the mechanisms behind the effect of the EndoBarrier device, looking at changes in gut hormones, metabolites, bile acids, microbiome, food hedonics and preferences, taste, brain reward system responses to food, eating and addictive behaviours, body fat content, insulin sensitivity, and intestinal tissue gene expression.

TRIAL REGISTRATION NUMBER

ISRCTN30845205, ClinicalTrials.gov Identifier NCT02459561.

Novel Nonsurgical Endoscopic Approaches for the Treatment of Obesity

Globally, obesity is a leading cause of preventable death and is associated with >60 comorbid medical conditions, including 10 types of cancer that are strongly associated with body mass index. There are a number of traditional obesity treatments-for example, lifestyle management (eg, decreased caloric intake and increased expenditure), pharmacotherapy, and bariatric surgery. Recently, endoscopic approaches have emerged as a viable alternative for weight loss. Endoscopically placed intragastric balloons were introduced in the early 1980s for the treatment of medically complicated obesity but, unfortunately, had high rates of complications, such as premature deflation leading to obstruction. Despite these shortcomings, these devices have experienced a renewal, with a second generation of improved devices being approved for clinical use in 2015. In addition to the intragastric balloons, there are a number of other endoscopic approaches to weight loss that are either Food and Drug Administration approved or undergoing evaluation (aspiration therapy, duodenal jejunal bypass sleeve). The current review examines the literature available and discusses the practical clinical considerations involved.

Small Bowel Target Devices and Techniques

The small bowel is a prime target for bariatric and metabolic endoscopic therapies. New insights into the mechanisms of action of surgical therapies have led to new endoscopic therapies for obesity, type 2 diabetes mellitus, and the metabolic syndrome. The development of endoluminal sleeves that bypass the proximal duodenum have replicated some of the effects of surgical bypass procedures. The endoscopic dual-path enteral bypass has created new and treatment options for these conditions. Duodenal mucosal resurfacing offers significant promise for diabetes management. It is hoped that a durable endoscopic therapy for these conditions will be defined and optimized.

Changes in glycemic control and body weight after explantation of the duodenal-jejunal bypass liner

BACKGROUND AND AIMS

The duodenal-jejunal bypass liner (DJBL) is an endoscopic device that induces weight loss and improves glycemic control in patients with type 2 diabetes mellitus (T2DM). The aim of the current study was to assess the effects of DJBL explantation on glycemic control and body weight.

METHODS

This prospective, observational study included only patients with T2DM who had the DJBL implanted for at least 6 months and had a follow-up of at least 12 months after explantation. The primary endpoints were changes in glycosylated hemoglobin A_1c (HbA_1c) and body weight during the 12 months after explantation. Secondary endpoints were changes in fasting plasma glucose, blood pressure, and plasma lipid levels.

RESULTS

In total, 59 patients completed the 12-month follow-up after explantation. During this period body weight increased by 5.6 (standard deviation, 6.4) kg (P < .001) and HbA_1c rose from 65 (SD 17) to 70 (SD 20) mmol/mol (P < .001). However, body weight remained 8.0 (SD 8.6) kg (P < .001) lower than before implantation, that is, corresponding to a net total body weight loss of 7.4% (SD 7.6) (P < .001). Although HbA_1c was significantly higher 12 months after explantation compared with baseline and the mean daily dose of insulin used was comparable, the number of patients on insulin remained significantly lower than before implantation.

CONCLUSIONS

Explantation of the DJBL is associated with weight gain and worsening of glycemic control, although some beneficial effects remained detectable 12 months after explantation. A change in strategy is needed to preserve the beneficial effects of DJBL treatment. (Clinical trial registration number: 746∖100111.).

Role of Malabsorptive Endoscopic Procedures in Obesity Treatment

The incidence of obesity is increasing, and more definitive treatment modalities are needed. Endoluminal procedures, including restrictive endoscopic procedures, endoscopic gastroplasty, and malabsorptive endoscopic procedures, can reduce weight in obese patients and control obesity-related comorbidities. Malabsorptive endoscopic interventions also offer the potential for an ambulatory procedure that may be safer and more cost-effective compared with laparoscopic surgery. Malabsorptive endoscopic intervention can induce weight reduction and improve obesity-related metabolic parameters, despite complications such as device migration, obstruction, and abdominal pain. Improvement in technique will follow the development of new devices.

Bariatric endoscopy: current state of the art, emerging technologies, and challenges

INTRODUCTION

Over the last few decades obesity has become a major health issue worldwide. Although dietary and lifestyle changes are the cornerstone of obesity management, it still poses a huge challenge for the majority of patients to permanently change their eating habits. Bariatric endoscopy represents an evolving filed of minimally invasive techniques and procedures for weight loss trying to respond to these challenges by developing new methods with the increasing role of endoscopists in the management of obesity. Areas covered: The aim of this article is to review the role and the advantages of bariatric endoscopy in the management of obesity by providing a comprehensive reference source and evaluating the currently available and emerging endoscopic devices and techniques for weight loss. Expert commentary: Endoscopic methods for weight loss represent a useful armamentarium in the management of obesity by providing improved effectiveness compared with medications, with a lower risk profile than traditional bariatric surgery. Although preliminary results of recently introduced methods are encouraging, many questions remain regarding the safety and efficacy of such interventions. Combining scientific background with advancements in technology is the key strategy for the further development of bariatric endoscopy.

Weight reduction and improvement in diabetes by the duodenal-jejunal bypass liner: a 198 patient cohort study

BACKGROUND

The duodenal-jejunal bypass liner (DJBL) is an endoscopic treatment for patients with type 2 diabetes mellitus (T2DM) and (morbid) obesity. The aim of the current study was to determine its efficacy and safety profile.

METHODS

Inclusion criteria for treatment with a DJBL were: age 18-70 years, BMI 28-45 kg/m², and T2DM with a HbA1c > 48 mmol/mol. Primary outcomes were changes in HbA1c and body weight. Secondary outcomes included changes in blood pressure, lipids, and anti-diabetic medication. Predictive factors for success of treatment with the DJBL were determined.

RESULTS

Between 2011 and 2014, 185 out of 198 patients successfully underwent a DJBL implantation procedure, with an intended implantation time of 12 months. In these 185 patients, body weight decreased by 12.8 ± 8.0 kg (total body weight loss of 11.9 ± 6.9 %, p < 0.001), HbA1c decreased from 67 to 61 mmol/mol (p < 0.001) despite a reduction in anti-diabetic medication, and blood pressure and serum lipid levels all decreased. In total, 57 (31 %) DJBLs were explanted early after a median duration of 33 weeks. Adverse events occurred in 17 % of patients. C-peptide ≥1.0 nmol/L and body weight ≥107 kg at screening were independent predictive factors for success.

CONCLUSIONS

Treatment with the DJBL in T2DM patients with (morbid) obesity results in improvement in glucose control, a reduction in anti-diabetic medication, and significant weight loss. The largest changes are observed within the first 3-6 months. Initial C-peptide levels and body weight may help to select patients with the greatest chance of success.

Recent Trends in Endoscopic Management of Obesity

Obesity remains a tremendous public health, clinical, and scientific challenge globally. Conventional approaches in the management of obesity offer limited potential for sustained weight loss. Bariatric surgery, although it represents the most effective weight loss treatment, has its own risks and is associated with substantial costs and limited patient applicability. Endoscopic weight loss procedures are considered as the major breakthrough in the management of obesity. Endoluminal interventions performed entirely through the gastrointestinal tract have evolved as a result of an attempt to replicate some of the anatomical features and the physiological effects of the traditional weight loss surgery while being reversible, less invasive, and more cost-effective. Restrictive procedures act to decrease gastric volume by space-occupying devices and/or by suturing or stapling techniques that alter gastric anatomy, whereas malabsorptive procedures tend to create malabsorption by preventing food contact with the duodenum and proximal jejunum. Other procedures act by influencing gastric function (gastric botulinum injections, gastric pacing, and vagal nerve blocking) or by gastric aspiration. It is important to underline that the majority of endoscopic weight loss procedures are still being evaluated and are not yet available routinely. Even though some of the techniques and devices that have recently emerged have demonstrated promising short-term results, evidence on their safety and long-term efficacy from well-designed and well-conducted research should be given before they can become an inherent part of everyday clinical practice. Given the rapid development of endoscopic weight loss procedures, this review considers the current state and recent trends in endoscopic management of obesity.

Effect of the EndoBarrier Gastrointestinal Liner on obesity and type 2 diabetes: a systematic review and meta-analysis

Compared with bariatric surgery, less invasive and reversible techniques to counteract obesity and type 2 diabetes (T2D) have been developed, including the EndoBarrier Gastrointestinal Liner [duodenal-jejunal bypass sleeve (DJBS)]. We conducted a systematic review and meta-analyses of eligible trials to evaluate the efficacy and safety of the DJBS. Five randomized controlled trials (RCTs; 235 subjects) and 10 observational studies (211 subjects) were included. The risk of bias was evaluated as high in all studies. The mean body mass index ranged from 30 to 49.2 kg/m(2) and 10-100% of the subjects had T2D. Meta-analysis showed that the DJBS was associated with significant mean differences in body weight and excess weight loss of -5.1 kg [95% confidence interval (CI) -7.3, -3.0; four trials; n = 151; I(2)  = 37%] and 12.6% (95% CI 9.0, 16.2; four trials; n = 166; I(2)  = 24%), respectively, compared with diet modification. The mean differences in glycated haemoglobin (-0.9%; 95% CI -1.8, 0.0) and fasting plasma glucose (-3.7 mM; 95% CI -8.2, 0.8) among subjects with T2D did not reach statistical significance. Adverse events consisted mainly of abdominal pain, nausea and vomiting. No deaths occurred. Future high-quality long-term RCTs are needed to further assess efficacy and safety.

Safety experience with the duodenal-jejunal bypass liner: an endoscopic treatment for diabetes and obesity

BACKGROUND

The duodenal-jejunal bypass liner (DJBL) is a new, device-based endoscopic treatment for type 2 diabetes mellitus (T2DM) and obesity.

OBJECTIVE

To report serious safety events of subjects treated with the DJBL while offering a simple guideline to mitigate risk.

DESIGN

Single-center observational study.

SETTING

Tertiary referral center.

PATIENTS

For commercial use, patients were eligible for implantation of the DJBL when they met the following criteria: age 18 to 65 years, body mass index 28 to 45 kg/m(2), T2DM, and negative serum Helicobacter pylori test.

INTERVENTIONS

Endoscopic implantation of the DJBL.

MAIN OUTCOME MEASUREMENTS

Adverse events, serious adverse events, early explantation.

RESULTS

Between October 2007 and January 2014, 152 of 165 planned implantations (92%) and 94 explantations were performed in our center. Significant weight loss and improvement in T2DM and other cardiovascular parameters were achieved. Early removal of the device occurred because of persistent GI symptoms in 16 patients (11%). Serious adverse events were observed in a subset of patients: 7 GI bleeds, 5 of which required early removal; 2 cases of pancreatitis; 1 case of hepatic abscess; and 1 obstruction of the sleeve. Explantation resulted in an esophageal tear in 2 cases.

LIMITATIONS

Single-center study.

CONCLUSION

The DJBL improves glycemic control while causing weight loss. The safety profile of the DJBL demonstrates a reasonable tolerability profile. However, serious safety adverse events can occur. Patient selection, expert use of the device at placement and removal, and the supportive care of an experienced multidisciplinary team are key for safe and effective use of the DJBL.

Endoscopic Bypass Using Endobarrier Devices: Efficacy in Treating Obesity and Metabolic Syndrome

Obesity is a rapidly growing pandemic. Scope of pharmacotherapy and bariatric surgery in managing obesity is ever rising. The role of minimally invasive techniques to achieve preoperative weight loss and improve postbariatric surgery outcomes is an area of new interest. The initial experience with endobarrier devices in achieving weight loss among obese subjects has shown promising results. In addition, the impact of these interventions on comorbidities commonly associated with obesity like diabetes mellitus type 2 and hyperlipidemia has further expanded their potential for use in future. In this review article, we have summarized case report, prospective single and multicenter studies, and randomized-controlled trials describing the use of endobarrier devices. Indications, techniques, outcomes, limitations, and complications reported are discussed.

ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies

The increasing global burden of obesity and its associated comorbidities has created an urgent need for additional treatment options to fight this pandemic. Endoscopic bariatric therapies (EBTs) provide an effective and minimally invasive treatment approach to obesity that would increase treatment options beyond surgery, medications, and lifestyle measures. This systematic review and meta-analysis were performed by the American Society for Gastrointestinal Endoscopy (ASGE) Bariatric Endoscopy Task Force comprising experts in the subject area and the ASGE Technology Committee Chair to specifically assess whether acceptable performance thresholds outlined by an ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) document for clinical adoption of available EBTs have been met. After conducting a comprehensive search of several English-language databases, we performed direct meta-analyses by using random-effects models to assess whether the Orbera intragastric balloon (IGB) (Apollo Endosurgery, Austin, Tex) and the EndoBarrier duodenal-jejunal bypass sleeve (DJBS) (GI Dynamics, Lexington, Mass) have met the PIVI thresholds. The meta-analyses results indicate that the Orbera IGB meets the PIVI thresholds for both primary and nonprimary bridge obesity therapy. Based on a meta-analysis of 17 studies including 1683 patients, the percentage of excess weight loss (%EWL) with the Orbera IGB at 12 months was 25.44% (95% confidence interval [CI], 21.47%-29.41%) (random model) with a mean difference in %EWL over controls of 26.9% (95% CI, 15.66%-38.24%; P ≤ .01) in 3 randomized, controlled trials. Furthermore, the pooled percentage of total body weight loss (% TBWL) after Orbera IGB implantation was 12.3% (95% CI, 7.9%–16.73%), 13.16% (95% CI, 12.37%–13.95%), and 11.27% (95% CI, 8.17%–14.36%) at 3, 6, and 12 months after implantation, respectively, thus exceeding the PIVI threshold of 5% TBWL for nonprimary (bridge) obesity therapy. With the data available, the DJBS liner does appear to meet the %EWL PIVI threshold at 12 months, resulting in 35% EWL (95% CI, 24%-46%) but does not meet the 15% EWL over control required by the PIVI. We await review of the pivotal trial data on the efficacy and safety of this device. Data are insufficient to evaluate PIVI thresholds for any other EBT at this time. Both evaluated EBTs had ≤5% incidence of serious adverse events as set by the PIVI document to indicate acceptable safety profiles. Our task force consequently recognizes the Orbera IGB for meeting the PIVI criteria for the management of obesity. As additional data from the other EBTs become available, we will update our recommendations accordingly.

Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration

A new paradigm in the treatment of obesity and metabolic disease is developing. The global obesity epidemic continues to expand despite the availability of diet and lifestyle counseling, pharmacologic therapy, and weight loss surgery. Endoscopic procedures have the potential to bridge the gap between medical therapy and surgery. Current primary endoscopic bariatric therapies can be classified as restrictive, bypass, space-occupying, or aspiration therapy. Restrictive procedures include the USGI Primary Obesity Surgery Endolumenal procedure, endoscopic sleeve gastroplasty using Apollo OverStitch, TransOral GAstroplasty, gastric volume reduction using the ACE stapler, and insertion of the TERIS restrictive device. Intestinal bypass has been reported using the EndoBarrier duodenal-jejunal bypass liner. A number of space-occupying devices have been studied or are in use, including intragastric balloons (Orbera, Reshape Duo, Heliosphere BAG, Obalon), Transpyloric Shuttle, and SatiSphere. The AspireAssist aspiration system has demonstrated efficacy. Finally, endoscopic revision of gastric bypass to address weight regain has been studied using Apollo OverStitch, the USGI Incisionless Operating Platform Revision Obesity Surgery Endolumenal procedure, Stomaphyx, and endoscopic sclerotherapy. Endoscopic therapies for weight loss are potentially reversible, repeatable, less invasive, and lower cost than various medical and surgical alternatives. Given the variety of devices under development, in clinical trials, and currently in use, patients will have multiple endoscopic options with greater efficacy than medical therapy, and with lower invasiveness and greater accessibility than surgery.

Advances in the Endoscopic Management of Obesity

Obesity has become a worldwide epidemic with significant impact on quality of life, morbidity, and mortality rates. Over the past two decades, bariatric surgery has established itself as the most effective and durable treatment for patients with obesity and its associated comorbidities. However, despite the use of minimally invasive techniques, bariatric surgery is associated with complications in approximately 15% of patients, has a substantial cost, and is used by only 1% of patients who are eligible. Therefore, there is a need for effective minimally invasive therapies, which will be utilized by the large proportion of obese patients who are in desperate need of treatment but are not receiving any. Endoscopic approaches to the management of obesity have been developed, with the aim of delivering more effective, durable, and safer methods of weight reduction. In this paper, we review currently available and future endoscopic therapies that will likely join the armamentarium used in the management of obesity.

The effect of the endoscopic duodenal-jejunal bypass liner on obesity and type 2 diabetes mellitus, a multicenter randomized controlled trial

OBJECTIVE

Investigate the safety and efficacy of 6 months' duodenal-jejunal bypass liner (DJBL) treatment in comparison with dietary intervention for obesity and type 2 diabetes mellitus (T2DM).

BACKGROUND

The DJBL is a bariatric procedure involving an impermeable sleeve that is delivered endoscopically in the proximal intestine. This procedure not only is less invasive than conventional surgical techniques but also has beneficial effects on obesity and T2DM.

METHODS

A multicenter randomized controlled trial was conducted. Seventy-seven patients with obesity and T2DM were included. Thirty-eight patients were randomized to 6 months' DJBL treatment in combination with dietary intervention (34 successfully implanted, 31 completed the study), 39 patients received only dietary intervention (controls, 35 completed the study). Total study duration for both groups was 12 months, including 6 months of post-DJBL removal follow-up.

RESULTS

After 6 months, just before DJBL removal, the DJBL group had lost 32.0% [22.0%-46.7%] of their excess weight versus 16.4% [4.1%-34.6%] in the control group (P < 0.05). Glycated hemoglobin A1c levels improved to 7.0% [6.4%-7.5%] in the DJBL group and to 7.9% [6.6%-8.3%] in the control group (P < 0.05). In addition, 85.3% of DJBL patients showed decreased postprandial glucose excursions versus 48.7% of control patients (P < 0.05). At 12 months, excess weight loss of the DJBL group was 19.8% [10.6%-45.0%] versus 11.7% [1.4%-25.4%] in the control group (P < 0.05). HbA1c was 7.3% [6.6%-8.0%] versus 8.0% [6.8%-8.8%], DJBL versus control respectively (P = ns).

CONCLUSIONS

The DJBL is a safe and effective alternative to invasive bariatric procedures. Six months of DJBL treatment combined with diet leads to superior weight loss and improvement of T2DM when compared with diet alone.

Outcome reporting in bariatric surgery: an in-depth analysis to inform the development of a core outcome set, the BARIACT Study

Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.

Endoscopic treatment: the past, the present and the future

The obesity epidemic asks for an active involvement of gastroenterologists: many of the co-morbidities associated with obesity involve the gastrointestinal tract; a small proportion of obese patients will need bariatric surgery and may suffer from surgical complications that may be solved by minimally invasive endoscopic techniques; and finally, the majority will not be eligible for bariatric surgery and will need some other form of treatment. The first approach should consist of an energy-restricted diet, physical exercise and behaviour modification, followed by pharmacotherapy. For patients who do not respond to medical therapy but are not or not yet surgical candidates, an endoscopic treatment might look attractive. So, endoscopic bariatric therapy has a role to play either as an alternative or adjunct to medical treatment. The different endoscopic modalities may vary in mechanisms of action: by gastric distension and space occupation, delayed gastric emptying, gastric restriction and decreased distensibility, impaired gastric accommodation, stimulation of antroduodenal receptors, or by duodenal exclusion and malabsorption. These treatments will be discussed into detail.

Duodeno-jejunal tube placement in an experimental model of obesity: effects on food behaviour and basal energy expenditure

BACKGROUND

Metabolic surgery can modulate weight as well as food intake and basal energy expenditure. In this study, we evaluate the effectiveness of duodenal exclusion by analysing anthropometric results, intake variations, food behaviour and calorimetric parameters.

METHODS

This is an experimental study with 8-week-old Sprague-Dawley male rats. The sequences used are as follows: Cafeteria diet for 3 weeks, followed by surgery and sacrifice at 4 weeks. Four experimental groups are as follows: two non-obese groups (n = 15; surgery = 10, sham = 5) and two obese groups by cafeteria diet (n = 15; surgery = 10, sham = 5). Surgery performed was duodenal exclusion with physical barrier. Weight, intake, glycaemia and basal energy expenditure by indirect calorimetry were monitored before and after surgery.

RESULTS

Weight changes in groups that underwent intervention were significant. The reduction in calorie consumption after surgery was significant in the obese intervention group despite an increased standard feed consumption (161 ± 11 vs 139 ± 13 Kcal/day, p < 0.05; due to a lower consumption of cafeteria diet). In non-obese animals, changes were transient. Basal energy expenditure decreased in both intervention groups: 6.2 ± 0.5 vs 5.5 ± 0.4 Kcal/kg/h in non-obese animals and 5.6 ± 0.3 vs 4.7 ± 0.3 Kcal/kg/h in obese animals (p < 0.05).

CONCLUSIONS

Duodeno-jejunal tube placement stops weight gain in obese and non-obese animals. In obese animals, there is an important qualitative change in appetite towards standard feed with a significant decrease in caloric intake. In non-obese animals, changes in quantitative intake are transient. This surgery decreases basal energy expenditure in obese animals. This may be attributed to an enhanced thermogenic effect of food and a slowing in the animal's weight gain.

A new endoscopically implantable device (SatiSphere) for treatment of obesity--efficacy, safety, and metabolic effects on glucose, insulin, and GLP-1 levels

BACKGROUND

The endoluminal mechanical device SatiSphere is a new endoscopically implantable device designed to delay transit time of nutrients through the duodenum. It consists of a 1-mm nitinol wire with pigtail ends and several mesh spheres mounted along its course, released in the duodenum and gastric antrum to conform to the duodenal C loop configuration and thereby self-anchor.

METHODS

The objective is to test the safety, efficacy, and effect on body weight in a 2:1 randomized study, as well as incretin secretion in a subgroup.

RESULTS

Of 31 included cases (11 men, mean age 42.9 years, mean BMI 41.3 kg/m2), 21 patients treated with endoscopic device insertion with scheduled device removal after 3 months were compared with 10 controls. In 10 of 21 patients, device migration occurred, in two cases necessitating emergency surgery, which led to termination of the trial. Weight loss after 3 months was 6.7, 4.6, and 2.2 kg in the groups completing therapy, all treatment cases using intention to treat (ITT) analysis and controls. Excess weight loss was significantly increased by endoluminal mechanical device insertion (18.4, 12.2, and 4.4% in completers, ITT analysis group and controls; p = 0.02 for completers vs. controls). Measuring glucose, insulin, and glucagon-like peptide 1 (GLP-1) following a mixed-meal test with the device in place and after removal (n = 7), the device delayed glucose absorption and insulin secretion and altered kinetics in GLP-1 levels.

CONCLUSIONS

The device might be short-term effective in reducing body weight, which might be mediated through alterations in incretin metabolism. However, frequent device migration necessitates device modifications.

Novel/experimental bariatric techniques

Due to the documented effects regarding durable and pronounced weight loss as well as improvement/resolution of obesity-associated morbidity, the number of bariatric surgical procedures performed has increased in an 'epidemiologic' fashion during the last decade. Most common/established procedures used today have well-documented effects but are all associated with technique-specific advantages as well as shortcomings. In particular, complications in the short as well as long term constitute a drive for continuous development of new techniques. A common feature of such new techniques is to reduce the degree of surgical trauma by being less invasive. Some of the new techniques used for bariatric treatment have been in clinical practice for a long time. However, due to the lack of controlled data with documentation of their efficacy and risk of complications, these are still to be considered as experimental. Other techniques are newly being introduced, and therefore data on their potential use for treatment of morbidly obese patients are limited. In this article, an overview of some of the most important of such new techniques is given. Some recently presented methodologies in which very sparse documentation is present, but which have been appreciated for being innovative and sometimes controversial, are also mentioned.

Endoscopic duodenal-jejunal bypass liner rapidly improves type 2 diabetes

BACKGROUND

Bariatric procedures excluding the proximal small intestine improve glycemic control in type 2 diabetes within days. To gain insight into the mediators involved, we investigated factors regulating glucose homeostasis in patients with type 2 diabetes treated with the novel endoscopic duodenal-jejunal bypass liner (DJBL).

METHODS

Seventeen obese patients (BMI 30-50 kg/m(2)) with type 2 diabetes received the DJBL for 24 weeks. Body weight and type 2 diabetes parameters, including HbA1c and plasma levels of glucose, insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and glucagon, were analyzed after a standard meal before, during, and 1 week after DJBL treatment.

RESULTS

At 24 weeks after implantation, patients had lost 12.7 ± 1.3 kg (p < 0.01), while HbA1c had improved from 8.4 ± 0.2 to 7.0 ± 0.2 % (p < 0.01). Both fasting glucose levels and the postprandial glucose response were decreased at 1 week after implantation and remained decreased at 24 weeks (baseline vs. week 1 vs. week 24: 11.6 ± 0.5 vs. 9.0 ± 0.5 vs. 8.6 ± 0.5 mmol/L and 1,999 ± 85 vs. 1,536 ± 51 vs. 1,538 ± 72 mmol/L/min, both p < 0.01). In parallel, the glucagon response decreased (23,762 ± 4,732 vs. 15,989 ± 3,193 vs. 13,1207 ± 1,946 pg/mL/min, p < 0.05) and the GLP-1 response increased (4,440 ± 249 vs. 6,407 ± 480 vs. 6,008 ± 429 pmol/L/min, p < 0.01). The GIP response was decreased at week 24 (baseline-115,272 ± 10,971 vs. week 24-88,499 ± 10,971 pg/mL/min, p < 0.05). Insulin levels did not change significantly. Glycemic control was still improved 1 week after explantation.

CONCLUSIONS

The data indicate DJBL to be a promising treatment for obesity and type 2 diabetes, causing rapid improvement of glycemic control paralleled by changes in gut hormones.