Analysis of safety and efficacy of intragastric balloon in extremely obese patients

Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS)

The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for metabolic and bariatric surgery (MBS), replacing the previous guidelines established by the National Institutes of Health (NIH) over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams (MDTs), as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Intragastric Balloon as Bridging Therapy Prior to Bariatric Surgery for Patients with Severe Obesity (BMI ≥ 50 kg/m2): a Systematic Review and Meta-analysis

Bariatric surgery for patients with severe obesity (body mass index (BMI) ≥ 50kg/m²) is technically challenging. Intragastric balloon (IGB) has been proposed for weight loss before bariatric surgery to reduce surgical risks but its efficacy remains unclear. We conducted a systematic review and meta-analysis of the effectiveness of IGB as bridging therapy and assess potential complications. Amongst 2419 citations, 13 studies were included. IGB resulted in a BMI reduction of 6.60 kg/m² (MD=6.60, 95% CI: 5.06-8.15; I²=72%). The total post-procedural complication rate was 8.13% (95% CI: 4.04-13.17%), with majority being balloon intolerance. Overall, IGB is effective as a bridging therapy with adequate procedural safety profile, but further study is needed to evaluate the risk reduction for bariatric surgery and long-term weight-loss outcomes.

Gastric Balloon Implantation as Part of Morbid Adiposity Therapy Changes the Structure of the Stomach Wall

PURPOSE

The implantation of a gastric balloon (also known as intragastric balloon) is an established and reversible endoscopic procedure for adiposity therapy. Structural changes of the stomach wall are expected to occur with gastric balloon implantation; however, until now these changes have rarely been investigated.

METHODS

We compared the histological structure of the stomach wall after gastric-sleeve resection in a group of patients following gastric balloon implantation and a group without previous gastric balloon implantation.

RESULTS

Following gastric balloon implantation, the tunica muscularis was found to be significantly thicker than without gastric balloon implantation. The enlarging of the tunica muscularis is not caused by hyperplasia of the leiomyocytes, but by hypertrophy of the leiomyocytes and an increase in collagen fibers (fibrosis).

CONCLUSION

A longer-lasting hypertrophy of the tunica muscularis, particularly in the corpus, should be taken into account when surgical treatment follows gastric balloon implantation. The staple suture height should be adjusted to the altered tissue composition since reduced tissue elasticity must be expected due to fibrosis.

Safety and Effectiveness of an Intragastric Balloon as an Adjunct to Weight Reduction in a Post-Marketing Clinical Setting

BACKGROUND AND OBJECTIVES

Obesity and its related comorbidities are associated with serious health risks. This trial evaluated the safety and effectiveness of the ORBERA® Intragastric Balloon System (IGB) as an adjunct to lifestyle intervention in a post-marketing clinical setting.

METHODS AND MATERIALS

In this multicenter study, 258 adults with a body mass index of 30-40 kg/m² were treated with the IGB as an adjunct to weight reduction and followed for up to 12 months. The primary objective was to demonstrate in a post-marketing clinical setting that the incidence of device and procedure-related serious adverse events (SAEs) after 26 weeks of IGB treatment is no greater than 15%.

RESULTS

The incidence of device and procedure-related SAEs was 8.9% with a 1-sided upper limit confidence interval of 12.4%, compared with the 9.6% overall SAE rate seen in the US pivotal study; therefore, the primary safety endpoint was met. The key secondary effectiveness endpoint was also met with a mean maximum %TBWL of 12.5 being achieved at the time of IGB removal (26 weeks).

CONCLUSIONS

The post-marketing safety and effectiveness profile of the IGB are consistent with what was observed in the US pivotal study. No new risks were identified.

CLINICAL TRIAL REGISTRATION

CLINICAL TRIALS.GOV NCT02828657.

Efficacy and Safety of Intragastric Balloon (IGB) in Non-alcoholic Fatty Liver Disease (NAFLD): a Comprehensive Review and Meta-analysis

Intragastric balloon (IGB) therapy has shown efficacy in weight loss but its role in NAFLD remains unknown. We conducted a systematic review and meta-analysis to evaluate the efficacy of IGB in NAFLD. Meta-analysis was performed to estimate the pooled proportion of patients with improvement in steatosis as determined by imaging and histology following IGB placement. Nine studies were included in our analysis. Four hundred forty-two IGBs were placed. Improvement in steatosis was seen in 79.2% of patients and NAS in 83.5% of patients, and HOMA-IR score improved in 64.5% of patients. A reduction in liver volume by CT scan was noticed in 93.9% of patients undergoing IGB placement. IGB is an effective and safe short-term therapeutic modality for patients with NAFLD.

[Intragastric balloon for weight reduction: rationale, benefits, risks and indications]

Intragastric balloon (IGB) placement under endoscopy is a non-invasive method for weight loss.By placing a space-occupying balloon in the stomach, IGB treatment can achieve better effect of weight loss than medications.Herein we review the development of IGB, its effect on weight loss and the mechanism, and the eligible individuals for IGB treatment.We also examine the high-intensity postoperative management following IGB placement, which is important for maintaining long-term weight loss, and discuss the future development of IGB.The patients should understand that on the basis of ensuring a high safety, the weight-losing effect of IGB can be limited and relies heavily on postoperative management.Patients should make a decision on IGB placement after careful consideration of their own physical, economic, and psychological conditions, lifestyle and the line of work in addition to the indications of IGB.IGB placement combined with high-intensity postoperative management and active interventions of lifestyle and dietary habits help to achieve long-term effect of weight loss and improve obesity-related complications.

Intragastric balloon insertion and pancreatitis: Case series

INTRODUCTION

Obesity is a complex multifactorial disease that affects populations worldwide. In Kuwait, the prevalence of obesity is a major public health problem. Intra-Gastric Balloon (IGB) is commonly used as a non-operative strategy among bariatric patients. However, with the increasing use of IGB, life-threatening adverse outcomes are widely reported.

PRESENTATION OF CASES

A case series five patients presenting with pancreatitis from IGB in Kuwait is reported to better investigate the emerging complications of IGB. Three types of IGB were inserted, these include the Orbera Intragastric Balloon System, Orbera365 Intragastric Balloon System, and the Spatz Adjustable Gastric. The clinical course of balloon pancreatitis is described.

DISCUSSION

The case series examined existing case reports of IGB associated pancreatitis in the literature, in addition to the investigated clinical outcomes. Patients presented with mild pancreatitis, and removal of balloon resulted in significant improvement in symptoms. Pathogenesis of balloon pancreatitis could be secondary to the pancreas compression by the IGB.

CONCLUSION

Despite the rarity of balloon pancreatitis, it needs to be recognized as a complication of IGB insertion. Further research is needed to better understand the implications of the balloon size, shape, volume and location of balloon insertion in order to prevent this fatal complication.

Acute Pancreatitis: A Complication of Intragastric Balloon

PURPOSE

This study was carried out because intragastric balloon (IGB) is a widely used method to combat obesity, and acute pancreatitis complicating IGB is rare and yet to be understood.

METHOD

This study was a retrospective analysis of all patients with a history of IGB insertion, who developed acute pancreatitis before balloon removal.

RESULTS

A total of 4 cases were found, with a mean age of 27±2.9 years. The mean duration of IGB insertion was 2.25±1.25 months, with an average body mass index of 37.7±3.4 kg/m. Abdominal computed tomography visualized signs of pancreatitis with the balloon compressing the pancreatic body. Pancreatitis resolved after endoscopic balloon extraction, with an average aspiration of 607.5±64.5 mL of the fluid used to fill the balloon.

CONCLUSION

Our study demonstrates that acute pancreatitis can complicate IGB and recommends the need to measure amylase and lipase in patients who have a history of IGB insertion and present with a picture suggestive of pancreatitis.

ReShape Intragastric Balloon Complicated by Gastric Perforation and Peritonitis

BACKGROUND

Obesity is a growing global epidemic with tremendous financial burden and health care costs worldwide. Restrictive surgery has emerged as the definitive treatment option to combat morbid obesity and its associated comorbidities. The advent of endoscopy has new grounds in obesity with the introduction of inflatable balloon placed in the stomach that decreases satiety by volume restriction.

MATERIALS AND METHODS

We report a first case of gastric perforation with peritonitis after ReShape intragastric balloon placement that needed emergent surgical intervention. Decision was made to proceed with exploratory laparotomy, device deflation, and removal with subsequent gastric defect repair.

RESULTS

Postoperative period was uneventful, drain was removed on postoperative day 2, and patient tolerated diet and was discharged home subsequently. Biopsy of the perforation site demonstrated mild non-specific chronic gastritis.

CONCLUSION

In the modern era of minimal invasiveness, any new approach would roar popularity among patients and hence is of utmost importance for clinicians to be constantly educated on scientific research and innovations in their field.

Intragastric Balloon for Management of Severe Obesity: a Systematic Review

Older models of intragastric balloons (IGBs) had unacceptably high complication rates and inconsequential weight loss. With FDA approval of newer models, we aimed to systematically examine the literature regarding the efficacy of IGB therapy for obesity. A comprehensive electronic database search was completed. Title searching was restricted to the following keywords: bariatric, gastric, gastric bypass, gastric band, sleeve gastrectomy, and intragastric balloon. Twenty-six primary studies (n = 6101) were included. At balloon removal, mean change in weight and BMI were 15.7 ± 5.3 kg and 5.9 ± 1.0 kg/m(2). The most common complications were nausea/vomiting (23.3 %) and abdominal pain (19.9 %). Serious complications were rare: mortality (0.05 %) and gastric perforation (0.1 %). IGBs are associated with marked short-term weight loss with limited serious complications.

Intragastric balloon as an adjunct to lifestyle programme in severely obese adolescents: impact on biomedical outcomes and skeletal health

Intragastric Balloons are a temporary, reversible and safer option compared to bariatric surgery to promote significant weight loss, leading to improved metabolic outcomes. However, due to subsequent weight regain, alternative procedures are now preferred in adults. In adolescents, more amenable to lifestyle change, balloons may be an alternative to less reversible procedures. Our aim was to assess the tolerability and efficacy of the intragastric balloon in severely obese adolescents and the impact of associated weight loss on biomedical outcomes (glucose metabolism, blood pressure, lipid profiles) and bone density. A 2-year cohort study of 12 adolescents (BMI >3.5 s.d., Tanner stage >4) following 6 months intragastric balloon placement was carried out. Subjects underwent anthropometry, oral glucose tolerance test, and DEXA scans at 0, 6 and 24 months. The results showed clinically relevant improvements in blood pressure, insulin: glucose metabolism, liver function and sleep apnoea at 6 months. Changes were not sustained at 2 years though some parameters (Diastolic BP, HBA1c, insulin AUC) demonstrated longer-term improvement despite weight regain. Despite weight loss, bone mass accrual showed age appropriate increases. In conclusion, the intragastric balloon was safe, well tolerated and effective in supporting short-term weight loss and clinically relevant improvement in obesity-related complications, which resolved in some individuals. Benefits were not sustained in the majority at 2 years.

Evaluation of the results of treatment of morbid obesity by the endoscopic intragastric balloon implantation method

INTRODUCTION

Overweight and obesity are ranked in the fifth place among the risk factors responsible for the greatest number of deaths in the world.

AIM

To assess the effects of treatment of patients with morbid obesity using endoscopic intragastric balloon (IGB) implantation.

MATERIAL AND METHODS

Two hundred and seventy-two patients with obesity were treated using endoscopic intragastric balloon implantation. Upon analysis of the inclusion and exclusion criteria, the study covered a group of 63 patients with morbid obesity. The patients were implanted with the LexBal balloon. Reduction of excess body mass, changes to BMI values and ailments and complications divided into mild and severe were assessed.

RESULTS

Before intragastric balloon treatment, the average body mass index (BMI) value was 58.3 ±10.5 kg/m2, whereas after 6 months of treatment it decreased to 49.5 ±8.7 kg/m2. The patients with postoperative BMI equal to or greater than 50.0 kg/m2 reported nausea (69.7%), vomiting (51.5%), flatulence (45.5%), upper abdominal pain (36.4%) and general discomfort (424%) more frequently. Dehydration (9.1%) was also more frequent in this group, whereas frequency of occurrence of such ailments and complications as heartburn (23.3%) and oesophageal candidiasis (10.0%) was higher in the patients with postoperative BMI below 50.0 kg/m2.

CONCLUSIONS

Endoscopic intragastric balloon implantation is an effective and safe method of excess body mass reduction in patients with morbid obesity before a planned bariatric surgical procedure. Pre-operative excess body mass and BMI value and post-operative excess weight loss in patients with morbid obesity have no impact on frequency of occurrence of ailments and complications in IGB treatment.

Gastric Ulcer Hemorrhage - a Potential Life-Threatening Complication of Intragastric Balloon Treatment of Obesity

BACKGROUND

Some morbidly obese patients do not qualify for bariatric surgery due to general health contraindications. Intragastric balloon treatment might be a therapeutic option in the above-mentioned cases. It can prime super-obese patients with end-stage disease for bariatric surgery. As a neoadjuvant therapy before surgery, it leads to a downstage of the disease by preliminary weight reduction, to an improvement in general health and, in summary, to a reduction of the perioperative risk. It is generally considered to be a safe method. However, due to the wide range of possible complications and unusual symptoms after intragastric balloon treatment, an interdisciplinary, instead of only a surgical or endoscopic, treatment and follow-up might be recommended in these patients.

CASE REPORT

We here describe a potential life-threatening complication in the form of gastric bleeding as a consequence of intragastric balloon treatment and simultaneous aspirin taking and Helicobacter pylori infection.

CONCLUSION

There have been reports of some complications of intragastric balloon treatment. However, to the best of our knowledge there were no reports concerning life-threatening hemorrhage from gastric ulcer.

How to treat stenosis after sleeve gastrectomy?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has increasingly gained worldwide acceptance among bariatric surgeons during the past 10 years. Numerous articles have been written about the different approaches to the management of gastric fistulas, but limited data can be found concerning gastric stenosis after LSG.

SETTING

Private hospital, France.

METHODS

A total of 18 patients received endoscopic treatment for stenosis after LSG between May 2007 and June 2015. Stenosis was classified according to the endoscopic findings as functional (the passage of the endoscope was possible, but the sleeve was twisted with various degrees of rotation) or mechanical (the passage of the endoscope was very difficult or impossible).

RESULTS

This study included 13 women and 5 men, with an average age of 37.2±8.4 years and an average body mass index of 41.6±8.7 kg/m². The average number of endoscopic procedures was 1.3 (range, 1-4). No patient had stent migration. The successful rate of endoscopic approach for stenosis of LSG was 94.4%, with one patient requiring conversion to Roux-en-Y gastric bypass. The mean time from the LSG to the first endoscopic intervention was 28.2 days. All patients presented with midsleeve stricture, located near the incisura angularis, and no patient showed a stenosis in the upper part of the gastric tube.

CONCLUSIONS

The treatment of stenosis after LSG must be tailored to the clinical status of the patient and endoscopic findings. Both balloon dilation and stent deployment are useful and safe tools and must be used when appropriate.

Current status of intragastric balloon for obesity treatment

Endoscopic bariatric therapy may be a useful alternative to pharmacological treatment for obesity, and it provides greater efficacy with lower risks than do conventional surgical procedures. Among the various endoscopic treatments for obesity, the intragastric balloon is associated with significant efficacy in body weight reduction and relief of comorbid disease symptoms. Anatomically, this treatment is based on gastric space-occupying effects that increase the feeling of satiety and may also affect gut neuroendocrine signaling. The simplicity of the intragastric balloon procedure may account for its widespread role in obesity treatment and its applicability to various degrees of obesity. However, advances in device properties and procedural techniques are still needed in order to improve its safety and cost-effectiveness. Furthermore, verification of the physiological outcomes of intragastric balloon treatment and the clinical predictive factors for treatment responses should be considered. In this article, we discuss the types, efficacy, safety, and future directions of intragastric balloon treatment.

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.

Laparoscopic gastric bypass vs. sleeve gastrectomy in the super obese patient: early outcomes of an observational study

BACKGROUND

Super obesity [body mass index (BMI) > 50 kg/m2] can yield to higher morbidity/mortality in bariatric surgery, this could be related to patient's characteristics and/or surgeon's experience. In morbid obesity, both techniques proved to have a positive impact and sometimes comparable outcomes during the first 2 years. This has not been clearly analyzed in the super obese patient.

METHODS

Retrospective study comparing the records of 77 consecutive super obese patients (BMI: 50-59.9 kg/m2) submitted to either laparoscopic gastric bypass (LGBP, n = 32) or laparoscopic sleeve gastrectomy (LSG, n = 45) between 2010 and 2012 at a single institution. The primary objective was to analyze baseline demographics, comorbidities, operative outcomes, and early complications (<30 days). Secondarily, weight loss [BMI and % excess weight loss (%EWL)] was also described and compared during the first year.

RESULTS

Female sex comprised 72.7 % of all cases. Both groups had comparable BMI (52.7 ± 2.1 kg/m2 for LGBP vs. 53.87 ± 2.8 kg/m2 for LSG; p = 0.087) and homogeneous baseline characteristics. Operative time was lower for the LSG group (113.1 ± 35.3 vs. 186.9 ± 39 min for LGBP; p ≤ 0.001). Overall, early complications were observed in 16.8% of patients (LGBP 9% vs. LSG 22%; p = 0.217). There were four major complications (two in each group), with two reinterventions. Weight loss (%EWL) at 6, 9, and 12 months was significantly higher in the LGBP group (51.6 ± 12.9%, 56.5 ± 13%, 63.9 ± 13.3%, respectively) than in the LSG group (40 ± 12.8%, 45.1 ± 15.5%, 43.9 ± 10.4%, respectively).

CONCLUSIONS

Just like in morbid obesity, LGBP and LSG are effective and safe procedures in super obese patients. LGBP had better weight loss at 1 year.

A prospective controlled study to assess the antiemetic effect of midazolam following intragastric balloon insertion

BACKGROUND AND AIMS

Obesity is a chronic disease with considerable morbidity and mortality. The intragastric balloon appears attractive for a group of patients who do not respond to medical therapy and who are not surgical candidates. Postoperative nausea and vomiting (PONV) are distressing adverse effects for these patients. Midazolam has been used as an antiemetic, both as a preventive or rescue medication. The study aims at studying effect of combined use of ondansetron and midazolam to decrease the PONV following intragastric balloon insertion.

MATERIALS AND METHODS

The study was conducted on 54 patients presented for intragastric balloon insertion during the period between 1(st) of January 2012 and 31 December 2012. Patients were randomly allocated into two groups; Ondansetron group and ondansetron/midazolam group. Patients were assessed for the incidence of nausea and vomiting, nausea and vomiting score, degree of sedation and occurrence of adverse effects during the first 24 h after the operation.

RESULTS

Incidence of nausea and/or vomiting during the first 24 h postoperatively was 66% in the ondansetron group, while 34.5% among the ondansetron-midazolam group. There was significant reduction of nausea and/or vomiting in the second group. Degree of postoperative sedation was also significantly different between the two groups in the immediate postoperative period and 30min postoperatively.

CONCLUSION

Use of midazolam combined with ondansetron provides significant reduction and therefore better outcome regarding nausea and vomiting following intragastric balloon insertion.

The role of a multidisciplinary approach in the choice of the best surgery approach in a super-super-obesity case

INTRODUCTION

Obesity is a multifactorial chronic disease caused by a combination of hereditary, metabolic, dietary, cultural, social and psychological factors. Conservative treatments, such as diet and physical exercises, revealed a lack of long-term efficacy in patients with an extremely high BMI (>60 kg/m(2)).

METHODS

We present a multidisciplinary approach in a patient with an extremely high BMI: a twenty-one years old woman with a BMI 102 kg/m(2) (body weight 313 kg × height 175 cm) disabled to walk with severe depression and a psychological pattern of sweet eater and binge eating disorder. She was also amenorrheic and suffered from metabolic syndrome. The psychological assessment and the social-familial support were defined as priorities. Afterward, physical rehabilitation, behavior therapy, hypocaloric diet followed by intragastric balloon were planned as preoperative treatment. Finally a surgical program was scheduled: Sleeve Gastrectomy as first step of Biliopancreatic Diversion with Duodenal Switch.

RESULTS

Sixteenth months after the Sleeve Gastrectomy the weight was 130 kg (Excess Weight Loss = 74%) with a resumption of the menstrual cycle and a normalization of the metabolic syndrome.

CONCLUSION

Due to the results obtained with both surgery and an excellent psychological supporting network we decided not to perform the expected Biliopancreatic Diversion with Duodenal Switch. The timing of bariatric surgery in superobesity patients is a milestone, but the cooperation among the specialists is essential for the choice of the best successful surgery. The multidisciplinary team should point to a comprehensive tailored management, considering motivation, compliance and adherence to a long-term follow-up as the keys for surgical success.

Small bowel necrosis as a consequence of spontaneous deflation and migration of an air-filled intragastric balloon - a potentially life-threatening complication

Intragastric balloon placement is a common method of treatment of obesity and is often used by non-surgical teams in endoscopy departments. The likelihood of spontaneous intragastric balloon damage is a well-known phenomenon. We describe a patient who was disqualified from surgical obesity treatment and in whom intragastric fluid-filled balloons had already been inserted twice and removed due to their intolerance. Therefore we qualified this patient for placement of the air-filled balloon Heliosphere BAG. Two months after the planned check-up, he arrived at the surgery department complaining of nausea and vomiting and due to symptoms of ileus diagnosed with an X-ray and ultrasound examination we qualified him for emergency surgery. We would like to emphasise the following issues: the necessity of air-filled balloon removal according to the producer's instructions and multidisciplinary specialist team care along with appropriate diagnostic tools in every case of intragastric balloon insertion.

An intragastric balloon in the treatment of obese individuals with metabolic syndrome: a randomized controlled study

OBJECTIVE

There are limited controlled data for intragastric balloons (IGB) in obesity treatment. This randomized, controlled study evaluated the efficacy and safety of an IGB in obese individuals with metabolic syndrome (MS).

DESIGN AND METHODS

Sixty-six adults (BMI: 30-40 kg/m(2)) were randomized to IGB for 6 months, with a 12 month behavioral modification (IGB Group; "IGBG"), or 12 month behavioral modification alone (Control Group; "CG"). The primary outcome was percentage change in body weight.

RESULTS

Thirty-one subjects (female: 68%; mean age: 43; mean BMI: 36.0) were randomized to IGBG and 35 (66%; 48; 36.7) to CG. At 6 months, there was a significantly greater weight loss in the IGBG: -14.2 vs. -4.8; P < 0.0001. This was associated with a significantly greater reduction in waist circumference, and an improvement in quality of life, with a trend for a larger %MS remission (50% vs. 30%; n.s.). At month 12, the differences in weight loss were enduring: -9.2 vs. -5.2; P = 0.007. Gastrointestinal-related adverse events were common in the IGBG, resolving predominantly within two weeks. The IGB was removed prematurely in three subjects (one for refractory gastrointestinal symptoms).

CONCLUSIONS

Statistically significant and clinically relevant improvements in weight loss and health outcomes were observed with the IGBG at 6 months versus behavioral modification alone. The differential weight loss was still evident 6 months after IGB removal.

Inpatient weight loss as a precursor to bariatric surgery for adolescents with extreme obesity: optimizing bariatric surgery

BACKGROUND

As the obesity epidemic takes its toll on patients stricken with the disease and our health care system, debate continues regarding the use of weight loss surgery and its long-term consequences, especially for adolescents. One subset of patients regarding whom there is increased controversy is adolescents with extreme obesity (BMI > 60 kg/m(2)) because the risk of complications in this weight category is higher than for others undergoing bariatric surgery. Several strategies have been suggested for this patient group, including staged operations, combined operations, intragastric balloon use, and endoluminal sleeve placement. However, the device options are often not available to adolescents, and there are no data regarding staged or combined procedures in this age group.

METHODS

All adolescents with BMI >60 kg/m(2) referred to our program were evaluated for inpatient medical weight loss prior to laparoscopic sleeve gastrectomy. The program utilizes a multidisciplinary approach with a protein-sparing modified fast diet, exercise, and behavioral modification.

RESULTS

Three patients completed the program, and each achieved significant preoperative weight loss through the inpatient program and successfully underwent bariatric surgery.

CONCLUSIONS

Presurgical weight loss via an inpatient program for adolescents with a BMI >60 kg/m(2) results in total weight loss comparable to a primary surgical procedure alone, with the benefit of decreasing the perioperative risk.

Preoperative weight loss with intragastric balloon decreases the risk of significant adverse outcomes of laparoscopic gastric bypass in super-super obese patients

BACKGROUND

Extreme obesity increases morbi-mortality in bariatric surgery. We previously showed that significant weight loss can be obtained within 3 months in super-super obese patients (BMI > 60 kg/m(2)) with an intragastric balloon (IGB). Here, we explored the potential benefit of preoperative IGB on the outcome of laparoscopic gastric bypass (LGBP) in super-super obese patients.

METHODS

In this case-control study, we compared the records of 60 consecutive super-super obese patients (66.5 ± 3.4 kg/m(2)) submitted to a LGBP between 2004 and 2009, with preoperative IGB (n = 23, cases) or without (n = 37, controls). We analyzed the clinical outcome of surgery and a composite end point of significant adverse events defined as the presence of at least one of the following conditions: conversion to laparotomy, intensive care unit stay for more than 2 days, and overall hospital stay superior to 2 weeks.

RESULTS

All baseline clinical and biological characteristics were homogenous between both groups. IGB was maintained during 155 ± 62 days and induced a loss of 5.5 ± 1.3 kg/m(2) (11.2 ± 3.2% of excess body mass index) at the time of LGBP, associated with a decrease in systolic blood pressure and gamma-glutamyl transpeptidase level (p < 0.05 vs. baseline). Operative time was lower in the IGB group (146 ± 47 vs. 201 ± 81 min in controls; p < 0.01). Significant adverse events occurred less frequently after LGBP in the IGB group (2 vs. 13 in controls; p < 0.05). All patients were alive at 1 year and overall weight loss was similar in both groups (52.4 ± 17.3 vs. 50.3 ± 12.7 percent of excess BMI loss in controls; NS).

CONCLUSIONS

IGB prior to LGBP in super-super obese patients significantly reduced excess BMI. It was associated with a shorter operative time and a lower overall risk of significant adverse outcomes.

Endoscopic treatment of obesity

BACKGROUND

The increasing incidence of obesity and overweight among children and adolescents will be reflected by the imminent increase in the number of obese patients who require more definitive methods of treatment. There is great interest in new, safe, simple, nonsurgical procedures for weight loss.

OBJECTIVE

To provide an overview of new endoscopic methods for the treatment of obesity.

METHODS

An English-language literature search on endoscopic interventions, endoscopically placed devices and patient safety was performed in the MEDLINE and Cochrane Library databases.

RESULTS

The literature search yielded the following weight loss methods: space-occupying devices (widely used), gastric capacity reduction, modifying gastric motor function and malabsorptive procedures. A commercially available intragastric balloon was the most commonly used device for weight loss. In specific subgroups of patients, it improved quality of life, decreased comorbidities and served as a bridge to surgery. More evidence regarding the potential benefits and safety of other commercially available intragastric balloons is needed to clarify whether they are superior to the most commonly used one. Moreover, early experiences with transoral gastroplasty, the duodenal-jejunal bypass sleeve and an adjustable, totally implantable intragastric prosthesis, indicate that they may be viable options for obesity treatment. Other agents, such as botulinum toxin and a device known as the 'butterfly', are currently at the experimental stage.

CONCLUSION

New endoscopic methods for weight loss may be valuable in the treatment of obesity; however, more clinical experience and technical improvements are necessary before implementing their widespread use.

Deep brain stimulation for obesity--from theoretical foundations to designing the first human pilot study

Obesity is perhaps an evolutionary consequence of a species reared with intermittent caloric reward. Humans are hardwired to enjoy food, and our bodies voraciously extract and store energy from food as if each meal was the last. As an amalgam of behavioral and metabolic disturbance, obesity is an attractive target for deep brain stimulation (DBS) since neuromodulation may be able to influence both eating behavior and metabolism. The current pandemic proportions of obesity combined with the failures and morbidity of modern treatments remain the impetus behind the application of DBS to this complex disease. We review the rationale and scientific foundations for obesity DBS and explain how this preclinical evidence has helped sculpt the design of the first human pilot study.

Mechanical ileus induces surgical intervention due to gastric balloon: a case report and review of the literature

A temporary non-surgical approach for treatment of obesity is the gastric balloon that serves as an alternative procedure for many patients with frustrated diet attempts. Deflation and displacement of the balloon resulting in acute intestinal obstruction and subsequent surgical intervention is a rare complication. A BioEnterics Intragastric Balloon was endoscopically implanted in a 35-year-old female with a body mass index (BMI) of 28 kg/m(2). The procedure succeeded without complications, and weight loss was effective during the first 6 months. One year after balloon implantation, the patient presented with abdominal cramps and vomiting due to ileal obstruction. Since endoscopic efforts to remove the deflated and displaced balloon failed, emergency laparotomy and enterotomy were necessary. Vascularization of the dilated small bowel was compromised, but recovered after decompression. Patients' postoperative course was uneventful. The gastric balloon model can be associated with major complications and should be used critically. Removal of the balloon should be assured not later than 6 months when weight loss decreases.

Gustatory and reward brain circuits in the control of food intake

Gustation is a multisensory process allowing for the selection of nutrients and the rejection of irritating and/or toxic compounds. Since obesity is a highly prevalent condition that is critically dependent on food intake and energy expenditure, a deeper understanding of gustatory processing is an important objective in biomedical research. Recent findings have provided evidence that central gustatory processes are distributed across several cortical and subcortical brain areas. Furthermore, these gustatory sensory circuits are closely related to the circuits that process reward. Here, we present an overview of the activation and connectivity between central gustatory and reward areas. Moreover, and given the limitations in number and effectiveness of treatments currently available for overweight patients, we discuss the possibility of modulating neuronal activity in these circuits as an alternative in the treatment of obesity.

Intragastric balloon treatment for obesity: prospective single-center study findings

BACKGROUND

The intragastric balloon (IGB) procedure is an obesity treatment.

METHODS

A BioEnteric IGB was used in 33 patients between February 2006 and February 2009.

RESULTS

Of the 31 patients, 19 were female (61.3%). Mean age was 35.48 +/- 9.31 years. Following intravenous sedation, the balloon was inserted and inflated under direct vision by using saline (600 ml) and methylene blue (10 ml) solution. Average weight and mean BMI scores were as follows: 119.34 +/- 22.64 (range 80-170) kg and 41.84 +/- 8.28 (range 30-63.2) kg/m(2). Mean weight and BMI were measured as 104.31 +/- 21.33 (range 64-151) kg and 36.43 +/- 7.36 (range 26-52) kg/m(2) 6 months after the index procedure. Percent of excess weight loss (%EWL) and percent of excess body mass index loss (%EBMIL) were as follows: 29.16 +/- 15.99% (range 0.00-56.91%) and 35.45 +/- 19.46% (0-75.2%), respectively. All patients lost weight constantly for the 6-month period. Patients showed statistically significant weight and BMI losses for the first 3-month period but these decrements reached a plateau between the 4th and 6th month. Weight loss was not statistically significant during the second 3-month period. Few patients had mild complaints following balloon insertion; there was no balloon intolerance.

CONCLUSIONS

IGB is safe and effective for short-term weight reduction in obese patients. Weight reduction during the second half of the treatment period needs closer follow-up.