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

Intragastric balloons for obesity: critical review of device design, efficacy, tolerability, and unmet clinical needs

INTRODUCTION

Sustaining a healthy weight is a challenge and obesity, with associated risk of co-morbidities, is a major public health concern. Bariatric surgery has shown a great promise for many where pharmacological and lifestyle interventions failed to work. However, challenges and limitations associated with bariatric surgery has pushed the demand for less invasive, reversible (anatomically) interventions, such as intragastric balloons (IGBs).

AREAS COVERED

This review critically appraises IGBs used in the past, present, and those in clinical trials, discussing the device designs, limitations, placement and removal techniques, patient eligibility, efficacy, and safety issues.

EXPERT OPINION

Several intragastric balloons were developed over the years that brought excitement to patients and healthcare professionals alike. Albeit good efficacy, there had been several safety issues reported with IGBs such as spontaneous deflation, intestinal occlusion, gut perforation, and mucosal ulcerations. This led to evolution of IGBs design; device material, filling mechanism, fluid type, inflation volume, and further innovations to ease ingestion and removal of device. There are some IGB devices under development aimed to swallow like a conventional pill and excrete naturally through defecation, however, how successful they will be in clinical practice in terms of their efficacy and tolerability remains to be seen in the future.

Prediction Factors of Early Postoperative Bleeding after Bariatric Surgery

PURPOSE

Identifying the possible predictors of postoperative bleeding is advantageous to reduce healthcare costs and promote patients' recovery. The aim of this study was to determine early postoperative bleeding predictors after bariatric surgery.

MATERIALS AND METHODS

This retrospective study was conducted using data from 2260 patients who underwent bariatric surgery. We diagnosed early postoperative bleeding by the following symptoms: abdominal pain, hypotension, tachycardia, hematemesis, melena, decreased hemoglobin level, the need for at least two units of packed red blood cells (PRBCs) transfusion, and reoperation within the first 48 h after surgery.

RESULTS

Our results showed the odds of early postoperative bleeding in laparoscopic Roux-en-Y gastric bypass (LRYGB) were higher than in laparoscopic sleeve gastrectomy (LSG) (OR 3.49, 95% CI 1.79 to 6.80). In addition, prior intragastric balloon (IGB) (OR 3.14, 95% CI 1.18 to 8.34) and oral non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) (OR 5.91, 95% CI 1.79 to 20.63) were positively associated with the occurrence of postoperative bleeding. In contrast, there was an inverse relationship between staple line oversewing and the odds of postoperative bleeding (OR 0.18, 95% CI 0.04 to 0.81). After stratification data based on the type of the surgery, the positive association between IGB and the odds of bleeding was constant in the LRYGB group. In the LSG group, use of non-aspirin NSAIDs was linked to a higher incidence of postoperative bleeding, while oversewing of the staple line lowered the incidence of this event.

CONCLUSIONS

Our results demonstrated a positive association between type of procedure, history of IGB, and oral non-aspirin NSIADs use, as well as an inverse relationship between staple line oversewing and the odds of bleeding after bariatric surgery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

Isolated intestinal transit bipartition: a new strategy for staged surgery in superobesity

OBJECTIVE

biliopancreatic diversion with duodenal switch is a complex, malabsorptive procedure, associated with improved weight loss and metabolic control. Staged surgery with sleeve gastrectomy as the first stage is an option for reducing complications in superobese patients. However, some problems persist: large livers can hamper the surgical approach and complications such as leaks can be severe. Intestinal transit bipartition is a modified and simplified model of biliopancreatic diversion that complements sleeve gastrectomy. It is similar to the duodenal switch, but with less complexity and fewer nutritional consequences. This study assessed the feasibility and safety of isolated transit bipartition as the initial procedure in a two-step surgery to treat superobesity.

METHODS

this prospective study included 41 superobese patients, with mean BMI 54.5±3.5kg/m2. We performed a laparoscopic isolated transit bipartition as the first procedure in a new staged approach. We analyzed weight loss and complications during one year of follow-up.

RESULTS

we completed all the procedures by laparoscopy. After six months, the mean percent excess weight loss was 28%, remaining stable until the end of the study. There were no intraoperative difficulties. Half of the patients experienced early diarrhea, and three had marginal ulcers. There were no major surgical complications or deaths.

CONCLUSION

isolated laparoscopic transit bipartition is a new option for a staged approach in superobesity, which can provide a safer second procedure after effective weight loss over six months. It may be useful particularly in the management of patients with severe obesity.

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.

Advanced Endoscopic Procedures: An Update for Radiologists

OBJECTIVE. The purposes of this article are to familiarize radiologists with endoscopic techniques currently in use and to improve identification of clinically relevant imaging findings and procedural complications related to common endoscopic interventions. CONCLUSION. The frequency of performance of therapeutic endoscopic ultrasound-guided procedures has risen precipitously in the last decade. These procedures are replacing surgical and percutaneous approaches to a variety of disease entities. Recent advances include endoscopic bariatric procedures, endoscopic myotomies, and endoscopic ultrasound-guided drainage procedures.

The role of silent helicobacter pylori infection in intragastric ulcers induced by balloon insertion used for management of obesity

BACKGROUND

Obesity represents one of the common medical disorders that carries a high risk of morbidity and mortality. Insertion of intragastric balloon is one of the recently introduced lines of treatment of obesity. It allows patients to sense abdominal fullness and reduce their food intake. However, gastric ulceration may be a serious adverse effect that may be associated with intragastric balloon insertion.

AIM

To assess the role of silent helicobacter pylori infection in intragastric balloon-induced ulcers and to explore the possible methods for amelioration of this effect.

METHODS

Thirty patients were divided into 2 equal groups; one of them received triple therapy for helicobacter pylori eradication and the other group received placebo treatment. Then, they underwent intragastric balloon insertion. After removal of the balloon, gastroscopy was performed to evaluate the gastric mucosal lesions, if present.

RESULTS

There was significant decrease in the incidence of gastric erosions and ulcerations in the group that received triple therapy for helicobacter pylori eradication compared to the group that received placebo treatment.

CONCLUSION

Eradication of silent helicobacter pylori infection may represent a promising hope to decrease the incidence and improve symptoms of gastric erosions and ulceration that may be associated with intragastric balloon insertion.

Intragastric balloon therapy leads to normalization of brain magnetic resonance spectroscopic markers of diabetes in morbidly obese patients

Elevated brain myo-inositol (m-Ins) concentration (a putative marker of neuroinflammation) has been reported in patients suffering from type 2 diabetes mellitus (T2DM). Obesity alone and T2DM have been found to be associated with a lower concentration of N-acetyloaspartate and N-acetylaspartylglutamate (tNAA, a marker of neuronal integrity, reflecting neuronal loss or metabolic derangement). It is not clear if these changes reverse with weight loss. The intra-gastric balloon (IGB) is an endoscopic bariatric therapy that leads to massive weight loss and improvement of glycemic control. In this study we evaluated if tNAA/tCr and m-Ins/tCr metabolite ratios are affected by weight loss, where tCr is the signal of creatine containing compounds. Twenty-three morbidly obese patients, 12 of them with T2DM (OD) and 11 without T2DM (OB), as well as 11 healthy controls of normal weight (CON), underwent single voxel spectroscopy at 3 T. Spectra were obtained within a region in the left parietal white matter one month before IGB insertion, three months after IGB insertion, and one month after IGB removal. Before IGB insertion, m-Ins/tCr was 15% higher in OD than in OB (p = 0.005) and 12% higher in OD than in CON (p = 0.03). m-Ins/tCr decreased significantly by 8% over the first three months after IGB insertion (p = 0.01) and remained normal after IGB removal. tNAA/tCr was normal in all groups throughout the study, pointing to normal brain metabolism. Normalization of m-Ins/tCr is consistent with remission of neuroinflammation in patients with T2DM. An evaluation of long-term effects of IGB treatment is necessary.