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

Obesity Surgery Mortality Risk Score as a Predictor for Intensive Care Unit Admission in Patients Undergoing Laparoscopic Bariatric Surgery

Background: Laparoscopic bariatric surgery provides many benefits including lower postoperative pain scores, reduced opioid consumption, shorter hospital stays, and improved quality of recovery. However, the anaesthetic management of obese patients requires caution in determining postoperative risk and in planning adequate postoperative pathways. Currently, there are no specific indications for intensive care unit (ICU) admission in this surgical population and most decisions are made on a case-by-case basis. The aim of this study is to investigate whether Obesity Surgery Mortality Risk Score (OS-MRS) is able to predict ICU admission in patients undergoing laparoscopic bariatric surgery (LBS). Methods: We retrospectively reviewed data of patients who underwent LBS during a 2-year period (2017-2019). The collected data included demographics, comorbidities and surgery-related variables. Postoperative ICU admission was decided via bariatric anaesthesiologists' evaluations, based on the high risk of postoperative cardiac or respiratory complications. Anaesthesia protocol was standardized. Logistic regression was used for statistical analysis. Results: ICU admission was required in 2% (n = 15) of the 763 patients. The intermediate risk group of the OS-MRS was detected in 84% of patients, while the American Society of Anaesthesiologists class III was reported in 80% of patients. A greater OS-MRS (p = 0.01), advanced age (p = 0.04), male gender (p = 0.001), longer duration of surgery (p = 0.0001), increased number of patient comorbidities (p = 0.002), and previous abdominal surgeries (p = 0.003) were predictive factors for ICU admission. Conclusions: ICU admission in obese patients undergoing LBS is predicted by OS-MRS together with age, male gender, number of comorbidities, previous abdominal surgeries, and duration of surgery.

Sustained weight loss after duodenal-jejunal bypass liner treatment in patients with body mass index below, but not above 35 kg/m2 : A retrospective cohort study

Previous data from short term studies have shown an efficacy of the duodenal-jejunal bypass liner (DJBL) for weight loss. However, less data is available regarding weight change after device removal and possible predictors for weight loss. This is a retrospective chart review of all patients who had DJBL inserted at the University Hospital Zurich between December 2012 and June 2015. A total of 27 patients had DJBL insertion. The median BMI at baseline was 38.5 (34.0-42.2) kg/m² . In the 24 patients with DJBL treatment >3 months (failed implantation or early removal due to side effects in 3 patients), the mean duration of implantation was 42.9 ± 13.1 weeks. During the treatment, the mean total body weight loss (%TBWL) was 15.0 ± 8.3%. Fifteen patients had long-term follow-up data available (mean duration of follow-up 4.0 ± 0.9 years). The mean weight change was 12.7 ± 12.8 kg, corresponding with a mean % weight regain of 13.3 ± 13.3%. Five patients (33.3%) subsequently underwent bariatric surgery. In patients with class I obesity (BMI <35 kg/m² at baseline), 4 out of 6 (66.7%) had a stable weight or only a weight regain <7%. In contrast, no patient with BMI >35 kg/m² at baseline was able to keep weight regain below 7%. DJBL is an effective treatment for obesity, but substantial weight regain occurs during long-term follow up after the device removal, in particular in patients with BMI > 35 kg/m² .

Poly(vinylidene fluoride) Intestinal Sleeve Implants for the Treatment of Obesity and Type 2 Diabetes

Currently, treatment of diabetes and associated obesity involves Roux-en-Y gastric bypass or sleeve gastrectomy to reduce the absorption of nutrients from the intestine to achieve blood glucose control. However, the surgical procedure and subsequent recovery are physically and psychologically burdensome for patients, with possible side effects, so alternative treatments are being developed. In this study, two methods, solution casting and machine direction orientation (MDO), were used to prepare intestinal implants made of poly(vinylidene fluoride) (PVDF) film and implant them into the duodenum of type 2 diabetic rats for the treatment of obesity and blood glucose control. The PVDF film obtained by the MDO process was characterized by FT-IR, Raman spectroscopy, XRD and piezoelectricity tests, which showed higher composition of β crystalline phase and better elongation and mechanical strength in specific directions. Therefore, the material was finally tested on rats after it was proven to be non-toxic by biological toxicity tests. The PVDF was implanted into alloxan-induced diabetic rats, which were used as a model of impaired insulin secretion due to pancreatic beta cell destruction rather than obesity-induced diabetes, and rats were tracked for 24 days, showing significantly improved body weight and blood glucose levels. As an alternative therapeutic option, intestinal sleeve implant showed future potential for application.

Endoscopic bariatric therapies for obesity: a review

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two-thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15-20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.

Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography: a comparative systematic review and meta-analysis

BACKGROUND AND AIM

There is wide variation in choice of sedation and airway management for endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review and meta-analysis to investigate safety outcomes of deep sedation with monitored anesthesia care (MAC) versus general endotracheal anesthesia (GETA).

METHODS

Individualized search strategies were performed in accordance with PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions using random effects models. Measured outcomes included procedure success, all-cause and anesthesia-associated adverse events, and post-procedure recovery time. Heterogeneity was assessed with I² statistics and publication bias by funnel plot and Egger regression testing.

RESULTS

Five studies (MAC: n = 1284 vs GETA: n = 615) were included. Patients in the GETA group were younger, had higher body mass index (BMI), and higher mean ASA scores (all P < 0.001) with no difference in Mallampati scores (P = 0.923). Procedure success, all-cause adverse events, and anesthesia-associated events were similar between groups [OR 1.16 (95% CI 0.51-2.64); OR 1.16 (95% CI 0.29-4.70); OR 1.33 (95% CI 0.27-6.49), respectively]. MAC resulted in fewer hypotensive episodes [OR 0.32 (95% CI 0.12-0.87], increased hypoxemic events [OR 5.61 (95% CI 1.54-20.37)], and no difference in cardiac arrhythmias [OR 0.48 (95% CI 0.13-1.78)]. Procedure time was decreased for MAC [standard difference - 0.39 (95% CI - 0.78-0.00)] with no difference in recovery time [standard difference - 0.48 (95% CI - 1.04-0.07)].

CONCLUSIONS

This study suggests MAC may be a safe alternative to GETA for ERCP; however, MAC may not be appropriate in all patients given an increased risk of hypoxemia.

Bariatrische Chirurgie – welche Therapieoptionen?

Adipositas und damit einhergehende Komorbiditäten wie Diabetes mellitus Typ 2 (DMII), arterielle Hypertonie, Schlafapnoe, Erkrankungen des Bewegungsapparates usw. nehmen weltweit stetig zu. Bariatrische/metabolische Operationen stellen die bei Weitem effizienteste Methode dar, um langfristig Gewicht zu reduzieren und Komorbiditäten zu verbessern bzw. komplett in Remission zu bringen. Die Wirkungsmechanismen dieser Eingriffe umfassen neben Malabsorption und/oder Restriktion eine veränderte Ausschüttung verschiedener Hormone und Botenstoffe im Körper („gut hormones“, Adipozytokine usw.) sowie Veränderungen von Gallensäuren und des Mikrobioms. Die Indikation zu einer bariatrischen/metabolischen Operation (OP) kann ab einem BMI von ≥ 40 kg/m2 oder von ≥ 35 kg/m2 bei Bestehen mindestens einer der oben genannten Komorbiditäten gestellt werden. Gemäß den aktuellen Richtlinien der Amerikanischen Diabetesgesellschaft (ADA) kann auch schon bei einem BMI ≥ 30 kg/m2 eine OP in Erwägung gezogen werden, wenn bei bestehendem DMII kein suffizienter Gewichtsverlust oder keine glykämische Kontrolle auf konservative Art und Weise erreicht werden kann. Die derzeit am häufigsten durchgeführten bariatrischen/metabolischen Operationsmethoden sind die Sleeve-Gastrektomie (Schlauchmagen), der Y‑Roux-Magenbypass und der One-anastomosis-Magenbypass, wobei die Wahl der Operationsmethode von mehreren Faktoren abhängt und für jeden Patienten individuell entschieden werden sollte. Zur Evaluierung der passenden OP-Methode, zur Abschätzung des Risikos und zur individuellen Vorbereitung des Patienten müssen im Vorfeld der OP verschiedene Untersuchungen durchgeführt werden. Es konnte mittlerweile in vielen Studien gezeigt werden, dass die metabolische Chirurgie sehr sicher ist und die Lebenserwartung sowie die Lebensqualität des Patienten dadurch erheblich verlängert bzw. verbessert werden. Durch metabolische Chirurgie ist es im Langzeitverlauf möglich, neben Gewichtsverlust eine erhebliche Verbesserung/Remission von DMII, kardiovaskulären Erkrankungen, Erkrankungen des Bewegungs- und Stützapparats und Lebererkrankungen zu erreichen sowie das Risiko, an Karzinomen zu erkranken (bzw. daran zu versterben), erheblich zu reduzieren.

Endoscopic Sleeve Gastroplasty (ESG) for High-Risk Patients, High Body Mass Index (> 50 kg/m2) Patients, and Contraindication to Abdominal Surgery

BACKGROUND

For high-risk classified patients, patients with superobesity and in cases of contraindication to abdominal surgery, traditional bariatric surgery might lead to potential morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a novel and effective bariatric therapy for morbidly obese patients. Our research group initially evaluated the safety, feasibility, and efficacy of ESG for high-risk, high body mass index (BMI) patients, and patients contraindicated to abdominal surgeries.

METHODS

Eligible patients characterized as high-risk for bariatric surgery due to high-BMI, severe comorbidities, or impenetrable abdomen were prospectively documented. ESG was performed by using Overstich® (Apollo Endosurgery, Austin, TX, USA). Primary outcomes included technical success, post-procedure adverse events and mortality, and the change of weight and BMI.

RESULTS

ESG was successfully performed for all patients (N = 24, mean age was 55.6 (± 9.2) years old, 75% male). Baseline weight and BMI were 157.9 (± 49.1) kg and 49.9 (± 14.4) kg/m². According to Edmonton Obesity Staging System (EOSS), 8 (33.3%), 14 (58.3%), and 2 (8.3%) patients were respectively classified as EOSS 2, 3, and 4. Mean operation time was 114.7 (± 26.0) min, without intraoperative complication. Weight loss, BMI reduction, %total weight loss (%TWL), and %excess weight loss (%EWL) were 17.5 (± 14.6) kg, 5.6 (± 4.6) kg/m², 12.2% (± 8.9%), and 29.1% (± 17.9%) at post-ESG 12-month, respectively. One (4.2%) moderate post-procedure adverse event (gastric mucosal bleeding) was observed.

CONCLUSIONS

ESG can be used as a safe, feasible, and effective option for the therapy of patients with superobesity, high-risk patients, and patients contraindicated to abdominal surgery. Graphical Abstract.

EndoBarrier™ Implantation Rapidly Improves Insulin Sensitivity in Obese Individuals with Type 2 Diabetes Mellitus

The EndoBarrier™ medical device is a duodenal-jejunal bypass liner designed to mimic the effects of gastric bypass surgery to induce weight loss and glycaemic improvement. In this study, 10 participants with type 2 diabetes mellitus (T2DM), a mean body mass index (BMI) of 43.3 ± 5.0 (kg/m²) and a mean glycated haemoglobin A1c (HbA1c) of 60.6 ± 8.6 mmol/mol were examined at baseline (before implantation of EndoBarrier™), 4 weeks after implantation, at 36 weeks (right before explantation) and 24 weeks after the removal of the device to explore the short and long-term effects on glucose metabolism. Besides a significant reduction in body weight and fat mass, EndoBarrier™ treatment significantly improved insulin sensitivity during Botnia clamp investigations after four weeks of implantation. The beneficial effects decreased over time but remained significant 24 weeks after removal of the device.

Duodenal-Jejunal Bypass Liner (DJBL) Improves Cardiovascular Risk Biomarkers and Predicted 4-Year Risk of Major CV Events in Patients with Type 2 Diabetes and Metabolic Syndrome

BACKGROUND

The duodenal-jejunal bypass liner (DJBL) represents a novel endoscopic minimally invasive treatment option for obesity-associated type 2 diabetes (T2D), affecting body weight and metabolic control. Until now, the effects of DJBL on cardiovascular risk have never been investigated.

METHODS

Between 2012 and 2017, 71 patients with T2D and metabolic syndrome (MS) were recruited for implantation of DJBL for 9-12 months. Within DJBL treatment and a follow-up period of 6 months, patients were analysed for dynamics of cardiovascular biomarkers. Overall cardiovascular risk was estimated by the ADVANCE Risk Engine at time of implantation, explantation and 6 months after explantation of DJBL.

RESULTS

DJBL-induced weight loss and improvements in blood sugar control were accompanied by significant decreases of the cardiovascular biomarkers high-sensitive CRP, lipoprotein-associated phospholipase A2 and small dense lipoprotein fraction LDL-4 (p = 0.001, p < 0.001 and p = 0.04, respectively). Estimated overall cardiovascular risk decreased significantly after DJBL implantation and remained stable within 6 months after explantation.

CONCLUSIONS

In addition to beneficial effects of DJBL on weight loss, glycaemic control and lipid parameters in patients with MS, this is the first study that could further reveal significant impact on serological cardiovascular biomarkers and estimated CV risk, suggesting putative protective effects of DJBL on CV outcome.

Role of Prophylactic Cholecystectomy After Endoscopic Sphincterotomy for Biliary Stone Disease: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this study was to perform a structured systematic review and meta-analysis to evaluate the effectiveness and complication rate of cholecystectomy deferral versus prophylactic cholecystectomy among patients post-endoscopic biliary sphincterotomy for common bile duct stones.

BACKGROUND

Although previous reports suggest a decreased risk of biliary complications with prophylactic cholecystectomy, biliary endoscopic cholangiopancreatography (ERCP) with sphincterotomy may provide a role for deferring cholecystectomy with the gallbladder left in situ.

METHODS

Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through August 2019 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Measured outcomes included: mortality, recurrent biliary pain or cholecystitis, pancreatitis, cholangitis, and eventual need for cholecystectomy. Random effects models were used to determine pooled effect size and corresponding 95% confidence intervals (CIs).

RESULTS

Nine studies (n = 1605) were included. A total of 53.8% (n = 864) patients had deferred cholecystectomy post-sphincterotomy. Deferral cholecystectomy as compared to prophylactic cholecystectomy resulted in a significant increased risk of mortality [odds raio (OR) 2.56 (95% confidence interval, CI 1.54-4.23); P < 0.0001; I2 = 18.49]. Patients who did not undergo prophylactic cholecystectomy developed more recurrent biliary pain or cholecystitis [OR 5.10 (95% CI 3.39-7.67); P < 0.0001; I2 = 0.00]. Rate of pancreatitis [OR 3.11 (95% CI 0.99-9.83); P = 0.053; I2 = 0.00] and cholangitis [OR 1.49 (95% CI 0.74-2.98); P = 0.264; I2 = 0.00] was unaffected. Overall, 26.00% (95% CI 14.00-40.00) of patients with deferred prophylactic cholecystectomy required eventual cholecystectomy.

CONCLUSIONS

Prophylactic cholecystectomy remains the preferred strategy compared to a deferral approach with gallbladder in situ post-sphincterotomy for patients with bile duct stones. Future studies may highlight a subset of patients (ie, those with large balloon biliary dilation) that may not require cholecystectomy.

Bariatric Surgery-How Much Malabsorption Do We Need?-A Review of Various Limb Lengths in Different Gastric Bypass Procedures

The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.

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.

Endoscopic Management of Clinically Severe Obesity: Primary and Secondary Therapeutic Procedures

PURPOSE OF REVIEW

In the treatment of epidemic obesity and metabolic disorders, conservative approaches often fail to achieve the treatment goal in patients with very high BMI. To date, bariatric surgery accomplishes the most sustainable results in patients with morbid obesity. This leads to a treatment gap for lower and middle classes of obesity defined by BMI. Primary endoscopic procedures, which are less invasive than surgery, may be able to sufficiently fill this gap. Furthermore, secondary endoscopic procedures have developed into an essential addition regarding complication management of bariatric surgeries. The purpose of this review was to point out the latest developments in the field of bariatric endoscopy, including both primary and secondary procedures.

RECENT FINDINGS

Innovative devices and their possible applications will be discussed. These include various endoscopic suturing techniques as well as newly developed implants for the upper gastrointestinal tract to counteract the obesity epidemic. The growing understanding of the pathophysiology of obesity and the role of the gastrointestinal tract allows for the development of more effective endoscopic procedures regarding obesity treatment.