The effect of intragastric balloon on plasma ghrelin, leptin, and adiponectin levels in patients with morbid obesity

Gut motility and hormone changes after bariatric procedures

PURPOSE OF REVIEW

Metabolic and bariatric surgery (MBS) and endoscopic bariatric therapies (EBT) are being increasingly utilized for the management of obesity. They work through multiple mechanisms, including restriction, malabsorption, and changes in the gastrointestinal hormonal and motility.

RECENT FINDINGS

Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) cause decrease in leptin, increase in GLP-1 and PYY, and variable changes in ghrelin (generally thought to decrease). RYGB and LSG lead to rapid gastric emptying, increase in small bowel motility, and possible decrease in colonic motility. Endoscopic sleeve gastroplasty (ESG) causes decrease in leptin and increase in GLP-1, ghrelin, and PYY; and delayed gastric motility.

SUMMARY

Understanding mechanisms of action for MBS and EBT is critical for optimal care of patients and will help in further refinement of these interventions.

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

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

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

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

Endobariatrics: a Still Underutilized Weight Loss Tool

Purpose of review

Bariatric and metabolic endoscopic therapies provide an option for patients seeking clinically significant weight loss with fewer adverse events than conventional bariatric surgery. Our aims are to provide an overview of the current state of primary endoscopic treatment options for weight loss and to emphasize the importance of including these therapies when presenting weight loss options to qualified patients.

Recent findings

Bariatric endoscopy procedures are associated with a lower adverse event rate when compared to bariatric surgery and result in more weight loss than most existing pharmacotherapies approved by the Food and Drug Administration.

Summary

Sufficient evidence exists to implement bariatric endoscopic therapies-namely, the intragastric balloon and endoscopic sleeve gastroplasty-as safe and effective treatment options for weight loss when used in combination with lifestyle changes. However, bariatric endoscopy remains an underutilized option by weight management providers. Future studies are needed to identify patient and provider-level barriers to adopting endoscopic bariatric therapies as an option for the treatment of obesity.

Curriculum for bariatric endoscopy and endoscopic treatment of the complications of bariatric surgery: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Obesity is a chronic, relapsing, degenerative, multifactorial disease that is associated with many co-morbidities. The global increasing burden of obesity has led to calls for an urgent need for additional treatment options. Given the rapid expansion of bariatric endoscopy and bariatric surgery across Europe, the European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This curriculum is set out in terms of the prerequisites prior to training, minimum number of procedures, the steps for training and quality of training, and how competence should be defined and evidenced before independent practice. 1: ESGE recommends that every endoscopist should have achieved competence in upper gastrointestinal endoscopy before commencing training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. 2: Trainees in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery should have basic knowledge of the definition, classification, and social impact of obesity, its pathophysiology, and its related co-morbidities. The recognition and management of gastrointestinal diseases that are more common in patients with obesity, along with participation in multidisciplinary teams where obese patients are evaluated, are mandatory. 3 : ESGE recommends that competency in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery can be learned by attending validated training courses on simulators initially, structured training courses, and then hands-on training in tertiary referral centers.

Effects of exercise training on inflammatory and cardiometabolic health markers in overweight and obese adults: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The improvements in inflammation and cardiometabolic health play an important role in the prevention and treatment of obesity. However, the interactions between different exercise training (ET) modalities with inflammatory and cardiometabolic biomarkers are not completely understood. This systematic review and meta-analysis investigated the effects of ET on inflammatory and cardiometabolic health markers in overweight and obese adults.

EVIDENCE ACQUISITION

A systematic search was conducted in PubMed, CINAHL, MEDLINE, Cochrane, Google Scholar, Scopus and Web of Science up to December 15, 2021. Thirty-five studies including 2752 participants were included and analyzed using a random-effects model to estimate weighted mean differences (MD) with 95% confidence intervals (CI).

EVIDENCE SYNTHESIS

The meta-analysis found that ET significantly (P<0.05) increased adiponectin (WMD: 0.72 µg/mL; 95% CI: 0.60 to 0.84; SMD=0.65) and maximal oxygen consumption levels (WMD: 5.26 mL.kg.min; 95% CI: 3.84, 6.69; SMD=1.21). Moreover, ET significantly (P<0.05) reduced fasting insulin (WMD: -2.40 μIU/mL; 95% CI: -3.43 to -1.37; SMD=-0.87), fasting blood glucose (WMD: -5.41 mg/dL; 95% CI: -7.91, -2.91; SMD=-0.66), insulin resistance (WMD: -0.66; 95% CI: -1.08, -0.24; SMD=-0.66) and triglyceride levels (WMD: -10.88 mg/dL; 95% CI: -17.61, -4.15; SMD=-0.91). No significant changes were observed in interleukin-6, tumor necrosis factor-α, leptin, C-reactive protein and cholesterol concentrations. Subgroup analysis by type of training indicated that aerobic and resistance exercise had the most consistent beneficial effects as compared to other modalities.

CONCLUSIONS

Our findings suggest that ET may improve inflammation and cardiometabolic health in overweight and obese adults. Aerobic and resistance training appear to be more beneficial for improving adiponectin, fasting insulin, fasting blood glucose, insulin resistance index and triglyceride levels as compared to other exercise modalities. Further long-term studies are required to confirm and expand on these findings.

Gastric Emptying and Its Correlation With Weight Loss and Body Mass Index in Patients With an Intragastric Balloon: A Prospective Study With Six Years of Follow-Up

Background Obesity is the most well-established and prolonged pandemic in modern society. Having a better understanding of the available tools is important to improve weight loss and make the strategies more productive. This study aims to evaluate the effect of intragastric balloon (IGB) on gastric emptying time, its relationship with weight loss after IGB removal, and weight maintenance after six years. Methodology This prospective study analyzed data from patients undergoing IGB placement. A six-years follow-up was performed and data about weight maintenance were collected. We analyzed the impact of the IGB on gastrointestinal motility and its correlation with weight loss. Results Of the 20 patients included in the study, 52.4% were diagnosed with class I obesity and 47.6% with class II obesity. The mean weight of the patients was 96.5 ± 11.9 kg at baseline, 79.6 ± 11.4 kg at the time of IGB removal, 81.8 ± 9.1 kg at six months, and 93.2 ± 14.3 kg six years after IGB removal. The mean difference between the initial weight and that measured immediately after IGB removal was 16.68 ± 5.71 kg. Regarding gastric emptying time, there was a difference in retention on comparing the measurement before balloon placement to that after the balloon was in place (72.9% vs. 86.8%) after one hour of food intake. Comparing two hours after food intake, patients before IGB placement had a 30.6% food retention, while patients with IGB in place had a 69.2% retention. Conclusions In patients with class I or II obesity, the use of an IGB delayed gastric emptying of foods but showed no direct correlation with weight loss. Weight loss achieved after IGB placement was maintained in half of the patients at a six-year follow-up.

Endoscopic Bariatric and Metabolic Therapies for Liver Disease: Mechanisms, Benefits, and Associated Risks

Nonalcoholic fatty liver disease (NAFLD), including advanced-stage nonalcoholic steatohepatitis (NASH), is currently the most common chronic liver disease worldwide and is projected to become the leading indication for liver transplantation (LT). However, there are no effective pharmacological therapies for NAFLD. Endoscopic bariatric and metabolic therapies (EBMTs) are less invasive procedures for the treatment of obesity and its metabolic comorbidities. Several recent studies have demonstrated the beneficial effects of EBMTs on NAFLD/NASH. In this review, we summarize the major EBMTs and their mechanisms of action. We further discuss the current evidence on the efficacy and safety of EBMTs in people with NAFLD/NASH and obese cirrhotic LT candidates. The potential utility of EBMTs in reducing liver volume and perioperative complications in bariatric surgery candidates is also discussed. Moreover, we review the development of liver abscesses as a common serious adverse event in duodenal-jejunal bypass liner implantation.

Effects on physiologic measures of appetite from intragastric balloon and endoscopic sleeve gastroplasty: results of a prospective study

Background:

Endoscopic bariatric therapies can help address widening management gaps in obesity. Their ability to facilitate weight loss is largely tied to influences on appetite through perturbations of gastric emptying and accommodation. As these tools gain traction in obesity therapy, their physiologic underpinnings require exploration, which may enhance efficacy, tolerance, and patient-tailored care.

Methods:

We prospectively assessed consecutive subjects with fluid-filled intragastric balloons (IGBs) (n = 18) placed between October 2016 and June 2017 or underwent endoscopic sleeve gastroplasty (ESG) (n = 23) from March 2018 to June 2018. Patients underwent physiologic appraisal at 3 months with ¹³C-spirulina-based gastric emptying breath test to determine time to half emptying (T50), as well as maximum tolerated volume (MTV) of a standard nutrient drink test. Changes in T50 and MTV at 3 months were compared with percent total body weight loss (%TBWL) at 3 and 6 months using best-fit linear regression.

Results:

The change in T50 at 3 months correlated with %TBWL at 3 months for IGB (P = 0.01) and ESG (P = 0.01) but with greater impact on %TBWL in IGB compared to ESG (R² = 0.42 vs. 0.26). Change in T50 at 3 months was predictive of weight loss at 6 months for IGB (P = 0.01) but not ESG (P = 0.11). ESG was associated with greater decrease in MTV compared to IGB (340.25 ± 297.97 mL vs. 183.00 ± 217.13 mL, P = 0.08), indicting an enhanced effect on satiation through decreased gastric accommodation. Changes in MTV at 3 months did not correlate with %TBWL for either IGB (P = 0.26) or ESG (P = 0.49) but trended toward significance for predicting %TBWL at 6 months for ESG (P = 0.06) but not IGB (P = 0.19).

Conclusion:

IGB and ESG both induce weight loss but likely through distinct gastric motor function phenotypes, and gastric emptying may predict future weight loss in patients with IGB.

Effect of Novel Gastro-Duodenal Flow Restrictor on Relative Weight Loss and Glucose Levels in a Porcine Model: A Pilot Randomized Study

Endoscopic bariatric and metabolic therapies are promising for obesity. We developed a novel gastro-duodenal flow restrictor (G-DFR) device for relative weight loss and lowering of glucose level and evaluated its safety and efficacy in a porcine model. The G-DFR comprised self-expandable gastro-duodenal partially covered polytetrafluoroethylene (PTFE) metal stent distally attached to a PTFE skirt. Eleven juvenile pigs were randomized into the evaluation of migration (n = 3), mid-term efficacy (n = 5), and control (n = 3) groups. Five pigs showed G-DFR migration at 2, 4, 7, and 10 weeks after placement in the migration and mid-term efficacy group. Compared to the control group, the mid-term efficacy group showed up to 55.4% relative weight loss in 12 weeks. Compared to the case group, the control group showed higher mean ghrelin hormone level from 6 to 12 weeks. Glucose level was significantly lower in the efficacy group than in the control group after 6 weeks. Serum alanine transferase levels and histological collagen deposition were lower in the liver of the case group than in the control group. Although it did not demonstrate consistent performance with respect to migration, a well-positioned G-DFR in the pyloroduodenal portion may lead to relative weight loss, lowering of glucose levels, and improved hepatic parameters.

Effects of Three Different Modes of Resistance Training on Appetite Hormones in Males With Obesity

Purpose

This study explored the effect of three different modes of resistance training on appetite hormones [leptin, ghrelin, cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1), and peptide tyrosine–tyrosine (PYY)], cardiometabolic and anthropometric measures in males with obesity.

Methods

Forty-four males with obesity (age: 27.5 ± 9.4 yrs.; mean weight: 93.2 ± 2.2 kg, body mass index: 32.9 ± 1.2 kg/m²) were randomized to traditional resistance training (TRT, n = 11), circuit resistance training (CRT, n = 11), interval resistance training (IRT, n = 11) or control (C, n = 11) groups. All resistance training groups received 50 min of supervised training per session, three days per week, for 12 weeks. Measurements were taken at baseline and after 12 weeks of training.

Results

Plasma levels of leptin, ghrelin, CCK, and PYY decreased significantly in all three different modalities of resistance training groups when compared to the control group (p < 0.05). GLP-1 increased significantly in both CRT and IRT groups compared to TRT and C groups (p < 0.05). Glucose-dependent insulinotropic polypeptide decreased significantly in CRT and IRT groups compared to the C group (p < 0.05). Adiponectin levels increased significantly in all resistance training groups compared to the C group (p < 0.05).

Conclusion

Overall, CRT and IRT protocols had the greatest impact on appetite hormones compared to individuals who engaged in TRT or did not exercise (C).

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.

Ghrelin Response to Acute and Chronic Exercise: Insights and Implications from a Systematic Review of the Literature

BACKGROUND

Ghrelin is a peptide hormone predominantly produced by the stomach. It exerts a wide range of functions including stimulating growth hormone release and regulating appetite, food intake, and glucose and lipid metabolism. Since physical exercise affects all these aspects, a particular interest is accorded to the relationship between ghrelin and exercise. This systematic review aimed to summarize the current available data on the topic for a better understanding of the relationship.

METHODS

An extensive computerized search was performed in the PubMed and SPORTDiscus databases for retrieving relevant articles. The search contained the following keywords: ghrelin, appetite-related peptides, gastrointestinal peptides, gastrointestinal hormones, exercise, acute exercise, chronic exercise, training, and physical activity. Studies investigating the effects of acute/chronic exercise on circulating forms of ghrelin were included.

RESULTS

The initial search identified 840 articles. After screening, 80 articles were included. Despite a heterogeneity of studies and a variability of the findings, the review suggests that acute exercise suppresses acyl ghrelin production regardless of the participants and the exercise characteristics. Long- and very long-term exercise training programs mostly resulted in increased total and des-acyl ghrelin production. The increase is more noticeable in overweight/obese individuals, and is most likely due to weight loss resulting from the training program.

CONCLUSION

The review suggests that exercise may impact ghrelin production. While the precise mechanisms are unclear, the effects are likely due to blood flow redistribution and weight loss for acute and chronic exercise, respectively. These changes are expected to be metabolically beneficial. Further research is needed for a better understanding of the relationship between ghrelin and exercise.

Impact of intragastric balloon on blood pressure reduction: A retrospective study in Eastern North Carolina

BACKGROUND

Obesity has evolved into a global pandemic. The prevalence of obesity and hypertension in eastern North Carolina are comparable, if not higher, than the national prevalence. In the United States, an estimated 34% of adults have hypertension, the most modifiable risk factor for heart disease and stroke. Lifestyle and pharmacological interventions often do not provide sustained weight loss in obese patients. Bariatric surgery offers an effective weight reduction with short-and long-term health improvements; however, a higher body mass index is associated with higher surgical morbidity and mortality, longer hospitalization, and increasing rates of 30-day readmission due to co-morbidities. Intragastric balloon may bridge a critical gap in the treatment of obesity. The objective of this paper is to showcase the impact of endoscopic bariatric therapy on blood pressure reduction.

AIM

To investigate the impact of intragastric balloon on blood pressure reduction.

METHODS

A retrospective chart review was conducted from January 1, 2016 to January 31, 2019 of consecutive adults who received intragastric balloon therapy (IGBT) in a gastroenterology private practice in Eastern North Carolina. The balloon was introduced into the stomach under endoscopic guidance, and while in the region of the gastric body, inflation with saline was performed at increments of 50 mL until target volume between 500 to 650 mL of saline was attained depending on the patient's gastric capacity. No procedural complications were noted during endoscopic placement and removal of the balloon. A cohort study design was used for data analysis. A total of 172 patients had the Orbera^® intragastric balloon placed. Of the 172 patients who had IGBT at baseline, 11 patients (6.4%) requested early balloon removal due to foreign body sensation (n = 1), and/or intolerable gastrointestinal adverse events (n = 10). The reported gastrointestinal adverse events were nausea, vomiting, abdominal pain, and diarrhea. Eventually, 6-mo follow-up data were available for only 140 patients. As a result, only the 140 available at the 6-mo follow-up were included in the analysis. Univariate, bivariate, and multivariate statistical analyses were performed. Specifically, scatterplots were created to show the relationship between weight and blood pressure, and paired two-sample t-test was carried out to determine if there was a significant reduction in weight before and after the IGBT. Multiple regressions were also performed to examine the association between participants’ total body weight and blood pressure. The outcome variables for the multiple regression were systolic and diastolic blood pressure measured as continuous variables. This was followed by logistic regression analyses to determine the association between total body weight and hypertension at 6-mo post-implantation. The outcome variables for the logistic regression were systolic blood pressure–non-hypertensive (140 mmHg or less) or hypertensive (greater than 140 mmHg), and diastolic blood pressure–non-hypertensive (90 mmHg or less) or hypertensive (greater than 90 mmHg). All authors had access to the study data and reviewed and approved the final manuscript. All statistical analyses were done using STATA 14^®.

RESULTS

The study included 15% males and 85% females. 50% of the patients were white and just over 22% were non-white, and about 27% declined to give their race. The average baseline patients’ weight prior to IGBT was 231.61 Lbs. (SD = 46.53 Lbs.). However, the average patients’ weight after IGBT at the 6-mo follow-up was 203.88 Lbs. (SD = 41.04 Lbs.). Hence, on average, the percent total body weight loss at 6-mo is 11.97 after IGBT. The logistic regression performed revealed that weight (β = 0.0140, P < 0.000) and age (β = 0.0534, P < 0.000) are important factors in determining systolic blood pressure after IGBT. None of the other demographic characteristics or indicated comorbidities were found to be significant.

CONCLUSION

IGBT can be an effective short-term weight reduction modality with a relatively little risk of adverse event. Due to its improvement on systolic blood pressure, IGBT may help reduce cardiovascular risk.

Efficacy of Intragastric Balloons for Weight Loss in Overweight and Obese Adults: a Systematic Review and Meta-analysis of Randomized Controlled Trials

Intragastric balloons (IGB) are the most widely used endoscopic bariatric and metabolic therapies. We aimed to evaluate the efficacy of IGB in comparison with sham or lifestyle interventions for weight loss in overweight and obese patients. This systematic review and meta-analysis was performed following the PRISMA guidelines. Electronic searches were performed to identify randomized controlled trials, which compared IGB with sham or lifestyle intervention. Thirteen RCTs with 1523 patients were included. The difference in mean %EWL and %TWL at follow-up was 17.98%, and 4.40%, respectively, which was significantly higher in the IGB group. Similarly, the difference in mean AWL and BMIL was 6.12 kg, and 2.13 kg/m², respectively. IGB therapy is more effective than lifestyle intervention alone for weight loss in overweight and obese adults.

AGA Technical Review on Intragastric Balloons in the Management of Obesity

Several strategies are available to address the obesity epidemic and range from noninvasive lifestyle interventions to medications and bariatric surgical procedures. Endoscopic bariatric techniques, such as intragastric balloons, have become an attractive alternative as a tool for weight loss that can augment the effect of lifestyle interventions. This technical review includes multiple systematic reviews performed to support a clinical practice guideline by the American Gastroenterological Association on the role of intragastric balloons as a tool for weight loss. The systematic reviews targeted a priori selected clinical questions about the effectiveness and periprocedural care of intragastric balloons and concomitant and subsequent weight-loss strategies.

Endoscopic Balloon Therapy

Intragastric balloon therapy is an endoluminal treatment of obesity that is indicated for patients with moderate obesity (body mass index, 30-35 kg/m²) who have failed to lose weight with lifestyle and medical management. Treatment duration ranges from 4 to 12 months, and percent total body weight loss ranges from 6% to 15% at the time of balloon removal. Adverse events, such as bowel obstruction or gastric perforation, are rare, and early balloon removal because of intolerance is the most common complication. Long-term data are lacking, although weight regain after balloon removal seems to be common.

Weight loss with or without intragastric balloon causes divergent effects on ghrelin cell expression

Objective

The mechanism of action of intragastric balloons in the treatment of obesity is not fully understood. One of the hypotheses is that balloons might have an effect on the fundus, the area of ghrelin production.

Methods

Participants were randomized to a 13‐week period of sham or balloon treatment followed by a 13‐week period of balloon therapy in everyone. Blood samples for ghrelin levels were taken in the fasting state and after a breakfast at the start, after 13 and 26 weeks. Biopsies for ghrelin cell immunohistochemistry were taken from the fundus at endoscopy.

Results

Seven participants entered the balloon–balloon (BB) group and 11 the sham–balloon (SB) group. Despite a considerable weight loss, a median −17.9 kg (interquartile ranges −23.8 to −0.5) in the BB group and −18.3 kg (−22.7 to −14.7) in the SB group, fasting ghrelin and meal‐induced ghrelin response did not change. In the SB group, the number of ghrelin cells increased significantly (p 0.001) from 110.6 (83.6–118.9) to 160.2 (128.5–223.0) while on sham treatment and returned to initial levels, 116.3 (91.7–146.9) (p 0.001), when they received their first balloon. No significant changes in ghrelin cell numbers were observed in the BB group.

Conclusion

In participants without a balloon, weight loss induced an increase in ghrelin cell numbers in the fundus, which was annulled by the subsequent placement of a balloon. The effect of a balloon might be explained by effects on ghrelin cell numbers or ghrelin cell activity.

The Clinical and Metabolic Effects of Intragastric Balloon on Morbid Obesity and Its Related Comorbidities

Obesity is becoming increasingly prevalent worldwide, and its metabolic sequelae lead to a significant burden on healthcare resources. Options for the management of obesity include lifestyle modification, pharmacological treatment, surgery, and endoscopic bariatric therapies (EBTs). Among these, EBTs are more effective than diet and lifestyle modification and are less invasive than bariatric surgery. In recent years, there have been significant advances in technologies pertaining to EBTs. Of all the available EBTs, there is a significant amount of clinical experience and published data regarding intragastric balloons (IGBs) because of their comparatively long development period. Currently, the United States Food and Drug Administration (FDA) has approved three IGBs, including Orbera (Apollo Endosurgery, Austin, TX, USA), ReShape Duo (ReShape Medical, San Clemente, CA, USA), and Obalon (Obalon Therapeutics, Carlsbad, CA, USA). The aim of this review is to summarize the available literature on the efficacy of IGBs in weight loss and their impact on obesity-related metabolic diseases.

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.

Impact of Intragastric Balloon Treatment on Adipokines, Cytokines, and Metabolic Profile in Obese Individuals

BACKGROUND

Obesity is accompanied by adipose tissue remodeling characterized by increased production of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, leptin and resistin and reduced secretion of adiponectin, which favors inflammation, metabolic disorders, and cardiovascular diseases. Although intragastric balloon (IGB) can be considered safe and effective for weight loss, its effect on serum levels of these biomarkers has been evaluated only in a few studies, while no previous study evaluated its effect on circulating levels of resistin, TNF-α, and IL-6. The aim of this study was to evaluate the changes in serum levels of metabolic and inflammatory biomarkers in obese patients submitted to IGB treatment.

METHODS

A prospective observational study involving 42 patients with obesity using IGB for 6 months. The patients were evaluated, on the day of insertion and withdrawal or adjustment of IGB, for the following: anthropometric measures and serum levels of adiponectin, leptin, resistin, TNF-α, IL-6, high-sensitivity C-reactive protein (hs-CRP), glucose, insulin, uric acid, triglycerides, and total cholesterol and fractions.

RESULTS

The body mass index decreased from 35.15 ± 0.41 to 29.50 ± 0.54 kg/m². There was a reduction (p < 0.05) in leptin, hs-CRP, glucose, insulin, HOMA-IR, and triglycerides, while the adiponectin/leptin ratio increased (p < 0.05). Moreover, weight loss presented (1) a positive association with the decrease in leptin, hs-CRP, glucose, insulin, HOMA-IR, uric acid, and total cholesterol and (2) a negative association with the reduction in adiponectin/leptin ratio.

CONCLUSIONS

The present study suggests that 6 months of IGB treatment in obese individuals reduce serum leptin and hs-CRP and improves insulin resistance and lipid profile which may decrease cardiovascular risk.

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.

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.

Fluid-Filled Versus Gas-Filled Intragastric Balloons as Obesity Interventions: a Network Meta-analysis of Randomized Trials

BACKGROUND

Four commercially available intragastric balloons have been used for the management of obesity and underwent randomized controlled trials (RCTs), and we aimed to compare them using a network meta-analysis approach.

METHODS

Several databases were queried from inception to May 26, 2017, and we included RCTs enrolling patients treated with Orbera, Heliosphere, ReShape Duo, and Obalon compared with another balloon, sham, or open-label control group. Two investigators independently abstracted data. A random effects frequentist network meta-analysis and relative ranking of agents using surface under the cumulative ranking probabilities were performed.

RESULTS

We included 15 trials at low risk of bias (only two were head-to-head). Compared to control groups, the two fluid-filled devices were associated with significant outcome (% total body weight loss) at 6 months: Orbera, 6.72% (95% CI, 5.55, 7.89) and ReShape Duo 4% (95% CI 2.69, 5.31). Only one of the two gas-filled devices was associated with significant outcome at 6 months: Obalon 3.3% (95% CI 2.30, 4.30), and not the second: Heliosphere 6.71% (95% CI - 0.82, 14.23). Fluid-filled devices had the highest likelihood of superiority in achieving the outcome at 6 months (96.8%) and at 12 months (96.6%). The quality of evidence was high for comparisons against control.

CONCLUSIONS

Fluid-filled balloons are more likely to produce weight loss compared to gas-filled balloons or lifestyle intervention. However, they may be associated with a higher rate of intolerance and early removal. This information will aid clinicians in device selection and engaging patients in shared decision-making.

Endoscopic Bariatric Therapy: A Guide to the Intragastric Balloon

Intragastric balloons (IGBs) are the most widely available endoscopic bariatric therapy for class I and II obesity in the United States. Although simple in application and reversible by nature, these devices may help patients initiate the important first steps in weight loss maintenance, provided that parallel efforts are in motion to prevent weight recidivism. Too often, therapeutic nihilism stems from unrealistic expectations of a given therapy. In the case of IGBs, this sentiment may occur when these interventions are applied in a vacuum and not within the purview of a multidisciplinary program that actively involves dieticians, endocrinologists, gastroenterologists, and surgeons. There is a clear and present need to apply different tactics in the remissive strategy to control the obesity pandemic, more so in a struggling landscape of an ever-widening gap in bridging interventions. With such demand, the IGB is an available tool that could be helpful when correctly implemented. In this exposition, we summarize the current state of IGBs available worldwide, discuss their mechanism of action, relay evidence for their short- and long-term efficacy, address safety profile concerns, and suggest procedural considerations in the real-world quotidian application.

Endoscopic Interventions in the Treatment of Obesity and Diabetes

Obesity is a global health problem which is on the rise and is strongly associated with the development of type 2 diabetes and other comorbidities. Bariatric surgery is now an established treatment for both these conditions, leading to impressive results in weight loss and glycemic control. More recently, we have seen the development of various endoscopic devices as potential alternatives or adjuncts to bariatric surgery. In this state-of-the-art review, we outline the current landscape of endoscopic treatments available for the management of both obesity and diabetes, including the clinical evidence supporting their use, efficacy, safety, and potential mechanisms of action.

Serum Leptin, Obestatin, and Ghrelin Levels and Gastric Emptying Rates of Liquid and Solid Meals in Non-obese Rats with Roux-en-Y Bypass Surgery or Prosthesis Placement: Implications for the Role of Vagal Afferents

BACKGROUND

The present study aimed to investigate the effects of Roux-en-Y gastric bypass (RYGB) and prosthesis placement on gastric emptying rate in conjunction with serum ghrelin-obestatin-leptin responses in non-obese rats with intact or denervated afferent innervation.

METHODS

Under anesthesia, male Sprague-Dawley rats underwent either sham operation, RYGB, prosthesis, and/or Gregory cannula placement. Three weeks later, liquid or solid gastric emptying tests were performed and serum ghrelin, leptin and obestatin levels were measured.

RESULTS

Both prosthesis placement and RYGB surgery delayed non-nutrient liquid emptying; while solid nutrient emptying was delayed only by RYGB. Nutrient-dependent (acid, hyperosmolal and peptone) delay in liquid emptying was abolished in rats with prosthesis. By vagal afferent denervation, delayed liquid emptying was abolished, while solid emptying was further delayed in rats with prosthesis. Ghrelin and obestatin levels were depressed in prosthesis-placed rats, but RYGB surgery had no impact on both levels. Leptin level was elevated in solid-food-given rats with prosthesis, but not changed in RYGB group, while it was reduced following liquid meal. All the changes observed in ghrelin, obestatin, or leptin levels in response to meal ingestion were reversed with vagal afferent denervation.

CONCLUSIONS

Both RYGB and prosthesis placement had delaying effects on gastric emptying rate of non-obese rats. Our results indicate that the short-term changes in gastric motility and hormone responses induced by volume reduction are reversed by afferent denervation, suggesting that sparing the vagal innervation could be essential for reaching optimum motility and hormone changes expected after bariatric surgery.

Medical devices for the treatment of obesity

Obesity is a major public health concern that leads to numerous metabolic, mechanical and psychological complications. Although lifestyle interventions are the cornerstone of obesity management, subsequent physiological neurohormonal adaptations limit weight loss, strongly favour weight regain and counteract sustained weight loss. A range of effective therapies are therefore needed to manage this chronic relapsing disease. Bariatric surgery delivers substantial, durable weight loss but limited access to care, perceived high risks and costs restrict uptake. Medical devices are uniquely positioned to bridge the gap between more conservative lifestyle intervention and weight-loss pharmacotherapy and more disruptive bariatric surgery. In this Review, we examine the range of gastrointestinal medical devices that are available in clinical practice to treat obesity, as well as those that are in advanced stages of development. We focus on the mechanisms of action as well as the efficacy and safety profiles of these devices. Many of these devices are placed endoscopically, which provides gastroenterologists with exciting opportunities for treatment.

Saponins as adipokines modulator: A possible therapeutic intervention for type 2 diabetes

Development of type 2 diabetes has been linked to β-cell failure coupled with insulin resistance and obesity. Adipose tissue, known as the fat store, secretes a number of hormones and proteins collectively termed adipokines some of which regulate insulin sensitivity. Dysregulation in the secretion of adipokines has been linked to insulin resistance and type 2 diabetes. In this review, we summarized evidence of the role of adipokines with focus on leptin, adiponectin, adipsin, visfatin and apelin in the pathogenesis of type 2 diabetes and discussed the potential of saponins to modify the ill-regulated adipokines secretions, which could promote the use of this class of phytochemicals as potential antidiabetics agents.

Efficacy of intragastric balloon on weight reduction: Saudi perspective

AIM

To evaluate the safety and efficacy of intragastric balloon (IGB) in weight reduction in obese patients referred to a tertiary hospital in the Kingdom of Saudi Arabia.

METHODS

Three hundred and one consecutive obese individuals, who underwent IGB placement during January 2009 to May 2015, were analyzed. The subjects aged 18 to 60 years and had a minimum body mass index (BMI) of 27 kg/m2. The IGB was placed under conscious sedation and kept for 6 mo. Anthropometric measurements were recorded during and after 6 mo of IGB removal.

RESULTS

The body weight, excess body weight, and BMI were significantly reduced at the time of IGB removal and 6 mo later. Body weight loss > 10% was achieved in 224 subjects at removal of IGB. End of treatment success and long-term success were both significantly observed in women (70 vs 11) (71 vs 12.5) respectively. Excess BMI loss was significantly higher in subjects retaining the IGB for over 6 mo both at the removal [43.44 ± 19.46 (n = 221) vs 55.60 ± 28.69 (n = 80); t = 4.19, P = 0.0001] as well as at the end of 6 mo' follow-up [46.57 ± 24.89 (n = 221) vs 63.52 ± 31.08 (n = 80); t = 4.87, P = 0.0001]. Within 3 d of IGB placement, two subjects developed pancreatitis and one subject developed cardiac arrhythmia. Intestinal obstruction due to displacement of IGB occurred in two subjects. All these subjects recovered uneventfully after immediate removal of the IGB.

CONCLUSION

IGB was effective in our cohorts. The observed weight reduction was maintained for at least 6 mo post IGB removal. IGB placement was safe with a satisfactory tolerance rate.

The Impact of Intragastric Balloons on Obesity-Related Co-Morbidities: A Systematic Review and Meta-Analysis

ObjectivesTherapies less invasive than surgery and more effective than lifestyle and pharmacotherapy are needed to contend with the obesity epidemic. Intragastric balloons (IGBs) are a minimally invasive endoscopic weight loss method recently approved for use in the US. The purpose of the study is to assess the effect of IGBs on metabolic outcomes associated with obesity.MethodsMEDLINE, Embase, and Cochrane Database were searched through July 2016. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. Primary outcomes included the change from baseline in metabolic parameters. Secondary outcomes included resolution and/or improvement in metabolic co-morbidities and association with baseline parameters.Results10 randomized controlled trials (RCT) and 30 observational studies including 5,668 subjects were analyzed. There was moderate-quality evidence for improvement in most metabolic parameters in subjects assigned to IGB therapy as compared to conventional non-surgical therapy in RCTs: mean difference (MD) in fasting glucose change: -12.7 mg/dl (95% confidence interval (CI) -21.5, -4); MD in triglycerides: -19 mg/dl (95% CI -42, 3.5); MD in waist circumference: -4.1 cm (95% CI -6.9, -1.4); MD in diastolic blood pressure: -2.9 mm Hg (95% CI -4.1, -1.8). The odds ratio for diabetes resolution after IGB therapy was 1.4 (95% CI 1.3, 1.6). The rate of serious adverse events was 1.3%.ConclusionsIGBs are more effective than diet in improving obesity-related metabolic risk factors with a low rate of adverse effects, however the strength of the evidence is limited given the small number of participants and lack of long-term follow-up.

Future Therapies in Obesity

Although diet and exercise have been the cornerstone of therapy for obesity, efficacy is suboptimal and short lived. Surgical procedures are durable but invasive therapy for obesity. Supplemental therapies for obesity that are minimally invasive, low risk, and effective are needed. Several therapeutic options are being developed that offer obese patients and their health care providers alternatives to what is currently available.

Short-term outcomes of the new intragastric balloon End-Ball® for treatment of obesity

INTRODUCTION

Intragastric balloons (IGBs) have been successfully used to treat obesity for the last 18 years. These balloons are made of different materials and filled with either air or saline. It seems that balloons filled with saline result in more effective weight loss, but are associated with worse tolerance after implantation. In contrast, balloons filled with air are associated with excellent tolerance, but result in less effective weight loss.

AIM

To report the early safety and effectiveness results of the End-Ball^® balloon and to encourage discussions on how to best use this new-generation IGB for endoscopic weight loss management.

MATERIAL AND METHODS

Twenty obese patients (mean age: 40.5 years; mean body mass index: 34.8 kg/m²) were included in a 6-month study. Balloons were inflated with 300 ml of saline containing 5 ml of methylene blue and 300 cm³ of air.

RESULTS

No serious adverse events occurred during treatment. Patients experienced varying degrees of nausea, vomiting (mean: 3.7 times the first day), and abdominal pain after implantation. Six months (23-29 weeks) after End-Ball^® balloon insertion, we observed a significant decrease in body weight (13.9 ±5.1 kg) and percent excess weight loss (37.9 ±12.9%). We also found a significant decrease in the levels of glycated hemoglobin (p < 0.001), C-peptide (p < 0.002), and triacylglycerols (p < 0.001) and an increase in the concentration of high-density lipoprotein cholesterol (p < 0.025).

CONCLUSIONS

The End-Ball^® IGB is a safe and effective treatment for morbid obesity, with positive effects on weight loss and saccharide metabolism.

Endoscopic treatment of obesity

PURPOSE OF REVIEW

Obesity and its comorbid illnesses affect millions worldwide and are one of the major causes of preventable death in the world. Bariatric surgery is currently offered to individuals with a BMI greater than 40 kg/m or greater than 35 kg/m with obesity-related comorbidities such as hypertension or diabetes. Endoscopic bariatric therapies, with their reduced invasiveness and potential reversibility, may complement surgical approaches for achieving weight loss.

RECENT FINDINGS

At the time of this writing, two endoscopically placed intragastric balloons and an endoscopically placed aspiration tube have been approved by the Food and Drug Administration for weight loss purposes. Some devices employ a suturing platform to create plications or to appose two surfaces. Other endoscopic strategies under investigation to treat obesity-related comorbidities such as diabetes include duodenal mucosal resurfacing and creation of a partial jejunoileal diversion using self-assembling magnets.

SUMMARY

Current endoscopic methods for the treatment of obesity utilize various mechanisms, including occupying gastric volume, reducing gastric capacity, altering caloric absorption, or aspirating gastric contents. The long-term outcomes and cost-effectiveness of these strategies remain to be fully elucidated. The landscape of endoscopic bariatric therapies continues to evolve.

Intragastric Balloon for Overweight Patients

BACKGROUND AND OBJECTIVES

Current treatments for overweight adults include reduced-calorie diet, exercise, behavior modification, and selective use of medications. Many achieve suboptimal results with these measures and progress to obesity. Whether the intragastric balloon (IGB), a reversible device approved for treatment of obesity, is a safe and effective option in overweight adults is less well studied. We conducted a study to prospectively analyze the safety and effectiveness of IGB in overweight adults, to compare the results to a simultaneously studied cohort of obese patients, and to share procedural tips for safe IGB placement and removal.

METHODS

One hundred thirty-nine patients were evaluated in this prospective, nonrandomized study. Twenty-six overweight [body mass index (BMI), 26-30)] and 113 obese (BMI > 30) patients underwent outpatient, endoscopic IGB placement under intravenous sedation. The IGB was filled with a 550-900 mL (average, 640 mL) solution of saline, radiological contrast, and methylene blue, with an approximate final proportion of 65:2:1. The patients were followed up at 1-2 weeks and then monthly for 6 months. At 6 months, they underwent IGB removal via an esophageal overtube to optimize safety, and then they were observed for 6 more months.

RESULTS

IGB time was 190 ± 36 d in the overweight patients and 192 ± 43 d in the obese patients. Symptoms of IGB intolerance included nausea and pain, which were transiently present in 50-95% of patients for several days, and necessitated early IGB removal in 6% of patients. There were no procedure-related complications and no IGB-related esophagitis, erosion, perforation, or obstruction. The percentage of excess weight loss (EWL%) was 96 ± 54% in the overweight group and 41 ± 26% in the obese group (P < 0.001).

CONCLUSION

In overweight adults failing standard treatments, IGB placement for 6 months had an acceptable safety profile and excellent weight loss.

Current status of intragastric balloon for obesity treatment

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

Is Endoluminal Bariatric Therapy a New Paradigm of Treatment for Obesity?

The prevalence of obesity has steadily increased throughout recent decades, and along with it, the costs of caring for the associated comorbid conditions has increased as well. Traditional bariatric surgical procedures generally are safe and effective, but patient acceptance, the risk of minor and sometimes serious complications, costs, and insurance coverage have limited the application of these techniques to the treatment of a minority of patients. Endoluminal techniques represent newer approaches to weight loss that can be used independently or in concert with traditional medical and surgical treatments for obesity, with varying degrees of success. It is anticipated that less invasiveness will increase the appeal across a broader representation of patients, perhaps increasing the number of obese patients who choose an intervention over medical management and possibly resulting in a greater total loss of excess body weight across a population; this may reduce costs involved in treating the complications of weight-related comorbidities. Acceptance of endoluminal bariatric procedures and devices will hinge on proving safety, efficacy, and value.

Variation in blood levels of hormones in obese patients following weight reduction induced by endoscopic and surgical bariatric therapies

BACKGROUND

Beneficial clinical effects of weight reduction following bariatric therapies is not fully understood and maybe related to the complex interactions between leptin, adiponectin, visfatin, omentin, and ghrelin. The aim of study was to investigate their timeline changes associated with weight reduction and their profile in relation to the type of treatment and its efficacy.

METHODS

Circulating hormones levels were analyzed before and after endoscopic and surgical procedures in 67 obese patients and compared to non-obese healthy controls.

RESULTS

Obese patients had higher leptin levels and lower levels of adiponectin, visfatin, omentin, and ghrelin than non-obese controls. During the consecutive follow-up visits after treatment, there was a gradual decrease in leptin levels and an increase in adiponectin levels to the levels observed in non-obese. At 50-54weeks, the ghrelin levels were lower and the levels of adiponectin and visfatin, but not omentin, were higher compared to their baseline values. BMI correlated with ghrelin and leptin levels. The percentage of total weight loss correlated positively with adiponectin levels and negatively with leptin levels. Patients with adequate weight loss had a significantly lower leptin concentration than those with treatment failure. There were timeline variations in hormone levels between endoscopic and bariatric therapies, however there were no significant differences in the median their concentration at 50-54weeks after therapy.

CONCLUSION

Our study supports observations that weight loss itself, rather than the procedure type, is responsible for hormonal variation. The leptin levels reflect the best the body weight changes after bariatric therapies.

ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies

The increasing global burden of obesity and its associated comorbidities has created an urgent need for additional treatment options to fight this pandemic. Endoscopic bariatric therapies (EBTs) provide an effective and minimally invasive treatment approach to obesity that would increase treatment options beyond surgery, medications, and lifestyle measures. This systematic review and meta-analysis were performed by the American Society for Gastrointestinal Endoscopy (ASGE) Bariatric Endoscopy Task Force comprising experts in the subject area and the ASGE Technology Committee Chair to specifically assess whether acceptable performance thresholds outlined by an ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) document for clinical adoption of available EBTs have been met. After conducting a comprehensive search of several English-language databases, we performed direct meta-analyses by using random-effects models to assess whether the Orbera intragastric balloon (IGB) (Apollo Endosurgery, Austin, Tex) and the EndoBarrier duodenal-jejunal bypass sleeve (DJBS) (GI Dynamics, Lexington, Mass) have met the PIVI thresholds. The meta-analyses results indicate that the Orbera IGB meets the PIVI thresholds for both primary and nonprimary bridge obesity therapy. Based on a meta-analysis of 17 studies including 1683 patients, the percentage of excess weight loss (%EWL) with the Orbera IGB at 12 months was 25.44% (95% confidence interval [CI], 21.47%-29.41%) (random model) with a mean difference in %EWL over controls of 26.9% (95% CI, 15.66%-38.24%; P ≤ .01) in 3 randomized, controlled trials. Furthermore, the pooled percentage of total body weight loss (% TBWL) after Orbera IGB implantation was 12.3% (95% CI, 7.9%–16.73%), 13.16% (95% CI, 12.37%–13.95%), and 11.27% (95% CI, 8.17%–14.36%) at 3, 6, and 12 months after implantation, respectively, thus exceeding the PIVI threshold of 5% TBWL for nonprimary (bridge) obesity therapy. With the data available, the DJBS liner does appear to meet the %EWL PIVI threshold at 12 months, resulting in 35% EWL (95% CI, 24%-46%) but does not meet the 15% EWL over control required by the PIVI. We await review of the pivotal trial data on the efficacy and safety of this device. Data are insufficient to evaluate PIVI thresholds for any other EBT at this time. Both evaluated EBTs had ≤5% incidence of serious adverse events as set by the PIVI document to indicate acceptable safety profiles. Our task force consequently recognizes the Orbera IGB for meeting the PIVI criteria for the management of obesity. As additional data from the other EBTs become available, we will update our recommendations accordingly.

Effects of the intragastric balloon MedSil on weight loss, fat tissue, lipid metabolism, and hormones involved in energy balance

Background

The prevalence of obesity continues to increase worldwide. Because obesity is associated with a number health-related problems as well as a shortened life span, treating obesity is an important clinical concern. Although various treatments are currently available, many are not efficacious in the long term. Therefore, additional medical treatment options for morbidly obese individuals must be explored. In this study, we examined the effects of the intragastric balloon MedSil® on anthropometric measures and hormones associated with lipid and energy metabolism.

Methods

Twenty-two obese patients underwent insertion of the intragastric balloon MedSil® following a clinical exam, body composition scan, and collection of blood samples. Six months following implantation of the balloon, additional anthropometric and serological measures were taken.

Results

Six months following insertion of the MedSil® balloon, we observed significant decreases in body weight, body mass index, and fat mass. Compared with baseline levels, ghrelin serum levels were increased significantly, while leptin, FGF21, and glycated hemoglobin levels significantly decreased, 6 months after balloon insertion.

Conclusions

The MedSil® intragastric balloon is a safe and effective treatment for morbid obesity, with positive effects on anthropometric measures and lipid metabolism.

Effects of lifestyle interventions that include a physical activity component in class II and III obese individuals: a systematic review and meta-analysis

BACKGROUND

In class II and III obese individuals, lifestyle intervention is the first step to achieve weight loss and treat obesity-related comorbidities before considering bariatric surgery. A systematic review, meta-analysis, and meta-regression were performed to assess the impact of lifestyle interventions incorporating a physical activity (PA) component on health outcomes of class II and III obese individuals.

METHODS

An electronic search was conducted in 4 databases (Medline, Scopus, CINAHL and Sportdiscus). Two independent investigators selected original studies assessing the impact of lifestyle interventions with PA components on anthropometric parameters, cardiometabolic risk factors (fat mass, blood pressure, lipid and glucose metabolism), behaviour modification (PA and nutritional changes), and quality of life in adults with body mass index (BMI) ≥ 35 kg/m2. Estimates were pooled using a random-effect model (DerSimonian and Laird method). Heterogeneity between studies was assessed by the Cochran's chi-square test and quantified through an estimation of the I².

RESULTS

Of the 3,170 identified articles, 56 met our eligibility criteria, with a large majority of uncontrolled studies (80%). The meta-analysis based on uncontrolled studies showed significant heterogeneity among all included studies. The pooled mean difference in weight loss was 8.9 kg (95% CI, 10.2-7.7; p < 0.01) and 2.8 kg/m² in BMI loss (95% CI, 3.4-2.2; p < 0.01). Long-term interventions produced superior weight loss (11.3 kg) compared to short-term (7.2 kg) and intermediate-term (8.0 kg) interventions. A significant global effect of lifestyle intervention on fat mass, waist circumference, blood pressure, total cholesterol, LDL-C, triglycerides and fasting insulin was found (p<0.01), without significant effect on HDL-C and fasting blood glucose.

CONCLUSIONS

Lifestyle interventions incorporating a PA component can improve weight and various cardiometabolic risk factors in class II and III obese individuals. However, further high quality trials are needed to confirm this evidence, especially beyond weight loss.

Fasting and meal-suppressed ghrelin levels before and after intragastric balloons and balloon-induced weight loss

BACKGROUND

Intragastric balloons may be an option for obese patients with weight loss failure. Its mode of action remains enigmatic. We hypothesised depressed fasting ghrelin concentrations and enhanced meal suppression of ghrelin secretion by the gastric fundus through balloon contact and balloon-induced delayed gastric emptying.

METHODS

Patients were randomised to a 13-week period of sham or balloon treatment, followed by a 13-week period of balloon treatment in everyone. Blood samples for ghrelin measurement were taken in the fasting state and every 15 min for 1 h after a breakfast meal at the start, after 13 weeks and after 26 weeks. Patients filled out scales to assess satiety and kept a food diary.

RESULTS

Forty obese patients (BMI 43.1 kg/m(2)) participated. At the start, fasting ghrelin values were low with a blunted ghrelin response to a test meal. The presence of a balloon had no influence on fasting or meal-suppressed ghrelin concentrations. Despite a weight loss of 10 % after 13 weeks and 15 % after 26 weeks, fasting ghrelin concentrations did not change; neither did the ghrelin response to a meal. No relation was found between ghrelin and insulin, satiety, intermeal interval, the number of meals or subsequent energy intake. Ghrelin concentrations were more suppressed with greater weight loss or with balloons located in the fundus.

CONCLUSIONS

Ghrelin concentrations did not change by balloon treatment after 13 and 26 weeks and, unexpectedly, did not rise despite substantial weight loss and negative energy balance. This suppression might be of benefit in the maintenance of weight loss but could not be ascribed to the balloon treatment.

An intragastric balloon produces large weight losses in the absence of a change in ghrelin or peptide YY

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT?: The development of obesity is a multi-factorial process that results in an alteration in the neuroendocrine hormones that help regulate appetite and body weight. Weight loss has been shown to alter this neuroendocrine balance so as to promote weight regain. An intragastric balloon is an effective method to achieve significant weight loss in obese patients and is well suited for those patients who are looking for an alternative to lifestyle modification alone, and those who are not ready or suitable for surgical intervention. Limited research has shown that the weight loss achieved with an intragastric balloon is mediated by altered secretion of the hormones that regulate appetite and weight. WHAT DOES THIS STUDY ADD?: There are currently limited data on the effects of intragastric balloons on appetite and weight-related hormones. In the current study, we have investigated a broad range of gut hormones and adipokines and their response to weight loss induced by differing methods, and the subsequent effect this may have on weight regain. This is an important research area as novel therapies and long-term strategies are needed to counteract the unfavourable changes to the neuroendocrine control of appetite and satiety associated with diet-induced weight loss. This study aims to determine the effect of weight loss achieved with different methods on fasting levels of appetite hormones. Sixty-six obese adults with metabolic syndrome were randomized to intragastric balloon (IGB) for 6 months, with a 12-month behavioural modification programme (IGB group, 'IGBG') or a 12-month behavioural modification programme alone (control group, 'CG'). Anthropometric assessments and blood samples were taken every 3 months and total ghrelin, peptide YY (PYY), adiponectin and leptin were measured. Significant weight-loss differences favouring the IGBG were evident between groups at all time points. Ghrelin increased when the IGB was in situ (+39.3 pmol L(-1) vs. baseline) and returned to baseline after its removal (-34.7 pmol L(-1) ). Adiponectin and PYY levels remained stable in the IGBG, with transient increases noted in the CG. There were no significant between-group differences for ghrelin, PYY or adiponectin. In the IGBG, despite a decrease in leptin at 6 months (-11.7 ng mL(-1) ), levels increased to baseline after IGB removal (-3.7 ng mL(-1) ). In summary, weight loss associated with the IGB did not alter fasting levels of PYY or adiponectin. There was a return of ghrelin and leptin levels to baseline values after IGB removal. No compensatory rise in ghrelin was evident in either group 12 months after initial weight reduction, suggesting that such treatment strategies may lead to better long-term sustainable weight loss.

Effects of exercise training on gut hormone levels after a single bout of exercise in middle-aged Japanese women

The purpose of this study was to investigate the effects of 12 weeks of exercise training on gut hormone levels after a single bout of exercise in middle-aged Japanese women. Twenty healthy middle-aged women were recruited for this study. Several measurements were performed pre and post exercise training, including: body weight and composition, peak oxygen consumption (peak VO2), energy intake after the single bout of exercise, and the release of gut hormones with fasting and after the single bout of exercise. Exercise training resulted in significant increases in acylated ghrelin fasting levels (from 126.6 ± 5.6 to 135.9 ± 5.4 pmol/l, P < 0.01), with no significant changes in GLP-1 (from 0.54 ± 0.04 to 0.55 ± 0.03 pmol/ml) and PYY (from 1.20 ± 0.07 to 1.23 ± 0.06 pmol/ml) fasting levels. GLP-1 levels post exercise training after the single bout of exercise were significantly higher than those pre exercise training (areas under the curve (AUC); from 238.4 ± 65.2 to 286.5 ± 51.2 pmol/ml x 120 min, P < 0.001). There was a tendency for higher AUC for the time courses of PYY post exercise training than for those pre exercise training (AUC; from 519.5 ± 135.5 to 551.4 ± 128.7 pmol/ml x 120 min, P = 0.06). Changes in (delta) GLP-1 AUC were significantly correlated with decreases in body weight (r = -0.743, P < 0.001), body mass index (r = -0.732, P < 0.001), percent body fat (r = -0.731, P < 0.001), and energy intake after a single bout exercise (r = -0.649, P < 0.01) and increases in peak VO2 (r = 0.558, P < 0.05). These results suggest that the ability of exercise training to create a negative energy balance relies not only directly on its impact on energy expenditure, but also indirectly on its potential to modulate energy intake.