Intragastric Balloon Treatment for Obesity: Review of Recent Studies

Esophageal laceration after failed endoscopic intragastric ballon retrieval and open approach treatment case report

INTRODUCTION AND IMPORTANCE

The intragastric ballon (IGB) is an minimal invasive alternative treatment of weight loss, it has a rate of complications of 2.8-5.5 %. This case highlights the importance of surveillance of the patients to prevent further complications.

CASE REPORT

We present a case of a 43 years old women with IMC of 31.25 kg/m2 and diabetes mellitus background, who underwent to insertion of intragastric ballon, unfortunately the patient lost the follow up with the endoscopy without surveillance and remain with the intragastric ballon for 9 months. The patient started to experience abdominal pain, vomit and oral intolerance so the patient attended to the endoscopist to evaluate the cause of her symptoms. The patient was brought to the endoscopy where the retrieval was not successful. The patient is brought to the emergency room for surgical extraction.

DISCUSSION

Given the high cost, complication risk and invasiveness of bariatric surgery, intragastric ballon treatment may present a safer and lower cost option for weight reduction. Most of the available IGB are recommended time for gastric ballon removal is 6-12 months, with the appropriate surveillance. In our case it was not possible to endoscopic retrieval due malfunction of the Spatz-3's valve, thickening wall and its partial migration towards the fundus and cardia which causes an esophageal laceration and gastric bleeding.

CONCLUSION

Mandatory education and accreditation of physicians dealing with bariatric endoscopy and strict supervision of obese individuals throughout the time they have the balloon in their stomachs will eliminate most complications.

Weighing your options-intragastric balloon versus semaglutide

INTRODUCTION

Over half of Americans and up to 78% of US Veteran population meet criteria for obesity. Perioperatively placed intragastric balloon (IGB) can accelerate weight loss goals for safe surgical candidacy, however weight regain is common after removal. Glucagon-like peptide-1-receptor agonists (GLP1RA) may provide a more sustainable weight loss solution after surgery. We hypothesize that weight regain will be less at 1 year after initiation of GLP1RA than IGB placement in Veterans.

METHODS

Retrospective review of prospective databases of perioperatively placed intragastric balloon cohort from 1/2019-1/2023 compared to patients who received initiatory GLP1RA from 6/2021-8/2022 at a VA Medical Center(VAMC). All patients were enrolled in the VAMC MOVE! multidisciplinary weight management program for a minimum of 12 weeks. Outcomes measured were patients' weights at 0, 3, 6, and 12 months and weight change for these intervals. Exclusion criteria included history of bariatric surgery and incomplete weight loss data.

RESULTS

Two-hundred-twenty-three patients met inclusion criteria; 110 (49%) patients excluded. Mean age was 54 ± 11 years, the majority (78, 69%) were male, and the mean initial BMI was 37 ± 5.9 kg/m2. Seventeen (15%) patients underwent IGB placement and 96 (85%) patients received semaglutide. Weight (kg) change was measured at intervals: 0-3 months:- 11.8(- 17,- 9.5) IGB vs. - 5.1(- 7.4,- 2.3) semaglutide, p < 0.0001; 0-6 months:- 12.7(- 18.4,- 9.9) vs. - 9.4(- 12.6,- 6.1), p = 0.03; 3-6 months:- 0.5(- 2.3,2.3) vs. - 4.3(- 6.8,- 1.6), p < 0.0001; 6-12 months:3(0,7.3) vs. - 1.9(- 4.7,1), p = 0.0006.

CONCLUSION

Weight loss occurs more rapidly in the first 6 months after intragastric balloon placement compared to semaglutide (- 12.7 vs. - 9.4 kg, p = 0.03). Despite ongoing attendance in a comprehensive weight loss program, weight regain is common after IGB removal by an average of 3 kg (23.6%) at 1 year. In contrast, patients on GLP1RA (semaglutide) continue to lose weight during this period. Further studies are needed to determine if optimal long-term outcomes may result from combination therapy with intragastric balloon and semaglutide.

Weight regain after intragastric balloon for pre-surgical weight loss

BACKGROUND

Over one-third of Americans carry the diagnosis of obesity, many also with obesity-related comorbidities. This can place patients at increased risk of operative and postoperative complications. The intragastric balloon has been shown to aid in minor weight loss, however its weight recidivism in patients requiring short interval weight loss has not been well studied.

AIM

To evaluate weight loss, ability to undergo successful elective surgery after intragastric balloon placement, and weight management after balloon removal.

METHODS

This study is a retrospective review of patients in a single academic institution undergoing intragastric balloon placement from 2019-2023 to aid in weight loss prior to undergoing elective surgery. Clinical outcomes including weight loss, duration of balloon placement, successful elective surgery, weight regain post-balloon and post-procedure complications were assessed. Exclusion criteria included those with balloon in place at time of study.

RESULTS

Thirty-three patients completed intragastric balloon therapy from 2019-2023 as a bridge to elective surgery. All patients were required to participate in a 12-month weight management program to be eligible for balloon therapy. Elective surgeries included incisional hernia repair, umbilical hernia repair, inguinal hernia repair, and knee and hip replacements. The average age at placement was 53 years ± 11 years, majority (91%) were male. The average duration of intragastric balloon therapy was 186 days ± 41 days. The average weight loss was 14.0 kg ± 7.4 kg and with an average percent excess body weight loss of 30.0% (7.9%-73.6%). Over half of the patients (52.0%) achieved the goal of 30-50 lbs (14-22 kg) weight loss. Twenty-one patients (64%) underwent their intended elective surgery, 2 patients (6%) deferred surgery due to symptom relief with weight loss alone. Twenty-one of the patients (64%) have documented weights in 3 months after balloon removal, in these patients the majority (76%) gained weight after balloon removed. In patients with weight regain at 3 months, they averaged 5.8 kg after balloon removal in the first 3 months, this averaged 58.4% weight regain of the initial weight lost.

CONCLUSION

Intragastric balloon placement is an option for short-term weight management, as a bridge to elective surgery in patients with body mass index (BMI) > 35. Patients lost an average of 14 kg with the balloon, allowing two-thirds of patients to undergo elective surgery at a healthy BMI. However, most patients regained an average of 58% of the original weight lost after balloon removal. The intragastric balloon successfully serves as a tool for rapid weight loss, though patients must be educated on the risks including weight regain.

Evaluating the Safety of the Intragastric Balloon: Spanish Multicenter Experience in 20,680 Cases and with 12 Different Balloon Models

INTRODUCTION

Intragastric balloon (IGB) is a minimally invasive and reversible option for obesity treatment. There is a worldwide growing number of different IGB models. The efficacy and safety profile for each model must be demonstrated. We aim to evaluate IGB safety profile according to the experience of the Spanish Bariatric Endoscopy Group (GETTEMO).

METHODS

A survey of 37 IGBs safety-related questions was sent to all GETTEMO members, to retrospectively collect a multicenter Spanish registry. Incidence, causes, and resolution of both major and minor complications and adverse events (AEs), including legal consequences, differentiated for each balloon model were evaluated. Secondary outcome was weight loss data to confirm efficacy.

RESULTS

Twenty-one Spanish hospitals experienced in IGBs responded. The overall data encompassed 20,680 IGBs, including 12 different models. Mean %TBWL of 17.66 ± 2.5% was observed. Early removal rate due to intolerance was 3.62%. Mean major complications rate was 0.70% (> 1% in Spatz2, HB, and Spatz3 models), mainly complicated gastric ulcer. Minor AEs rate was 6.37%, mainly esophagitis. Nine cases (0.04%) required surgery. A single case of mortality (0.0048%) occurred. Seven lawsuits (0.0034%) were received, all with favorable resolution.

CONCLUSIONS

In the Spanish experience accumulating 20,680 IGBs and including 12 different balloon models, a low incidence rate of major complications and minor AEs are observed (0.70% and 6.37%, respectively), mostly resolved with medical/endoscopic management. IGB shows good tolerance and efficacy profile. These safety data are within the accepted quality standards.

Bilateral Subdiaphragmatic Vagal Nerve Stimulation Using a Novel Waveform Decreases Body Weight, Food Consumption, Adiposity, and Activity in Obesity-Prone Rats

INTRODUCTION

Obesity affects millions of Americans. The vagal nerves convey the degree of stomach fullness to the brain via afferent visceral fibers. Studies have found that vagal nerve stimulation (VNS) promotes reduced food intake, causes weight loss, and reduces cravings and appetite.

METHODS

Here, we evaluate the efficacy of a novel stimulus waveform applied bilaterally to the subdiaphragmatic vagal nerve stimulation (sVNS) for almost 13 weeks. A stimulating cuff electrode was implanted in obesity-prone Sprague Dawley rats maintained on a high-fat diet. Body weight, food consumption, and daily movement were tracked over time and compared against three control groups: sham rats on a high-fat diet that were implanted with non-operational cuffs, rats on a high-fat diet that were not implanted, and rats on a standard diet that were not implanted.

RESULTS

Results showed that rats on a high-fat diet that received sVNS attained a similar weight to rats on a standard diet due primarily to a reduction in daily caloric intake. Rats on a high-fat diet that received sVNS had significantly less body fat than other high-fat controls. Rats receiving sVNS also began moving a similar amount to rats on the standard diet.

CONCLUSION

Results from this study suggest that bilateral subdiaphragmatic vagal nerve stimulation can alter the rate of growth of rats maintained on a high-fat diet through a reduction in daily caloric intake, returning their body weight to that which is similar to rats on a standard diet over approximately 13 weeks.

A vibrating ingestible bioelectronic stimulator modulates gastric stretch receptors for illusory satiety

Effective therapies for obesity require invasive surgical and endoscopic interventions or high patient adherence, making it challenging for patients with obesity to effectively manage their disease. Gastric mechanoreceptors sense distension of the stomach and perform volume-dependent vagal signaling to initiate the gastric phase and influence satiety. In this study, we developed a new luminal stimulation modality to specifically activate these gastric stretch receptors to elicit a vagal afferent response commensurate with mechanical distension. We designed the Vibrating Ingestible BioElectronic Stimulator (VIBES) pill, an ingestible device that performs luminal vibratory stimulation to activate mechanoreceptors and stroke mucosal receptors, which induces serotonin release and yields a hormonal metabolic response commensurate with a fed state. We evaluated VIBES across 108 meals in swine which consistently led to diminished food intake (~40%, P < 0.0001) and minimized the weight gain rate (P < 0.05) as compared to untreated controls. Application of mechanoreceptor biology could transform our capacity to help patients suffering from nutritional disorders.

Overview on the endoscopic treatment for obesity: A review

Obesity rates have increased, and so has the need for more specific treatments. This trend has raised interest in non-surgical weight loss techniques that are novel, safe, and straightforward. Thus, the present review describes the endoscopic bariatric treatment for obesity, its most recent supporting data, the questions it raises, and its future directions. Various endoscopic bariatric therapies for weight reduction, such as intragastric balloons (IGBs), aspiration therapy (AT), small bowel endoscopy, endoscopic sleeve gastroplasty, endoluminal procedures, malabsorption endoscopic procedures, and methods of regulating gastric emptying, were explored through literature sourced from different databases. IGBs, AT, and small bowel endoscopy have short-term effects with a possibility of weight regain. Minor adverse events have occurred; however, all procedures reduce weight. Vomiting and nausea are common side effects, although serious complications have also been observed.

Losing weight to achieve joint or hernia surgery: is the intragastric balloon the answer?

BACKGROUND

Obesity is an epidemic, with its accompanying medical conditions putting patients at increased risk of postoperative complications. For patients undergoing elective surgery, preoperative weight loss provides an opportunity to decrease complications. We sought to evaluate the safety and efficacy of an intragastric balloon in achieving a body mass index (BMI) < 35 kg/m2 prior to elective joint replacement or hernia repair.

METHODS

Retrospective review of all patients who had intragastric balloon placement at a level 1A VA medical center from 1/2019 to 1/2023. Patients who had a scheduled qualifying procedure (knee/hip replacement or hernia repair) and had a BMI > 35 kg/m2 were offered intragastric balloon placement to achieve 30-50lbs (13-28 kg) weight loss prior to surgery. Participation in a standardized weight loss program for 12 months was required. Balloons were removed 6 months after placement, preferentially concomitant with the qualifying procedure. Baseline demographics, duration of balloon therapy, weight loss and progression to qualifying procedure were recorded.

RESULTS

Twenty patients completed intragastric balloon therapy and had balloon removal. Mean age 54 (34-71 years), majority (95%) male. Mean balloon duration was 200 ± 37 days. Mean weight loss was 30.8 ± 17.7lbs (14.0 ± 8.0 kg) with an average BMI reduction of 4.4 ± 2.9. Seventeen (85%) patients were successful, 15 (75%) underwent elective surgery and 2 (10%) were no longer symptomatic after weight loss. Three patients (15%) did not lose sufficient weight to qualify or were too ill to undergo surgery. Nausea was the most frequent side effect. One (5%) patient was readmitted within 30 days for pneumonia.

DISCUSSION

Intragastric balloon placement resulted in an average 30lbs (14 kg) weight loss over 6 months allowing more than 75% of patients to undergo joint replacement or hernia repair at an optimal weight. Intragastric balloons should be considered in patients requiring 30-50lbs (13-28 kg) weight loss prior to elective surgery. More study is needed to determine the long-term benefit of preoperative weight loss prior to elective surgery.

Efficacy of Intragastric Balloon versus Liraglutide as Bridge to Surgery in Super-Obese Patients

INTRODUCTION

Bariatric surgery is a safe and effective treatment for obesity, although in super-obese patients (BMI ≥50 kg/m2) it can become challenging for anatomical and anesthesiologic issues. Several bridging therapies have been proposed to increase preoperative weight loss and decrease perioperative morbidity and mortality. The aim of this study was to compare the efficacy and safety of different two-stage approaches in super-obese patients: laparoscopic sleeve gastrectomy (LSG) following preoperative liraglutide therapy versus LSG with preoperative intragastric balloon (IGB) during a 1-year follow-up.

METHODS

Clinical records of 86 patients affected by super-obesity who underwent two-stage approach between January 2019 and January 2022 were retrospectively reviewed using a prospectively maintained database. Patients were separated into two groups: those managed with preoperative IGB and those with liraglutide 3.0 mg prior to LSG. Weight (kg), BMI (kg/m2), %EWL, and %EBWL were reported and compared between the two groups at the end of bridging therapy, at 6th month and 12th month postoperatively. Postoperative complications were recorded.

RESULTS

Forty-four patients underwent IGB insertion prior to LSG, while 42 were treated with liraglutide. There were no statistical differences in baseline weight and BMI. At the end of preoperative treatment, the group treated with IGB reported a significant reduction in BMI (47.24 kg/m2 vs. 53.6 kg/m2; p < 0.391) compared to liraglutide group. There were no differences recorded between the two groups concerning postoperative complications. At 6 months, the liraglutide group had lower %EWL (15.8 vs. 29.84; p < 0.05) and %EBWL (27.8 vs. 55.6; p < 0.05) when compared to IGB group. At 12 months, the IGB preserved with higher %EWL (39.9 vs. 25; p < 0.05) and %EBWL (71.2 vs. 42; p < 0.05).

CONCLUSION

A two-stage therapeutic approach with IGB prior to LSG in super-obese patients could be considered an attractive alternative to liraglutide as bridging therapy before bariatric surgery.

A Vibrating Ingestible BioElectronic Stimulator Modulates Gastric Stretch Receptors for Illusory Satiety

Effective therapies for obesity either require invasive surgical or endoscopic interventions or high patient adherence, making it challenging for the nearly 42% of American adults who suffer from obesity to effectively manage their disease. Gastric mechanoreceptors sense distension of the stomach and perform volume-dependent vagal signaling to initiate the gastric phase and influence satiety. In this study, we developed a new luminal stimulation modality to specifically activate these gastric stretch receptors to elicit a vagal afferent response commensurate with mechanical distension. Here we developed the Vibrating Ingestible BioElectronic Stimulator (VIBES) pill - an ingestible device that performs luminal vibratory stimulation to activate mechanoreceptors and stroke mucosal receptors, which induces serotonin release as well as yields a hormonal metabolic response commensurate with a fed state. We evaluated VIBES across 108 meals in swine which consistently led to diminished food intake (~40%, p< 0.0001) and minimized the weight gain rate (p< 0.03) as compared to untreated controls. Application of mechanoreceptor biology could transform our capacity to help patients suffering from nutritional disorders.

Applying dyadic digital psychological interventions for reducing caregiver burden in the illness context: a systematic review and a meta-analysis protocol

INTRODUCTION

Providing informal care to one's romantic partner who is ill may become a highly distressing and demanding task. Based on the innovative dyadic coping model, several support interventions have been developed to alleviate informal caregivers' burden, including both caregivers' and care receivers' needs. Considering the unique challenges characterising the caregiving phenomenon, such as geographical barriers and time restrictions, digital solutions should be considered. However, there is a lack of research examining the effectiveness of dyadic digital solutions. Thus, this review aims to examine the existing literature on the efficacy of dyadic digital psychological interventions designed for caregivers and their care-receivers couples within the illness context.

METHODS AND ANALYSIS

Randomised controlled trials targeting caregivers' burden among dyads of informal caregivers and care receivers will be identified via an electronic search of the following databases: PubMed, Embase, the Cochrane Library, Cinhal, Scopus, PsycINFO, MEDLINE and supplemented by hand searching of previous systematic reviews. The search will be undertaken following the PICO (population, intervention, comparison and outcome) elements. If possible, a meta-analysis will be conducted to examine: (1) the effectiveness of dyadic digital psychological interventions for reducing caregivers' burden (primary outcome) among caregivers who are in a romantic relationship with the care receivers; (2) the effectiveness of dyadic digital psychological interventions on secondary outcomes such as anxiety, depression, stress, quality of life, well-being and self-efficacy among caregivers and care receivers; and (3) moderating effects of clinical and methodological factors on caregivers' burden. Prior to inclusion in the review, retrieved papers will be critically appraised by two independent reviewers. The Cochrane Risk of Bias tool will assess the risk of bias for randomised controlled trials.

ETHICS AND DISSEMINATION

Ethical approval is not required as no primary data will be collected. Findings will be disseminated through peer-reviewed publications, presentations at academic conferences and lay summaries for various stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42022299125.

Factors Affecting Weight Reduction after Intragastric Balloon Insertion: A Retrospective Study

BACKGROUND AND OBJECTIVES

Intragastric balloon (IGB) is a safe option for obesity management. However, studies determining the factors influencing the procedure's outcomes are scarce. Therefore, our goal was to determine the factors affecting weight reduction after IGB insertion.

MATERIALS AND METHODS

This retrospective study included 126 obese patients who underwent IGB treatment using the ORBERA^® Intragastric Balloon System. Patients' records were retrieved; and demographic data, initial body mass index (BMI), complications, compliance with both diet and exercise programs, and percentage of excess weight reduction were recorded.

RESULTS

The study included 108 female (85.7%) and 18 male (14.3%) patients. The mean age was 31.7 ± 8.1 years. The percentage of excess weight loss (EWL) was 55.8 ± 35.7%. The mean weight loss was 13.01 ± 7.51 kg. A significant association was found between EWL and age, initial weight, initial body mass index, and the number of pregnancies. No major complications were observed. However, the balloon had to be removed early in two patients (1.59%) due to its rupture and in two other patients (1.59%) due to severe gastritis.

CONCLUSIONS

IGB therapy is a safe and effective option for obesity management, associated with low rates of complications. The EWL after IGB insertion is significantly higher among older patients, those with a relatively low initial body mass index, those with a longer duration of IGB insertion, and female patients with less parity. Larger prospective studies are needed to support our results.

[Endoscopic treatment for obesity and diabetes]

Obesity and diabetes are associated with increased mortality and morbidity. After failure of conservative therapy such as pharmacotherapy and lifestyle management, bariatric treatment is indicated for selected patients. Endoscopic techniques for weight reduction are well-established treatment for obese population who do not qualify for or are not willing to undergo bariatric surgery. This article is an overview of currently applied endoscopic techniques and summarized current published data.

Comparison of The Short-Term Effects of Intragastric Balloon and Botulinum Toxin Injection On Weight Loss

Aim: To compare the effects of endoscopic intragastric balloon (IGB) placement and intragastric botulinum toxin-A (BTX-A) injection in terms of weight loss among patients with non-morbid obesity. Methods: This retrospective single center study was conducted between 01.08.2020 and 01.01.2022. A total of 39 patients with a body mass index (BMI) of &lt;40 without comorbidities were included in the study. Nineteen underwent intragastric BTX-A injection and 20 underwent IGB placement. Patients were evaluated 1 month and 6 months after the procedures. Results: Mean age was 39.4 ± 8.6 in the BTX-A group and 37.3 ± 10.4 in the IGB group (p = 0.496). 78.9% of the BTX-A group and 75.0% of the IGB group were female (p = 1.000). In both groups, the median weight 1 month after the procedure was significantly lower than before the procedure, and the median weight 6 months after the procedure was significantly lower than 1 month after the procedure (p&lt;0.001 for both groups). The median weight loss in the IGB group at both the 1st and 6th months was significantly greater than the corresponding values of the BTX-A group (p &lt; 0.001 for both). Conclusion: IGB insertion appears to be a more successful endoscopic bariatric procedure than intragastric BTX-A injection, as measured by weight loss at post-intervention 1 month and 6 months. IGB may be preferred in patients with a BMI below 40 without obesity-related comorbidity.

[Indications in Obesity Therapy - Surgeons First?]

Obesity is a growing problem worldwide. For the first time since 2010, more people have been overweight than underweight. In particular, obesity-associated diseases, above all type 2 diabetes mellitus, pose enormous challenges to the healthcare system. On July 3, 2020, the German Bundestag recognised obesity as a disease and initiated the development of a diseases management program (DMP), which is currently being drawn up. So far, the indication for treatment of obesity in Germany has been based on the S3 guideline "Surgery of obesity and metabolic diseases" of the DGAV from 2018 and the S3 guideline "Prevention and therapy of obesity" of the German Obesity Society e. V. from 2014. This article gives an overview of the currently available conservative, medical, endoscopic and surgical treatment methods for overweight and obesity in Germany and explains the indications. Against the background of the reorientation of obesity treatment as a part of the DMP and the forthcoming revisions of the guidelines, the previous indication should be discussed critically. The scientific findings of the last few years show that surgical treatment of obesity not only achieves the greatest weight loss in the long term, but also that obesity-associated diseases are then treated more effectively and overall mortality is reduced significantly more effectively than with conservative treatment.

Bariatric surgery, gastrointestinal hormones, and the microbiome: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of bariatric surgery (i.e., bariatric procedures that improve metabolic disease are often termed "metabolic and bariatric surgery"), gastrointestinal hormones, and the microbiome as they relate to patients with obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS includes the pros and cons of the most common types of bariatric procedures; the roles of gastrointestinal (GI) hormones in regulating hunger, digestion, and postabsorptive nutrient metabolism; and the microbiome's function and relationship with body weight. This CPS also describes patient screening for bariatric surgery, patient care after bariatric surgery, and treatment of potential nutrient deficiencies before and after bariatric surgery. Finally, this CPS explores the interactions between bariatric surgery, GI hormones, and the microbiome.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding bariatric surgery, gastrointestinal hormones, and the microbiome is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Implementation of appropriate care before and after bariatric surgery, as well as an awareness of GI hormones and the microbiome, may improve the health of patients with obesity, especially patients with adverse fat mass and adiposopathic metabolic consequences.

Endoscopic Bariatric and Metabolic Therapies and Their Effects on Metabolic Syndrome and Non-alcoholic Fatty Liver Disease - A Systematic Review and Meta-Analysis

Background

Endoscopic bariatric and metabolic therapies (EBMTs) are procedures that utilize instruments that require flexible endoscopy or placement of devices for inducing weight loss. We perform a systematic review and meta-analysis to evaluate four modalities – intragastric balloon (IGB), endoscopic sleeve gastroplasty (ESG), duodeno-jejunal bypass liner (DJBL), and duodenal mucosa resurfacing (DMR), for their efficacy and safety on weight loss, non-alcoholic fatty liver disease, and metabolic syndrome.

Methods

Databases MEDLINE via PubMed, and EMBASE are searched and relevant publications up to January 26, 2022 are assessed. Studies are included if they involved human participants diagnosed with obesity and obesity-related comorbid conditions who are treated with any of the 4 EBMTs. IGB and DJBL were chosen as the interventions for the meta-analysis with weight loss (percentage total body weight loss or body mass index) and glycemic control (fasting plasma glucose or HbA1c) as the two main outcomes analyzed.

Results

Six hundred and forty-eight records are reviewed, of which 15 studies are found to be duplicates. Of the 633 records screened, 442 studies are excluded. One hundred and ninety-one articles are assessed for eligibility, for which 171 are excluded. A total of 21 publications are included. Twelve studies are on IGB, two studies on ESG, five studies on DJBL, and two studies on DMR. In these studies with appropriate control, IGB, ESG, and DJBL showed promising benefits on weight loss reduction compared to standard medical therapy (SMT), while DMR appeared to have the least weight reduction benefit. However, the impact on glycemic control featured more prominently in DMR as compared to the rest of the modalities. Different EBMTs have different adverse effect profiles, although device-related adverse events are featured more prominently in DJBL. In the IGB group, there was a significant reduction in 6-month %TBWL [weighted mean difference (WMD) 5.45 (3.88, 7.05)] and FPG WMD −4.89 mg/dL (−7.74, −2.04) compared to the SMT group. There was no significant reduction in BMI between the DJBL and SMT group WMD −2.73 (−5.52, 0.07) kg/m2.

Conclusion

EBMTs have demonstrated a significant impact on weight loss and metabolic comorbidities, and reasonable safety profiles in the studies reviewed. Some data is available to demonstrate reduction of hepatic steatosis, but there is no high-quality data supporting benefits on hepatic lobular inflammation or fibrosis.

Foundations of gastrointestinal-based drug delivery and future developments

Gastrointestinal-based drug delivery is considered the preferred mode of drug administration owing to its convenience for patients, which improves adherence. However, unique characteristics of the gastrointestinal tract (such as the digestive environment and constraints on transport across the gastrointestinal mucosa) limit the absorption of drugs. As a result, many medications, in particular biologics, still exist only or predominantly in injectable form. In this Review, we examine the fundamentals of gastrointestinal drug delivery to inform clinicians and pharmaceutical scientists. We discuss general principles, including the challenges that need to be overcome for successful drug formulation, and describe the unique features to consider for each gastrointestinal compartment when designing drug formulations for topical and systemic applications. We then discuss emerging technologies that seek to address remaining obstacles to successful gastrointestinal-based drug delivery.

Neural signalling of gut mechanosensation in ingestive and digestive processes

Eating and drinking generate sequential mechanosensory signals along the digestive tract. These signals are communicated to the brain for the timely initiation and regulation of diverse ingestive and digestive processes - ranging from appetite control and tactile perception to gut motility, digestive fluid secretion and defecation - that are vital for the proper intake, breakdown and absorption of nutrients and water. Gut mechanosensation has been investigated for over a century as a common pillar of energy, fluid and gastrointestinal homeostasis, and recent discoveries of specific mechanoreceptors, contributing ion channels and the well-defined circuits underlying gut mechanosensation signalling and function have further expanded our understanding of ingestive and digestive processes at the molecular and cellular levels. In this Review, we discuss our current understanding of the generation of mechanosensory signals from the digestive periphery, the neural afferent pathways that relay these signals to the brain and the neural circuit mechanisms that control ingestive and digestive processes, focusing on the four major digestive tract parts: the oral and pharyngeal cavities, oesophagus, stomach and intestines. We also discuss the clinical implications of gut mechanosensation in ingestive and digestive disorders.

Psychological Aspects of Treatment with Intragastric Balloon for Management of Obesity: A Systematic Review of the Literature

INTRODUCTION

Optimizing maintenance of weight loss for people with obesity following intragastric balloon (IGB) therapy hinges on the degree to which health care providers can recognize both the impact of emotional problems and mood difficulties on their capacity to self-manage, and requirements for additional support. However, there is limited research on the psychological correlates of IGB therapy. This systematic review, for the first time, attempts to identify and synthesize the empirical evidence for the reciprocal influence between psychological variables and IGB outcomes.

METHODS

A literature search was performed in the PubMed, SCOPUS, MEDLINE, and Google Scholar databases. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least 2 reviewers. The selected articles were assessed for quality using the Strengthening the Reporting of Observational Studies Epidemiology (STROBE) checklist. Data were extracted to address the review aims and presented as a narrative synthesis. The review protocol was preregistered (Prospero CRD42019121291).

RESULTS

A total of 16,179 titles, 14,369 abstracts, and 51 full-text articles were screened, of which 16 studies were included. Findings suggest that female gender, older age, basic educational level, and single/divorced civil status, together with lower levels of depression, binge eating, higher perceived quality of life, and motivation to change were predictors of enhanced IGB treatment outcomes. Dissatisfaction with treatment was higher in those with impaired obesity-related social-life difficulties. The IGB treatment was effective in reducing weight and improving depression, anxiety, eating disorder symptoms, and the overall life quality of patients with obesity - mainly within 6 months from the device positioning and in conjunction with conventional therapies.

DISCUSSION/CONCLUSION

In line with the available literature on obesity and bariatric surgery interventions, poor mental health appears to be an important barrier for successful weight loss among patients with obesity undergoing IGB treatment. In order to improve the efficacy and effectiveness of the IGB therapy, more comprehensive and standardized studies are needed to provide insight into the psychological mechanisms maintaining weight management issues.

Primary obesity surgery endoluminal (POSE) for the treatment of obesity: a systematic review and meta-analysis

BACKGROUND

Primary obesity surgery endoluminal (POSE) utilizes an incision-less operating platform system to create full-thickness plications in the gastric fundus and body (original POSE). Many studies have demonstrated the safety and efficacy of original POSE for the treatment of obesity.

OBJECTIVE

We aimed to conduct a systematic review and meta-analysis of available literature in an attempt to evaluate the outcomes of original POSE per the ASGE task force thresholds.

METHODS

Bibliographic databases were systematically searched for studies assessing the outcomes of POSE for the treatment of obesity. All randomized controlled trials (RCTs) and observational studies that assessed outcomes of POSE were included. Studies were included if they reported percent total weight loss (%TWL) or percent excess weight loss (%EWL) and the incidence of serious adverse events (SAE).

RESULTS

A total of seven studies with 613 patients were included. Two included studies were RCTs, while the remaining were observational studies. Pooled mean %EWL at 3-6 months and 12-15 months were 42.62 (95% CI 37.56-47.68) and 48.86 (95% CI 42.31-55.41), respectively. Pooled mean %TWL at 3-6 months and 12-15 months was 13.45 (95% CI 8.93-17.97) and 12.68 (95% CI 8.13-17.23), respectively. Subgroup analysis of two RCTs showed that weight loss at 1 year was significantly higher in POSE patients (%EWL difference in means 19.45 (95% CI 4.65-34.24, p value = 0.01). The overall incidence of serious adverse events was only 2.84% and included GI bleeding, extra-gastric bleeding, hepatic abscess, severe pain, severe nausea, and severe vomiting. The mean number of total anchors placed in the fundus and body was 13.18 (95% CI 11.77-14.58), and the mean procedure time was 44.55 min (95% CI 36.44-52.65).

CONCLUSION

POSE, a minimally invasive endoscopic bariatric therapy, is a safe and effective modality for the treatment of obesity. The outcomes of POSE meet and surpass the ASGE joint task force thresholds. Future studies should evaluate newer versions of this procedure that emphasize gastric body plication sparing the fundus.

Endoscopic Treatment of Obesity and Nutritional Aspects of Bariatric Endoscopy

Obesity is a significant problem worldwide. Several serious diseases that decrease patient quality of life and increase mortality (high blood pressure, dyslipidaemia, type 2 diabetes etc.) are associated with obesity. Obesity treatment is a multidisciplinary and complex process that requires maximum patient compliance. Change of lifestyle is fundamental in the treatment of obesity. While pharmacotherapeutic options are available, their efficacy is limited. Surgical treatment though highly effective, carries the risk of complications and is thus indicated mostly in advanced stages of obesity. Endoscopic treatments of obesity are less invasive than surgical options, and are associated with fewer complications and nutritional deficits. Currently, there is a large spectrum of endoscopic methods based on the principles of gastric volume reduction, size restriction and gastric or small bowel bypass being explored with only few available in routine practice. The aim of this publication is to present an up-to-date summary of available endoscopic methods for the treatment of obesity focusing on their efficacy, safety and nutritional aspects.

Biomimetic cellulose-based superabsorbent hydrogels for treating obesity

In the treatment of obesity, nutritional and behavioral modifications are difficult to implement and maintain. Since vegetable consumption is a fundamental part of many dietary interventions and daily nutrient requirements, we developed a novel cellulose-based superabsorbent hydrogel (CB-SAH) platform, inspired by the composition and mechanical properties of raw vegetables, as a mechanobiological therapy. The CB-SAHs properties were studied in a simulated gastrointestinal environment, while their impact on gut tissue was investigated by an ex vivo organ culture (EVOC) model. Functional fibers and raw vegetables were used as reference. CB-SAHs demonstrated orders of magnitude higher elasticity in comparison to the tested functional fibers, however performed similar to the tested raw vegetables. Notably, the biomimetic CB-SAHs with elasticity levels similar to raw vegetables showed benefits in preserving and regulating the gut tissue in the EVOC model. Non-systemic oral mechanotherapeutics based on this technology were advanced through clinical studies, with a first product cleared as an aid for weight management in the US and Europe.

Influence of the Elipse Intragastric Balloon on Obesity and Metabolic Profile: A Systematic Review and Meta-Analysis

BACKGROUND

Intragastric balloons (IGBs) have been used to bridge the obesity treatment gap with the benefits of being minimally invasive but still required endoscopy. The Elipse IGB is a swallowable balloon that is spontaneously excreted at ∼16 weeks. However, studies are limited by small sample sizes. The authors aim to assess clinically relevant endpoints, namely weight loss outcomes, metabolic profile, balloon tolerability, and adverse events.

METHODS

A literature search was performed from several databases from inception to July 2020. The pooled means and proportions of our data were analyzed using a random effects model.

RESULTS

Seven studies involving 2152 patients met our eligibility criteria and were included. The mean baseline body mass index ranged from 32.1 to 38.6. The pooled mean difference (MD) in body mass index was 0.88 [confidence interval (CI): 0.58-1.18, I2=98%]. Total body weight loss was 12% (CI: 10.1-14.3, I2=94%) and excess body weight loss was 49.1% (CI: 30.6-67.5, I2=97%). The MD in waist circumference was 0.89 (CI: 0.72-1.05, I2=53%). MD in triglyceride level was 0.66 (CI: 0.21-1.1, I2=96%). Pooled early deflation rate was 1.8% (CI: 0.6-5.1, I2=74%). Our study also showed that the Elipse balloon was associated with less adverse events when compared with other IGBs.

CONCLUSIONS

This meta-analysis demonstrates that the Elipse intragastric balloon is a safe, effective, and tolerable device for weight loss and obesity with a minimal side effect profile.

Advances in Pharmacotherapeutics, Metabolic Surgery, and Technology for Diabetes

Remarkable advances in diabetes management have occurred since the discovery of insulin 100 years ago. Advances across a therapeutic spectrum, including pharmacotherapy, metabolic surgery, and diabetes technology, offer superior treatment options for diabetes management. New medication classes (glucagon-like peptide-1 receptor analogs and SGLT-2 inhibitors) have demonstrated cardiorenal benefits beyond glycemic control in type 2 diabetes mellitus, while evolving metabolic surgical interventions also help patients achieve diabetes remission. The use of artificial pancreas systems has shown consistent improvement in glycemic control in type 1 diabetes mellitus. It is time for policy changes to expand access to such advantageous therapies.

Gray matter volume increases induced by intragastric balloon treatment and their associations with neuroinflammation: A magnetic resonance study

OBJECTIVE

We simultaneously performed structural MRI, ¹H magnetic resonance spectroscopy, and whole-body hydration status assessment to evaluate brain changes in patients with morbid obesity treated with intra-gastric balloon (IGB) for six months. We asked, if changes in myo-inositol ratios (marker of neuroinflammation) are related to brain volume increases accompanying IGB-induced weight loss.

METHODS

Twenty five patients with morbid obesity (OB, 43.9 ± 11.8 years, BMI = 49.1 ± 7.2, 12 females, 9 without co-morbid conditions) were treated with IGB for six months. They underwent magnetic resonance imaging at 3T one month before IGB insertion, three months after insertion (N = 19), and one month after IGB removal (N = 14).

RESULTS

Insertion of IGB lead to 8.9% and 12.3% weight reduction over the first three months and over the entire treatment, respectively. Over the entire treatment, total gray matter volume increased by 2.0% (p = 0.009). These changes were mostly pronounced in the left precuneus and in the right frontal pole (>1.9%, p < 0.009). The increases in cortical volume in the right hemisphere and the left posterior cingulate cortical thickness over the entire treatment were significantly related to decreases in myo-inositol ratios measured over the first three months of the treatment (r < -0.740, p < 0.006).

CONCLUSIONS

IGB treatment lead to brain structural improvements consistent with earlier studies of bariatric patients without co-morbid conditions. Our results also pointed to improvements in brain regions, where atrophy in other studies was related to type 2 diabetes and hypertension. The correlations point to neuroinflammation as one of the potential processes behind brain volume reductions in patients with morbid obesity.

Intragastric Balloon Versus Endoscopic Sleeve Gastroplasty for the Treatment of Obesity: a Systematic Review and Meta-analysis

BACKGROUND

We aimed to individually evaluate IGB and ESG procedures and compare the efficacy, durability, and safety of these procedures.

METHODS

Bibliographic databases were systematically searched for studies investigating the use of IGB and ESG for the treatment of obesity. Studies reporting percent total weight loss (%TWL) or percent excess weight loss (%EWL) with at least 12 months of follow-up were included.

RESULTS

A total of 28 studies were included in the final analysis. Only 1 study directly compared ESG to IGB, 9 studies evaluated ESG alone, while 18 studies evaluated IGB. At 12-month follow-up after ESG, mean %TWL was 17.51 (95% CI 16.44-18.58), and %EWL was 60.51 (95% CI 54.39-66.64). Mean %TWL and %EWL after IGB at 12 months was 10.35 (95% CI 8.38-12.32) and 29.65 (95% CI 25.40-33.91), respectively. Mean %TWL and %EWL after IGB were significantly decreased at 18 or 24 months compared to 6 months indicating weight regain after IGB removal. ESG achieved significantly superior weight loss compared to IGB, the difference in mean %TWL was 7.33 (95% CI 5.22-9.44, p value = 0.0001) at 12 months. Serious adverse events were observed in < 5% for both procedures.

CONCLUSION

Although ESG and IGB are safe and effective for weight loss, our study suggests that ESG results in more significant and sustained weight loss. Nevertheless, a variety of approaches are essential to care for this underserved population, and there are several factors other than weight loss that should be considered in selecting the ideal therapy for individual patients.

Endoscopic assessment of morphological and histopathological upper gastrointestinal changes after endoscopic sleeve gastroplasty

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is a promising bariatric endoluminal procedure. Restriction and shortening of the stomach are obtained by means of non-resorbable full-thickness sutures, thus inducing the formation of several endoluminal pouches in which food can stagnate. The effect of ESG on the upper gastrointestinal tract has never been investigated.

OBJECTIVES

This study objectively evaluates endoscopic macroscopic and histopathologic changes within 12-month follow-up (FU) in patients who underwent ESG.

SETTING

Retrospective study on a prospective database of patients who underwent ESG at our tertiary referral center between October 2016 and March 2019.

METHODS

All consecutive patients undergoing upper endoscopy (EGD) preoperatively and 6 and 12 months after ESG were included. The upper gastrointestinal tract was evaluated for mucosal abnormalities and biopsies were systematically taken.

RESULTS

Eighty-six patients were included. EGD results were as follows: esophagitis decreased from 14% preoperatively to 3.6% and 1.2% at 6- and 12-month FU, respectively (P = .001); 19.8% of patients presented preoperatively a type I hiatal hernia <4 cm and showed no size increment or de novo hiatal hernia at 6- and 12-months. The rate of preoperative hyperemic (23.2%) and erosive (3.5%) gastropathy decreased to 9.5% and 1.2% at 6 months and 17.4% and 1.2% at 12 months, respectively. Gastric ulcer (4.7%), duodenal hyperemic mucosa (1.2%) and duodenal micro-ulcerations (2.3%) detected preoperatively were not present at 6- and 12-month EGD. The rate of histopathological disease, which was 68.1% preoperatively, dropped to 29.2% at 12 months, chronic gastritis decreased from 40.3% to 26.4%, acute gastritis from 9.7% to 0%, and acute inflammation on chronic gastritis from 18% to 2.8% (P < .001).

CONCLUSION

ESG is a safe procedure that does not promote the new onset of macroscopic and histopathologic abnormalities within 1-year follow-up.

Effects of intragastric balloon on obesity in obese Korean women for 6 months post removal

BACKGROUND/OBJECTIVES

The prevalence of morbid obesity in Korean women has consistently been increasing, while the overall prevalence rate of obesity in Korean women seems to be stable. In addition to bariatric surgery, intragastric balloons (IGBs), as a nonsurgical therapy, have been reported to be effective in weight loss. However, the beneficial effects of IGB in Korean women with obesity have not been fully investigated. The aim of this study was to evaluate the changes in fat mass in Korean women with obesity who had undergone IGB treatment for 6 mon.

SUBJECTS/METHODS

Seventy-four women with obesity (body mass index [BMI] ≥ 25.0 kg/m²) were recruited. Clinical data, including general information, comorbidities with obesity, anthropometric data, and changes in the body fat composition before and after IGB treatment, were obtained from the subjects.

RESULTS

Most subjects had one or more comorbidities, such as osteoarthropathy and woman's disease, and had poor eating behaviors, including irregular mealtimes, eating quickly, and frequent overeating. Body composition measurements showed that weight, fat mass, and waist-hip circumference ratio decreased significantly at 6 mon after IGB treatment. In particular, women with morbid obesity (BMI ≥ 30 kg/m²) showed 33% excess weight loss. There was no significant difference in skeletal muscle mass and mineral contents after IGB treatment.

CONCLUSIONS

This study suggested that 6 mon of IGB treatment can be a beneficial treatment for obesity without muscle mass and bone mineral loss.

Vagally Mediated Gut-Brain Relationships in Appetite Control-Insights from Porcine Studies

Signals arising from the upper part of the gut are essential for the regulation of food intake, particularly satiation. This information is supplied to the brain partly by vagal nervous afferents. The porcine model, because of its sizeable gyrencephalic brain, omnivorous regimen, and comparative anatomy of the proximal part of the gut to that of humans, has provided several important insights relating to the relevance of vagally mediated gut-brain relationships to the regulation of food intake. Furthermore, its large size combined with the capacity to become obese while overeating a western diet makes it a pivotal addition to existing murine models, especially for translational studies relating to obesity. How gastric, proximal intestinal, and portal information relating to meal arrival and transit are encoded by vagal afferents and their further processing by primary and secondary brain projections are reviewed. Their peripheral and central plasticities in the context of obesity are emphasized. We also present recent insights derived from chronic stimulation of the abdominal vagi with specific reference to the modulation of mesolimbic structures and their role in the restoration of insulin sensitivity in the obese miniature pig model.

Hidden dangers and updated labels on gastric balloons

In recent years, intragastric balloons (IGBs) have emerged as an efficacious, nonsurgical modality to treat obesity. We present a case in which an IGB caused a gastric ulcer, only unearthed after the novel technique of deflation and early retrieval.

[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.

Use of an intragastric balloon for management of obesity in a dog

While various bariatric surgeries are commonplace in obesity medicine for humans, these techniques have not been commonly used in veterinary medicine. A technique used in humans consists in endoscopically placing an intragastric balloon. The intragastric balloon takes volume in the stomach causing a feeling of satiety and reducing food intake. A 57.6 kg, 9-year-old neutered female Labrador dog with chronic hypothyroidism was presented for overweight management. Combined levothyroxine treatment and dietary management with specific alimentation for obesity had failed to control overweight. An intragastric balloon was placed endoscopically in the stomach to allow the reduction of the gastric capacity and resulted in effective weight loss. The dog weight decreased to 40.9 kg at the time of intragastric balloon removal 198 days after placement. Further research including a larger sample size and long term follow-up is required to establish safety and effectiveness of this procedure.

Outcomes with Intra-gastric Balloon Therapy in BMI < 35 Non-morbid Obesity: 10-Year Follow-Up Study of an RCT

PURPOSE

Intra-gastric balloon (IGB) therapy is the most established endoscopic treatment of obesity, but there is a paucity of literature on long-term efficacy. This study aims to evaluate the short- and long-term weight loss efficacy of IGB.

MATERIALS AND METHODS

Double-blinded RCT with 6-month IGB vs with sham endoscopy, in body mass index (BMI) 27-35 patients. Anthropometric, fasting glucose, and lipid profile measurement as early outcomes (up to 2 years) and 10-year follow-up. Primary outcomes were total body weight loss (kg) and BMI. Secondary outcomes were new-onset diabetes mellitus, other new comorbidities, and willingness for further intervention.

RESULTS

Initial RCT recruited 99 patients (50 IGB vs 49 sibutramine group). Forty-nine patients (26 IGB vs 23 control group) participated in a 10-year review (follow-up rate of 51.6%). Total body weight loss at 6 (9.75 vs 7.48 kg, p = 0.03), 12 (6.52 vs 4.42 kg, p = 0.05), 18 (5.42 vs 3.57, p = 0.32), and 24 months (4.07 vs 2.93 kg, p = 0.56) favored the IGB group. Total weight loss (TWL) at 10 years (0.03 vs - 2.32 kg, p = 0.05) and %TWL (- 0.16 ± 12.8% vs - 2.84 ± 5.6%, p = 0.39) were not significantly different between groups. Follow-up BMI (30.97 ± 1.6 vs 30.38 ± 1.8 kg/m², p = 1.00) was similar. At 10 years, new-onset diabetes mellitus, sleep apnoea, metabolic syndrome, and arthralgia were not significant (p > 0.05). Twenty-three (81%) IGB group vs 13 (56%) control expressed a willingness for further intervention (p < 0.01).

CONCLUSION

IGB delivers weight loss to 2 years and is superior to control. However, new comorbidity development is not significantly different at 10 years. Patient that received IGB therapy were subsequently more willing for further bariatric metabolic intervention.

Safety and short-term effectiveness of endoscopic sleeve gastroplasty using overstitch: preliminary report from a multicenter study

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an option for patients with Class I and II obesity or patients who refuse to undergo a laparoscopic bariatric surgery. The aims of this study are as follows: (1) to demonstrate a short-term outcome after primary ESG and (2) to compare the effectiveness of weight loss between Class I and Class II obesity patients.

METHODS

Patients undergoing ESG at four bariatric centers in Brazil between April 1, 2017 and December 31, 2018 were prospectively enrolled in the study (BMI 30.0-39.9 kg/m²). ESG was performed using Overstitch (Apollo Endosurgery, Austin, TX). Descriptive analysis, t test, Chi-square test, and Mann-Whitney test were used to present the results.

RESULTS

A total of 233 patients underwent primary ESG. The mean age and BMI of the patients were 41.1 years and 34.7 kg/m², respectively. Following ESG, the mean percentage of total weight loss (TWL) was 17.1% at 6 months and 19.7% at 12 months. Percentage of excess BMI loss (EBMIL) was 47.3% at 6 months and 54.8% at 12 months after ESG. The mean EBMIL was significantly greater among patients with Class I obesity than those with Class II obesity at 6 (51.1% vs. 43.7%) and 12 months (60.2% vs. 49.2%). One patient experienced bleeding during the procedure that was managed with sclerotherapy.

CONCLUSION

Short-term results suggest that ESG is a safe and effective option for patients with Class I and II obesity.

Interoception and Its Role for Eating, Obesity, and Eating Disorders

Abstract. The importance of the sense of ourselves from within for understanding adaptive behavior and psychopathology has been increasingly recognized during the last decades. Interoception builds the foundation of our embodied self and dysfunctional interoception lies at the core of many psychosomatic disorders. Eating is fundamental for survival with consequences for health and well-being. It is deeply grounded in homoeostatic and allostatic psychophysiological needs and is driven by interoceptive signals of the body. This narrative review summarizes a selection of empirical findings and draws conclusions on the role of interoception in eating behavior, body weight, and eating disorders. Beyond disordered eating behavior, eating disorders are characterized by impairment of the sense of self, with dysfunctional interoception at its core. Predictive coding accounts are addressed to integrate conclusions and to underline the relevance of interventions to modify interoception.

New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review

Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.

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.

Extrinsic compression of pancreatic duct by intragastric balloon treatment and its potential to cause acute pancreatitis: Two case reports and clinical discussion

We describe two cases of increased pancreatic enzyme levels after intragastric balloon (IGB) placement possibly related to extrinsic pancreatic duct compression, followed by a short review of the literature. Case 1 is the first, to our knowledge, of a patient with asymptomatic increase of pancreatic enzymes due to pancreatic duct compression, with unknown clinical significance. We hypothesize that this finding maybe can be relatively common in IGB users and almost certainly an important risk factor for the development of acute pancreatitis (AP). On the other hand, case 2 reports an AP that occurred one day after IGB placement, presented with nausea and vomiting, making AP a differential diagnosis of initial IGB intolerance.

ASSESSMENT OF WEIGHT LOSS AFTER NON-ADJUSTABLE AND ADJUSTABLE INTRAGASTRIC BALLOON USE

BACKGROUND

Intragastric balloon (IGB) use is indicated for patients whose BMI precludes the option of bariatric surgery or who need to lose weight prior to undergoing surgery. It is a minimally invasive procedure and currently there are two main models of IGBs in use, the non-adjustable intragastric balloon (NIB), implanted for six months, and the adjustable intragastric balloon (AIB), implanted for up to 12 months.

OBJECTIVE

Analyze clinical characteristics between patients receiving non-adjustable gastric balloon and the adjustable (prolonged implantation) intragastric balloon.

METHODS

This was a cross-sectional study of 470 patients diagnosed as obese or overweight who had balloon implantation from October 2011 to July 2018. The associations between percentage excess weight loss versus clinical and demographic variables were calculated using the chi-squared test. Independent samples were submitted to the Student's t test to determine the quantitative variables, with a confidence interval of 95%. Calculation of excess weight was based on an estimated ideal weight that would correspond to a BMI of 24.99 kg/m2.

RESULTS

A total of 414 patients completed the treatment achieving an average total body weight loss (%TBWL) of 15.4±7 with the NIB and 15.5±9.6 with the AIB. Overweight patients achieved higher excess weight loss (%EWL) values using AIBs (157.2±82.5) and obese patients did so with NIB use (56±29.7). Women achieved higher %EWL values (65.6±62.2) than men (48±27.1). Individuals who attended >4 consultations with a nutritionist (60.8%) achieved TBWL >18%. All of those P-values were <0.001.

CONCLUSION

Obese individuals and women registered the greatest weight losses. Overweight patients achieved greater losses using AIB and obese patients did so using NIBs. NIB use was associated with higher EWL percentages. Nutritional accompaniment had a positive impact on the %TBWL.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures.

METHODS

A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement.

RESULTS

The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members.

CONCLUSIONS

Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Effectiveness of Intra-Gastric Balloon as a Bridge to Definitive Surgery in the Super Obese

BACKGROUND

British National guidelines (NICE) recommend bariatric surgery for patients with a body mass index (BMI) > 40 kg/m2, or BMI > 35 kg/m2 with any comorbidities of the metabolic syndrome. Intra-gastric balloons (IGB) can be used in super obese patients as a first step, before definitive surgery.

AIMS

Quantify weight loss 6 months after IGB placement, measure progression to definitive surgery and identify complications.

METHODS

Data collected retrospectively on 50 patients. Forty-six proposed for definitive bariatric surgery, four patients excluded. Analysis performed using SPSS v23.0.

RESULTS

Median weight decreased from 165.5 to 155 kg (range 78 to 212, p < 0.01), BMI from 57.4 to 52.15 (range 32.9 to 70.5, p < 0.01), percentage excess weight loss (%EWL) was 12.9% (range - 3.3 to 64.66%, p < 0.01) and BMI reduction was 4.25 kg/m2 (range - 1.3 to 13.9, p < 0.01). Twenty-nine out of 46 patients (63%) progressed to definitive bariatric surgery. Ten out of 46 patients (21.7%) had complications requiring readmission. Seven of these patients required early balloon removal and six failed to progress to definitive surgery. Six patients had a second balloon placement, their actual weight loss was less successful, with some regaining weight.

DISCUSSION

IGB is useful to aid weight loss prior to definitive bariatric surgery. Results from first balloon placement are encouraging and comparable with other studies "as reported by Genco et al. (Int J of Obes 30:129-133, 2006)." Readmission due to nausea, vomiting, dehydration and poor compliance may be associated with poor weight loss and failure to progress to definitive surgery. Second balloon placements were less successful.

CONCLUSION

IGB as bridging therapy is a safe and useful adjunct. Sequential IGBs do not seem to provide additional benefit.

Extrinsic compression of pancreactic duct by intragastric balloon treatment and its potential to cause acute pancreatitis: two case reports and clinical discussion

We describe two cases of increased pancreatic enzyme levels after intragastric balloon (IGB) placement possibly related to extrinsic pancreatic duct compression, followed by a short review of the literature. Case 1 is the first, to our knowledge, of a patient with asymptomatic increase of pancreatic enzymes due to pancreatic duct compression, with unknown clinical significance. We hypothesize that this finding maybe can be relatively common in IGB users and almost certainly an important risk factor for the development of acute pancreatitis (AP). On the other hand, case 2 reports an AP that occurred one day after IGB placement, presented with nausea and vomiting, making AP a differential diagnosis of initial IGB intolerance.

Endoscopic intragastric balloon: a gimmick or a viable option for obesity?

Worldwide, the prevalence of obesity has doubled since 1980 in 70 countries. More than one in three adults now suffer from overweight or obesity. Health problems related to obesity include orthopedic problems, psychiatric conditions, metabolic and cardiovascular diseases, and of increasing concern, cancer. Thus, obesity has an enormous impact on the individual’s wellbeing as well as on society’s workforce and health care expenses. Medical efforts are ongoing to find safe and effective treatment options for obesity and its metabolic implications. At present, available treatment options include lifestyle interventions, pharmacotherapy, endoscopic applications, and bariatric surgery. Within the range of endoscopic treatment options, the intragastric balloon is the most widely used device. The idea is simple: the gastric volume is reduced by a balloon that is in most cases implanted by an endoscopic procedure similar to a gastroscopy. During the past decades, different models have been developed, which we will briefly introduce in this review. We aim at reviewing the pathophysiology underlying the effect of endoscopic intragastric balloon on weight loss and metabolic changes. We will assess expected short-term and long-term benefits for the patient, and we will discuss common side effects as well as rare complications. We will compare endoscopic intragastric balloon to conservative treatment options with or without pharmacological support on the one hand and to the spectrum of bariatric surgery on the other hand. In most patients, obesity must be considered a chronic disease that requires a lifelong treatment concept. In view of current treatment options for obesity, we will discuss whether endoscopic intragastric balloon is a viable treatment option, and who may be the right patient to benefit from it.

Real Life Changes in Physical Activity Due to Intragastric Balloon Therapy and Their Relationship to Improving Cognitive Functions: Preliminary Findings

Background

We evaluated if the intragastric balloon (IGB) treatment leads to the increase in physical activity (PA) and whether they are related to cognitive improvements.

Methods

Fourteen morbidly obese patients (151 ± 24 kg, BMI = 51.8 ± 6.5, 107 ± 26% excess weight, 43.3 ± 10.6 years) underwent 6-day-long, uninterrupted evaluations of PA 1 month before IGB insertion and 1 month after its removal.

Results

Active energy expenditure and physical activity duration increased by more than 80% (p < 0.001) whereas the number of steps per day by 20% (p = 0.016). There was a pattern of relationships between cognitive improvements and increases in PA (p < 0.05). In particular, working memory improvements correlated with the increase in time spent on light physical activities (r = 0.673, p = 0.004).

Conclusion

The relationships suggest that an increase in physical activity mediates cognitive improvements in bariatric patients.

Safety and efficacy of endoscopic sleeve gastroplasty worldwide for treatment of obesity: a systematic review and meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) has gained momentum as a promising, minimally invasive bariatric therapy worldwide.

OBJECTIVE

We performed the first comprehensive systematic review and meta-analysis of studies to evaluate the efficacy, safety, and procedural technique of ESG.

METHODS

Bibliographic databases were systematically searched for studies assessing patients who underwent ESG for the treatment of obesity. Studies were included if they reported percent total weight loss or percent excess weight loss and the incidence of serious adverse events. Studies with <15 patients, follow-up period <6 months, and overlapping patients were excluded.

RESULTS

Eight observational studies with 1859 patients were included. Pooled mean percent total weight loss at 6, 12, and 24 months was 14.86 (95% confidence interval [CI]: 13.83-15.90), 16.43 (95%CI: 15.23-17.63), and 20.01 (95%CI:  16.92-23.11), respectively. Pooled mean percent excess weight loss at 6, 12, and 24 months was 55.75 (95%CI: 50.61-60.89), 61.84 (95%CI: 54.75-68.93), and 60.40 (95%CI: 48.88-71.92), respectively. The pooled incidence of serious adverse events was 2.26% (95%CI 1.25-4.03) and no mortality was reported. Gastrointestinal bleeding and perigastric fluid collection were the most common reported serious adverse events; however, the pooled incidence of both was <1%. Variations in procedural technique were seen, but the full-thickness nature of suturing was reported in all studies. A layer of reinforcement sutures was performed in the majority of studies (n = 6). Limitations include the lack of controlled studies, long-term follow-up data, and standardization of technique.

CONCLUSION

ESG, a minimally invasive bariatric therapy, is reproducible among centers worldwide with effective weight loss and favorable safety profile outcomes. Controlled studies would be valuable to further corroborate these findings.

Changes in resting metabolic rate and body composition due to intragastric balloon therapy

BACKGROUND

Intragastric balloon (IGB) insertion leads to dietary restriction; however, its neurohormonal actions were also described. Resting metabolic rate (RMR) adjusted for body mass (RMR/mass) seems to increase after bariatric interventions, whereas it generally decreases after caloric restriction-based therapies. However, no studies have evaluated the changes in body composition and RMR over IGB treatment.

OBJECTIVE

To evaluate the relationships between changes in body composition, RMR, RMR/mass, and RMR adjusted for fat-free mass (FFM) (RMR/FFM) over IGB treatment lasting 6 months.

SETTING

Single-center observational study.

METHODS

Twenty-one morbidly obese patients treated with IGB (143 ± 20 kg, body mass index [BMI] = 49.5 ± 7.3, 98% ± 29% percent excess weight, 43.6 ± 12.6 yr) were enrolled. Changes in body composition, RMR, RMR/mass, and RMR/FFM were evaluated between 1 month before IGB insertion (time point 1 [TP1]) and 3 months thereafter (TP2). Fourteen patients were also assessed 1 month after IGB removal (TP3).

RESULTS

There was a 9.5% reduction in weight, a 9.4% reduction in BMI, and 19.1% decrease in percent excess weight at TP2 (n = 21; P < .001); a further 6.5% reduction in weight and BMI and a 13.1% drop in percent excess weight (n = 14, P < .001) at TP3. They were accompanied by a 5.4% reduction in FFM between TP1 and TP2 (n = 21, P < .001). Compared with pretreatment values, at TP2 RMR was 12.5% lower (P < .001) but did not change thereafter. RMR/mass increased 12.4% between TP2 and TP3 (n = 14, P = .02) but on average did not change between TP1 and TP3. The results in the smaller cohort (n = 14) between TP1 and TP2 were consistent with results obtained for the entire cohort. Similar findings were obtained for RMR/FFM. The larger increases in RMR/mass between TP1 and TP3 were associated with more weight loss, larger drop in BMI, and more loss of excess weight (r < -.55, P < .03).

CONCLUSION

This is the first study to evaluate the relationship between changes in body composition and RMR over IGB treatment. IGB therapy leads to both fat and fat-free mass reductions and RMR decreases. More weight reduction is associated with larger increases in RMR/mass.