1
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Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, Kushnir V, Barthet M, Apovian CM, Boskoski I, Chapman CG, Davidson P, Donatelli G, Kumbhari V, Hayee B, Esker J, Hucl T, Pryor AD, Maselli R, Schulman AR, Pattou F, Zelber-Sagi S, Bain PA, Durieux V, Triantafyllou K, Thosani N, Huberty V, Sullivan S. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Gastrointest Endosc 2024; 99:867-885.e64. [PMID: 38639680 DOI: 10.1016/j.gie.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 04/20/2024]
Abstract
This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Árpád V Patai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stefan K Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Vladimir Kushnir
- Department of Medicine-Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marc Barthet
- Department of Hepatogastroenterology, Faculty of Medicine, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christopher G Chapman
- Center for Interventional and Therapeutic Endoscopy, Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois USA
| | - Paul Davidson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France and Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bu Hayee
- Division of Gastroenterology, Kings College London, London, United Kingdom
| | - Janelle Esker
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Aurora D Pryor
- Department of Surgery, Long Island Jewish Medical Center, Queens, New York, USA
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Clinical and Research Center IRCCS, Endoscopy Unit, Rozzano, Italy
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francois Pattou
- Department of Endocrine and Metabolic Surgery, CHU Lille, University of Lille, Inserm, Institut Pasteur Lille, Lille, France
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel and Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles, Brussels, Belgium
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, Division of Gastroenterology Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Vincent Huberty
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Shelby Sullivan
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Jirapinyo P, Hadefi A, Thompson CC, Patai ÁV, Pannala R, Goelder SK, Kushnir V, Barthet M, Apovian CM, Boskoski I, Chapman CG, Davidson P, Donatelli G, Kumbhari V, Hayee B, Esker J, Hucl T, Pryor AD, Maselli R, Schulman AR, Pattou F, Zelber-Sagi S, Bain PA, Durieux V, Triantafyllou K, Thosani N, Huberty V, Sullivan S. American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity. Endoscopy 2024; 56:437-456. [PMID: 38641332 DOI: 10.1055/a-2292-2494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.
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Affiliation(s)
- Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Árpád V Patai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stefan K Goelder
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Vladimir Kushnir
- Department of Medicine-Division of Gastroenterology, Washington University, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Marc Barthet
- Department of Hepatogastroenterology, Faculty of Medicine, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Caroline M Apovian
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Christopher G Chapman
- Center for Interventional and Therapeutic Endoscopy, Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois USA
| | - Paul Davidson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Ramsay Générale de Santé, Paris, France and Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bu Hayee
- Division of Gastroenterology, Kings College London, London, United Kingdom
| | - Janelle Esker
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Aurora D Pryor
- Department of Surgery, Long Island Jewish Medical Center, Queens, New York, USA
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Clinical and Research Center IRCCS, Endoscopy Unit, Rozzano, Italy
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Francois Pattou
- Department of Endocrine and Metabolic Surgery, CHU Lille, University of Lille, Inserm, Institut Pasteur Lille, Lille, France
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel and Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Valérie Durieux
- Bibliothèque des Sciences de la Santé, Université Libre de Bruxelles, Brussels, Belgium
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, Division of Gastroenterology Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Vincent Huberty
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Shelby Sullivan
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Igi WF, de Oliveira VL, Matar A, de Moura DTH. Role of endoscopic duodenojejunal bypass liner in obesity management and glycemic control. Clin Endosc 2024; 57:309-316. [PMID: 38356171 PMCID: PMC11133994 DOI: 10.5946/ce.2023.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 02/16/2024] Open
Abstract
The treatment of obesity and its comorbidities ranges from clinical management involving lifestyle changes and medications to bariat-ric and metabolic surgery. Various endoscopic bariatric and metabolic therapies recently emerged to address an important therapeutic gap by offering a less invasive alternative to surgery that is more effective than conservative therapies. This article compre-hensively reviews the technical aspects, mechanism of action, outcomes, and future perspectives of one of the most promising endoscopic bariatric and metabolic therapies, named duodenojejunal bypass liner. The duodenojejunal bypass liner mimics the mechanism of Roux-en-Y gastric bypass by preventing food contact with the duodenum and proximal jejunum, thereby initiating a series of hormonal changes that lead to delayed gastric emptying and malabsorptive effects. These physiological changes result in significant weight loss and improved metabolic control, leading to better glycemic levels, preventing dyslipidemia and non-alcoholic fatty liver disease, and mitigating cardiovascular risk. However, concern ex-ists regarding the safety profile of this device due to the reported high rates of severe adverse events, particularly liver abscesses. Ongo-ing technical changes aiming to reduce adverse events are being evaluated in clinical trials and may provide more reliable data to sup-port its routine use in clinical practice.
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Affiliation(s)
| | - Victor Lira de Oliveira
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ayah Matar
- American University of Beirut Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Gastrointestinal Endoscopy Division, Instituto D’Or de Pesquisa e Ensino, Hospital Vila Nova Star, São Paulo, Brazil
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Ryder REJ, Yadagiri M, Burbridge W, Irwin SP, Gandhi H, Bashir T, Allden RA, Wyres M, Cull M, Bleasdale JP, Fogden EN, Anderson MR, Sen Gupta P. Duodenal-jejunal bypass liner for the treatment of type 2 diabetes and obesity: 3-year outcomes in the First National Health Service (NHS) EndoBarrier Service. Diabet Med 2022; 39:e14827. [PMID: 35285080 PMCID: PMC9313821 DOI: 10.1111/dme.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | - Mahi Yadagiri
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
| | - Wyn Burbridge
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
| | - Susan P. Irwin
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
| | - Hardeep Gandhi
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
| | - Tahira Bashir
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
| | | | - Melanie Wyres
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
| | - Melissa Cull
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
| | | | | | | | - Piya Sen Gupta
- Sandwell & West Birmingham NHS TrustCity HospitalBirminghamUK
- Guy’s and St Thomas’ HospitalsLondonUK
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5
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Impact of duodenal-jejunal bypass liner (DJBL) on NAFLD in patients with obesity and type 2 diabetes mellitus. Nutrition 2022; 103-104:111806. [DOI: 10.1016/j.nut.2022.111806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/20/2022]
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Endoscopic Bariatric Treatment with Duodenal-Jejunal Bypass Liner Improves Non-invasive Markers of Non-alcoholic Steatohepatitis. Obes Surg 2022; 32:2495-2503. [PMID: 35713854 PMCID: PMC9273553 DOI: 10.1007/s11695-022-06150-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 06/07/2022] [Accepted: 06/07/2022] [Indexed: 01/06/2023]
Abstract
Purpose People with obesity often develop non-alcoholic fatty liver disease (NAFLD) and are at high risk of progression to non-alcoholic steatohepatitis (NASH). Few therapies are effective other than bariatric surgery. We therefore analyzed data from duodenal-jejunal bypass liner (DJBL) patients regarding steatosis, fibrosis, and NASH. Methods Consecutive DJBL patients with type 2 diabetes underwent standardized assessments up to device removal at 48 weeks. These included aspartate and alanine transaminase (AST, ALT), controlled attenuation parameter (CAP, for steatosis), and liver stiffness measurement (LSM, for fibrosis). The NAFLD fibrosis score (NFS), fibrosis-4 score (FIB4), and enhanced liver fibrosis (ELF) test were also used to assess fibrosis and the Fibroscan-AST (FAST) score to assess NASH. Mixed models were used and missing data were accounted for with multiple imputation. Results Thirty-two patients (18 female, mean age 55.1, mean BMI 40.2 kg/m2) were included. After 48 weeks, the change compared to baseline with 95% CI was a factor 0.74 (0.65 to 0.84) for AST, 0.63 (0.53 to 0.75) for ALT, and a difference of − 0.21 (− 0.28 to − 0.13) for FAST, all with p < 0.001. Fibrosis based on LSM, NFS, and ELF did not change whereas FIB4 exhibited slight improvement. Eight DJBL were explanted early due to device-related complications and eight complications led to hospitalization. Conclusions One year of DJBL therapy is associated with relevant improvements in non-invasive markers of steatosis and NASH, but not fibrosis, and is accompanied by a substantial number of complications. Given the lack of alternatives, DJBL deserves further attention. Graphical abstract ![]()
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7
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Ryder REJ, Yadagiri M, Burbridge W, Irwin SP, Gandhi H, Bashir T, Allden RA, Wyres M, Cull M, Bleasdale JP, Fogden EN, Anderson MR, Gupta PS. EndoBarrier
treatment for longstanding type 2 diabetes and obesity: outcomes one year after
EndoBarrier
in 90 consecutively treated patients. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Robert EJ Ryder
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Mahi Yadagiri
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Wyn Burbridge
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Susan P Irwin
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Hardeep Gandhi
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Tahira Bashir
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Rachael A Allden
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Melanie Wyres
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Melissa Cull
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - John P Bleasdale
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Edward N Fogden
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Mark R Anderson
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
| | - Piya Sen Gupta
- Sandwell & West Birmingham NHS Trust, City Hospital Birmingham UK
- Guy's and St Thomas’ Hospitals London UK
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Lee SY, Lai H, Chua YJ, Wang MX, Lee GH. Endoscopic Bariatric and Metabolic Therapies and Their Effects on Metabolic Syndrome and Non-alcoholic Fatty Liver Disease - A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:880749. [PMID: 35615095 PMCID: PMC9124896 DOI: 10.3389/fmed.2022.880749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEndoscopic 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.MethodsDatabases 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.ResultsSix 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.ConclusionEBMTs 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.
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Affiliation(s)
- Shi-Yan Lee
- Gastroenterology & Hepatology, National University Hospital, Singapore, Singapore
| | - Haoxing Lai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yang Jie Chua
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Min Xian Wang
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Centre of Infectious Disease Epidemiology and Research, National University of Singapore, Singapore, Singapore
| | - Guan-Huei Lee
- Gastroenterology & Hepatology, National University Hospital, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- *Correspondence: Guan-Huei Lee
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9
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Glycemic control and BMI changes after endoscopic implantation of a duodenojejunal bypass liner compared with laparoscopic Roux-en-Y gastric bypass surgery: a propensity score matching analysis. Surg Endosc 2022; 36:5979-5985. [PMID: 35378626 DOI: 10.1007/s00464-022-09177-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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10
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First fully endoscopic metabolic procedure with NOTES gastrojejunostomy, controlled bypass length and duodenal exclusion: a 9-month porcine study. Sci Rep 2022; 12:21. [PMID: 34996894 PMCID: PMC8741923 DOI: 10.1038/s41598-021-02921-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/18/2021] [Indexed: 01/14/2023] Open
Abstract
We conducted a pilot study of a potential endoscopic alternative to bariatric surgery. We developed a Natural Orifice Transluminal Endoscopic Surgery (NOTES) gastric bypass with controlled bypass limb length using four new devices including a dedicated lumen-apposing metal stent (GJ-LAMS) and pyloric duodenal exclusion device (DED). We evaluated procedural technical success, weight change from baseline, and adverse events in growing Landrace/Large-White pigs through 38 weeks after GJ-LAMS placement. Six pigs (age 2.5 months, mean baseline weight 26.1 ± 2.7 kg) had initial GJ-LAMS placement with controlled bypass limb length, followed by DED placement at 2 weeks. Technical success was 100%. GJ-LAMS migrated in 3 of 6, and DED migrated in 3 of 5 surviving pigs after mucosal abrasion. One pig died by Day 94. At 38 weeks, necropsy showed 100–240 cm limb length except for one at 760 cm. Weight gain was significantly lower in the pigs that underwent endoscopic bypass procedures compared to expected weight for age. This first survival study of a fully endoscopic controlled bypass length gastrojejunostomy with duodenal exclusion in a growing porcine model showed high technical success but significant adverse events. Future studies will include procedural and device optimizations and comparison to a control group.
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11
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Chen JH, Yu ZH, Liu QLF, Meng QG, Chen X. Research Progress of Duodenal-Jejunal Bypass Liner in the Treatment of Obesity and Type 2 Diabetes Mellitus. Diabetes Metab Syndr Obes 2022; 15:3319-3327. [PMID: 36329806 PMCID: PMC9624146 DOI: 10.2147/dmso.s382324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
With the development of economy and improvement of people's living standards, the incidence of obesity and type 2 diabetes mellitus (T2DM) has increased significantly and obesity has also become one of the most important risk factors of T2DM. In light of these trends, there have been many ways to take effect in losing weight. However, they also have corresponding deficiencies including inapparent curative effect, complex and incomplete reversible procedures and severe complications. Duodenal-Jejunal Bypass Liner (DJBL), which mimics Roux-en-Y gastric bypass (RYGB), is proved to play a key role in weight loss and control of T2DM. DJBL is reversible, less invasive and is more suitable for the treatment of obesity and T2DM, which is associated with multiple mechanisms, including incretin effect, gastric emptying mechanism, bile acid regulation, intestinal microbiota, inflammatory reaction mechanism and neural mechanism. In our review, we aimed to elaborate DJBL's clinical efficacy, safety and mechanisms in detail.
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Affiliation(s)
- Ji-Hua Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Zi-Han Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Qin-Ling Fei Liu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Qing-Guo Meng
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Correspondence: Xin Chen, Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China, Email
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Iwamoto SJ, Abushamat LA, Zaman A, Millard AJ, Cornier MA. Obesity Management in Cardiometabolic Disease: State of the Art. Curr Atheroscler Rep 2021; 23:59. [PMID: 34345933 PMCID: PMC8358925 DOI: 10.1007/s11883-021-00953-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To summarize research from the last 5 years on the effects of weight loss treatments, including lifestyle changes, anti-obesity medications, and bariatric procedures on cardiovascular disease (CVD) risk factors and CVD outcomes in adults. RECENT FINDINGS This narrative review includes and summarizes the contemporary evidence of the effects of these different weight loss approaches individually. A literature search was performed using the key words obesity, weight loss, CVD, cardiometabolic, and risk factors and included key clinical trials from the past 5 years. Obesity management through weight loss is associated with improvements in CVD risk factors, such as improved blood pressure, lipid profiles, and glycemic control, with greater weight loss leading to greater improvements in CVD risk factors. Bariatric surgery is associated with greater weight loss than the other procedures and treatments for obesity, and for this, and possibly for other reasons, it is associated with greater reductions in CVD outcomes and mortality. Obesity is an independent risk factor and modulator of other CVD risk factors, and thus, treatment of obesity should be an integral part of management strategies to reduce CVD risk. Future trials and real-world studies of longer duration are needed to inform providers and patients on how to individualize the approach to modifying risks of cardiometabolic disorders through obesity management.
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Affiliation(s)
- Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- Center for Women's Health Research, Department of Medicine, Anschutz Medical Campus, University of Colorado, 12348 E Montview Blvd, C263, Aurora, CO, USA
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA
- Rocky Mountain Regional Veterans Administration, Aurora, CO, USA
| | - Layla A Abushamat
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Adnin Zaman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA
| | - Anthony J Millard
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Marc-Andre Cornier
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA.
- Rocky Mountain Regional Veterans Administration, Aurora, CO, USA.
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13
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Telese A, Sehgal V, Magee CG, Naik S, Alqahtani S, Lovat L, Haidry RJ. Bariatric and Metabolic Endoscopy: A New Paradigm. Clin Transl Gastroenterol 2021; 12:e00364. [PMID: 34142665 PMCID: PMC8216681 DOI: 10.14309/ctg.0000000000000364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/14/2021] [Indexed: 12/26/2022] Open
Abstract
The prevalence of obesity, type 2 diabetes mellitus, and metabolic syndromes is increasing globally. Minimally invasive metabobariatric (MB) endoscopic therapies are adjunct treatments that can potentially bridge the gap between surgical interventions and medical therapy. A growing number of MB techniques are becoming available, allowing for more personalized and patient-targeted treatment options for specific disease states. MB techniques are less invasive than surgery and can precisely target different parts of the gastrointestinal tract that may be responsible for the pathophysiology of obesity and metabolic syndromes such as type 2 diabetes mellitus. These alternatives should be selected on an individualized patient basis to balance the expected clinical outcomes and desired anatomical targets with the level of invasiveness and degree of acceptable risk. Each MB intervention presents great flexibility allowing for a tailored intervention and different levels of patient engagement. Patient awareness and motivation are essential to avoid therapy withdrawal and failure. Differences between MB procedures in terms of weight loss and metabolic benefit will be discussed in this review, along with the insights on clinical decision-making processes to evaluate the potential of further evolution and growth of bariatric and metabolic endoscopy.
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Affiliation(s)
- Andrea Telese
- Department of Gastrointestinal Services, University College London Hospital, London, UK;
| | - Vinay Sehgal
- Department of Gastrointestinal Services, University College London Hospital, London, UK;
| | - Cormac G. Magee
- Department of Gastrointestinal Services, University College London Hospital, London, UK;
- Centre for Obesity research, University College London, London, UK;
| | - S. Naik
- Centre for Obesity research, University College London, London, UK;
| | - S.A. Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA;
- Liver Transplantation Unit, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - L.B. Lovat
- Department of Gastrointestinal Services, University College London Hospital, London, UK;
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Rehan J. Haidry
- Department of Gastrointestinal Services, University College London Hospital, London, UK;
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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. Obes Surg 2021; 30:1200-1210. [PMID: 31898040 DOI: 10.1007/s11695-019-04324-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Balint IB, Csaszar F, Somodi K, Ternyik L, Biro A, Kaposztas Z. Is duodeno-jejunal bypass liner superior to pylorus preserving bariatric surgery in terms of complications and efficacy? Langenbecks Arch Surg 2021; 406:1363-1377. [PMID: 33712874 PMCID: PMC8370966 DOI: 10.1007/s00423-021-02131-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 02/09/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Based on recent scientific evidence, bariatric surgery is more effective in the management of morbid obesity and related comorbidities than conservative therapy. Pylorus preserving surgical procedures (PPBS) such as laparoscopic single-anastomosis duodeno-jejunal or duodeno-ileal bypass with sleeve gastrectomy are modified duodenal switch (DS) surgical techniques. The duodeno-jejunal bypass liner (DJBL) is a novel surgical method in the inventory of metabolism focused manual interventions that excludes duodeno-jejunal mucosa from digestion, mimicking DS procedures without the risk of surgical intervention. The aim of this article is to summarize and compare differences between safety-related features and weight loss outcomes of DJBL and PPBS. METHODS A literature search was conducted in the PubMed database. Records of DJBL-related adverse events (AEs), occurrence of PPBS-related complications and reintervention rates were collected. Mean weight, mean body mass index (BMI), percent of excess of weight loss (EWL%), percent of total weight loss (TWL%) and BMI value alterations were recorded for weight loss outcomes. RESULTS A total of 11 publications on DJBL and 6 publications on PPBS were included, involving 800 and 1462 patients, respectively. The baseline characteristics of the patients were matched. Comparison of DJBL-related AEs and PPBS-related severe complications showed an almost equal risk (risk difference (RD): -0.03 and confidence interval (CI): -0.27 to 0.21), despite higher rates among patients having received endoscopic treatment. Overall AE and complication rates classified by Clavien-Dindo showed that PPBS was superior to DJBL due to an excess risk level of 25% (RD: 0.25, CI: 0.01-0.49). Reintervention rates were more favourable in the PPBS group, without significant differences in risk (RD: -0.03, CI: -0.27 to 0.20). However, PPBS seemed more efficient regarding weight loss outcomes at 1-year follow-up according to raw data, while meta-analysis did not reveal any significant difference (odds ratio (OR): 1.08, CI: 0.74-1.59 for BMI changes). CONCLUSION Only limited conclusions can be made based on our findings. PPBS was superior to DJBL with regard to safety outcomes (GRADE IIB), which failed to support the authors' hypothesis. Surgical procedures showed lower complication rates than the incidence of DJBL-related AEs, although it should be emphasized that the low number of PPBS-related mild to moderate complications reported could be the result of incomplete data recording from the analysed publications. Weight loss outcomes favoured bariatric surgery (GRADE IIB). As the DJBL is implanted into the upper gastrointestinal tract for 6 to 12 months, it seems a promising additional method in the inventory of metabolic interventions.
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Affiliation(s)
- Istvan Bence Balint
- Department of Surgery and Vascular Surgery, Zala County Saint Rafael Hospital, H-8900 Zrinyi Miklos street 1., Zalaegerszeg, Hungary.
| | - Ferenc Csaszar
- Doctoral School of Neurosciences, University of Pecs, Pécs, Hungary
| | - Krisztian Somodi
- Department of Surgery, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Laszlo Ternyik
- Department of Surgery, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Adrienn Biro
- Department of Surgery, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
| | - Zsolt Kaposztas
- Department of Surgery, Somogy County Kaposi Mor Teaching Hospital, Kaposvár, Hungary
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16
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Glaysher MA, Ward J, Aldhwayan M, Ruban A, Prechtl CG, Fisk HL, Chhina N, Al-Najim W, Smith C, Klimowska-Nassar N, Johnson N, Falaschetti E, Goldstone AP, Miras AD, Byrne JP, Calder PC, Teare JP. The effect of a duodenal-jejunal bypass liner on lipid profile and blood concentrations of long chain polyunsaturated fatty acids. Clin Nutr 2020; 40:2343-2354. [PMID: 33131909 DOI: 10.1016/j.clnu.2020.10.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/16/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Duodenal-jejunal bypass liners (DJBLs) prevent absorption in the proximal small intestine, the site of fatty acid absorption. We sought to investigate the effects of a DJBL on blood concentrations of essential fatty acids (EFAs) and bioactive polyunsaturated fatty acids (PUFAs). METHODS Sub-study of a multicentre, randomised, controlled trial with two treatment groups. Patients aged 18-65 years with type-2 diabetes mellitus and body mass index 30-50 kg/m2 were randomised to receive a DJBL for 12 months or best medical therapy, diet and exercise. Whole plasma PUFA concentrations were determined at baseline, 10 days, 6 and 11.5 months; data were available for n = 70 patients per group. RESULTS Weight loss was significantly greater in the DJBL group compared to controls after 11.5 months: total body weight loss 11.3 ± 5.3% versus 6.0 ± 5.7% (mean difference [95% CI] = 5.27% [3.75, 6.80], p < 0.001). Absolute concentrations of both EFAs, linoleic acid and α-linolenic acid, and their bioactive derivatives, arachidonic acid, eicosapentaenoic acid, docosapentaenoic acid and docosahexaenoic acid, were significantly lower in the DJBL group than in the control group at 6 and 11.5 months follow-up. Total serum cholesterol, LDL-cholesterol and HDL-cholesterol were also significantly lower in the DJBL group. CONCLUSION One year of DJBL therapy is associated with superior weight loss and greater reductions in total serum cholesterol and LDL-cholesterol, but also depletion of EFAs and their longer chain derivatives. DJBL therapy may need to be offset by maintaining an adequate dietary intake of PUFAs or by supplementation. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02459561.
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Affiliation(s)
| | - James Ward
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Madhawi Aldhwayan
- Imperial College London, London, UK; Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Helena L Fisk
- School of Human Development & Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Werd Al-Najim
- Imperial College London, London, UK; Diabetes Complications Research Centre, Conway Institute, School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | | | | | | | | | | | | | - James P Byrne
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Philip C Calder
- School of Human Development & Health, Faculty of Medicine, University of Southampton, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
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Condello G, Chen CY. Minireview: Current status of endoscopic duodenal mucosal resurfacing. Obes Res Clin Pract 2020; 14:504-507. [PMID: 32952067 DOI: 10.1016/j.orcp.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/01/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022]
Abstract
Several strategies are being pursued to overcome the alarming pandemics of obesity and type 2 diabetes (T2D). In recent years, duodenal mucosal resurfacing (DMR) has shown its potential to improve glycemic indices. Following animal studies, which demonstrated feasibility and safety, the procedure has been applied in two human studies. The DMR procedure has been considered feasible and safe in humans with a limited occurrence of complications and adverse events. Reductions in glycated haemoglobin, weight, fasting plasma glucose, and alanine transaminase have been proven at different follow-up time-points. The length of the ablation may induce different outcomes, having the patients with long duodenal segment ablated showed greater beneficial effects. The current evidence does not still prove the apparent insulin-sensitizing mechanism explaining the impact of the DMR procedure on hepatic glucose production. However, the initial findings have demonstrated a positive risk-benefit ratio and an effect on the treatment of metabolic diseases, such as T2D. Future studies should clarify the mechanisms underlying the positive effects and durability of the treatment using controlled trial conditions on larger number of patients.
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Affiliation(s)
- Giancarlo Condello
- Graduate Institute of Sports Training, Institute of Sports Sciences, University of Taipei, Taipei, Taiwan
| | - Chih-Yen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine and Institute of Emergency and Critical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Institutional Review Board, Taipei Veterans General Hospital, Taipei, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases, Guishan, Taoyuan, Taiwan; Chinese Taipei Society for the Study of Obesity, Taipei, Taiwan; World Health Organization-Strategic Initiative for Developing Capacity in Ethical Review/Forum for Ethical Review Committees in the Asian and Western Pacific Region, Pathumthani, Thailand.
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