Preoperative weight loss by intragastric balloon in super-obese patients treated with laparoscopic gastric banding: a case-control study

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.

Performance Characteristics of Endoscopic Sleeve Gastroplasty in Patients with Prior Intragastric Balloon: Results of a Propensity Score Matched Study

INTRODUCTION

The performance characteristics of endoscopic sleeve gastroplasty (ESG) for weight recurrence after intragastric balloon (IGB) are unknown.

METHODS

This is a retrospective propensity score matched study of ESG after IGB (IGB-to-ESG) vs ESG without prior IGB (ESG-only). The primary outcome was total weight loss (TWL) at 12 months. Secondary outcomes included TWL at 3 and 6 months, 12-month excess weight loss (EWL), procedural characteristics, and safety.

RESULTS

Thirty-nine adults underwent ESG from August 2020 to September 2022 after IGB explantation a median of 24 months (range 2-56 months) prior and a median post-IGB nadir weight increase of 100.0% (range 0 to 3200%). An ESG-only 2:1 age- sex- and BMI- propensity score matched cohort was derived from 649 patients (Pearson's goodness-of-fit: 0.86). TWL for IGB-to-ESG vs. ESG-only was 12.3 ± 13.5% vs. 12.4 ± 3.7% at 3 months (p = 0.97), 10.1 ± 7.1% vs. 15.4 ± 4.6% at 6 months (p < 0.001), and 8.7 ± 7.7% vs. 17.1 ± 5.7% at 12 months (p < 0.001). Twelve-month EWL for IGB-to-ESG vs ESG-only was 27.8 ± 46.9% vs 62.0 ± 21.0% (p < 0.001). There was no difference in mean procedural duration of ESG; however, more sutures were used with IGB-to-ESG vs. ESG-only (7 vs. 6, p < 0.0002). There were no serious adverse events in either cohort.

CONCLUSION

ESG after IGB produces safe, acceptable weight loss but with an attenuated effect compared to ESG alone. Further study is required to understand the factors driving this discrepancy.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Very Low-Calorie Ketogenic Diet (VLCKD) as Pre-Operative First-Line Dietary Therapy in Patients with Obesity Who Are Candidates for Bariatric Surgery

Bariatric surgery is currently the most effective method for achieving long-term weight loss and reducing the risk of comorbidities and mortality in individuals with severe obesity. The pre-operative diet is an important factor in determining patients' suitability for surgery, as well as their post-operative outcomes and success in achieving weight loss. Therefore, the nutritional management of bariatric patients requires specialized expertise. Very low-calorie diets and intragastric balloon placement have already been studied and shown to be effective in promoting pre-operative weight loss. In addition, the very low-calorie ketogenic diet has a well-established role in the treatment of obesity and type 2 diabetes mellitus, but its potential role as a pre-operative dietary treatment prior to bariatric surgery has received less attention. Thus, this article will provide a brief overview of the current evidence on the very low-calorie ketogenic diet as a pre-operative dietary treatment in patients with obesity who are candidates for bariatric surgery.

Ketogenic Diet for Preoperative Weight Reduction in Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) is the most effective treatment in reducing weight and the burden of comorbidities in patients with severe obesity. Despite the overall low mortality rate, intra- and post-operative complications remains quite common. Weight loss before BS reduces surgical risk, but studies are inconclusive regarding which is the best approach to apply. In this review, we summarize the current evidence on the effect of a ketogenic diet (KD) before BS. All studies agree that KD leads to considerable weight loss and important improvements in terms of surgical risk, but populations, interventions and outcomes are very heterogeneous. KD appears to be a safe and effective approach to induce weight loss before BS. However, randomized controlled trials with better-defined dietary protocols and homogeneous outcomes are necessary in order to draw firm conclusions.

Trends in the Utilization of Intragastric Balloons: a 5-Year Analysis of the MBSAQIP Registry

PURPOSE

The use of intragastric balloons (IGBs) for the treatment of obesity was approved by the US Food and Drug Administration in 2015. This study aims to characterize preoperative factors and outcomes of patients undergoing IGB therapy compared to bariatric surgery (non-IGB) and evaluate 5-year trends in IGB use.

METHODS

A retrospective cohort study was performed by extracting data from the MBSAQIP registry between 2015 and 2019. All non-IGB and IGB procedures were included while revisional and emergency surgeries were excluded. Multivariable logistic regression analysis was used to determine independent predictors of patient selection for IGB therapy.

RESULTS

Of 652,927 patients identified, only 2910 (0.4%) underwent IGB therapy. Patients who underwent IGB therapy were older (46.7 ± 11.4 years vs 44.4 ± 12.0 years; p < 0.0001), had lower BMI at baseline (37.0 ± 6.2 kg/m² vs 45.3 ± 7.8 kg/m²; p < 0.0001), and were overall healthier with fewer comorbidities and better functional status. The rate of early nonoperative reintervention was higher in the IGB cohort (7.7% vs 1.1%; p < 0.0001). Age was the only significant predictor of selection for IGB therapy (OR 1.32; 95% CI 1.24-1.37; p < 0.0001). The number of IGB procedures reported between 2016 and 2019 declined significantly (953 (0.62%) vs 418 (0.25%); p < 0.0001).

CONCLUSIONS

Appropriate indications for IGBs appear to be increasingly limited. The ongoing role of IGBs in the treatment of obesity is unclear given the safety and efficacy of modern bariatric surgery and new pharmacological agents for weight loss.

Intragastric Balloon as Bridging Therapy Prior to Bariatric Surgery for Patients with Severe Obesity (BMI ≥ 50 kg/m2): a Systematic Review and Meta-analysis

Bariatric surgery for patients with severe obesity (body mass index (BMI) ≥ 50kg/m²) is technically challenging. Intragastric balloon (IGB) has been proposed for weight loss before bariatric surgery to reduce surgical risks but its efficacy remains unclear. We conducted a systematic review and meta-analysis of the effectiveness of IGB as bridging therapy and assess potential complications. Amongst 2419 citations, 13 studies were included. IGB resulted in a BMI reduction of 6.60 kg/m² (MD=6.60, 95% CI: 5.06-8.15; I²=72%). The total post-procedural complication rate was 8.13% (95% CI: 4.04-13.17%), with majority being balloon intolerance. Overall, IGB is effective as a bridging therapy with adequate procedural safety profile, but further study is needed to evaluate the risk reduction for bariatric surgery and long-term weight-loss outcomes.

Nutritional Management in Bariatric Surgery Patients

The obesity epidemic, mainly due to lifestyle changes in recent decades, leads to serious comorbidities that reduce life expectancy. This situation is affecting the health policies of many nations around the world. Traditional measures such as diet, physical activity, and drugs are often not enough to achieve weight loss goals and to maintain the results over time. Bariatric surgery (BS) includes various techniques, which favor rapid and sustained weight loss. BS is a useful and, in most cases, the best treatment in severe and complicated obesity. In addition, it has a greater benefit/risk ratio than non-surgical traditional therapies. BS can allow the obese patient to lose weight quickly compared with traditional lifestyle changes, and with a greater probability of maintaining the results. Moreover, BS promotes improvements in metabolic parameters, even diabetes remission, and in the quality of life. These changes can lead to an increase of life expectancy by over 6 years on average. The nutrition of people before and after BS must be the subject of indications from a trained staff, and patients must be followed in the subsequent years to reduce the risk of malnutrition and the associated problems. In particular, it is still debated whether it is necessary to lose weight prior to surgery, a procedure that can facilitate the surgeon's work reducing the surgical risk, but at the same time, lengthens preparation times increasing the risks associated with concomitant pathologies. Furthermore, preventing nutritional deficiencies prior to the intervention can improve the results and reduce short- and long-term mortality.

The Procedureless Elipse Gastric Balloon Program: Multicenter Experience in 1770 Consecutive Patients

Purpose

The Elipse balloon is a novel, non-endoscopic option for weight loss. It is swallowed and filled with fluid. After 4 months, the balloon self-empties and is excreted naturally. Aim of the study was to evaluate safety and efficacy of Elipse balloon in a large, multicenter, population.

Materials and Methods

Data from 1770 consecutive Elipse balloon patients was analyzed. Data included weight loss, metabolic parameters, ease of placement, device performance, and complications.

Results

Baseline patient characteristics were mean age 38.8 ± 12, mean weight 94.6 ± 18.9 kg, and mean BMI 34.4 ± 5.3 kg/m². Triglycerides were 145.1 ± 62.8 mg/dL, LDL cholesterol was 133.1 ± 48.1 mg/dL, and HbA1c was 5.1 ± 1.1%. Four-month results were WL 13.5 ± 5.8 kg, %EWL 67.0 ± 64.1, BMI reduction 4.9 ± 2.0, and %TBWL 14.2 ± 5.0. All metabolic parameters improved. 99.9% of patients were able to swallow the device with 35.9% requiring stylet assistance. Eleven (0.6%) empty balloons were vomited after residence. Fifty-two (2.9%) patients had intolerance requiring balloon removal. Eleven (0.6%) balloons deflated early. There were three small bowel obstructions requiring laparoscopic surgery. All three occurred in 2016 from an earlier design of the balloon. Four (0.02%) spontaneous hyperinflations occurred. There was one (0.06%) case each of esophagitis, pancreatitis, gastric dilation, gastric outlet obstruction, delayed intestinal balloon transit, and gastric perforation (repaired laparoscopically).

Conclusion

The Elipse™ Balloon demonstrated an excellent safety profile. The balloon also exhibited remarkable efficacy with 14.2% TBWL and improvement across all metabolic parameters.

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.

Evaluation of endoscopic ultrasound-guided gastric botulinum toxin injections in the treatment of obesity

Background

Obesity is rapidly emerging as one of the greatest challenges of human health. Many randomized trials and open-label human studies described conflicting results of gastric intra-muscular injections of botulinum toxin type A (BTA). Endoscopic ultrasound (EUS) guidance can assure BTA injection into the subserosal layer and muscularis propria of the gastric wall which may optimize the efficacy of injection. The aim of the study is to assess the efficacy and safety of EUS-guided gastric BTA injections in weight reduction for obese subjects.

Results

The present study included 25 patients (2 males and 23 females with mean age 35.84 ± 7.776). For nutrient drink tests, median maximum tolerated volumes (MTVs) decreased from 720 cc (range 480–1680) as a baseline value 2 weeks before BTA injection to 360 cc (range 140–820) at 16 weeks after injection. Mean body weight reduction was 11.92 kg (10.8%) after 16 weeks of BTA injection. Mean body weight continued to decrease during the study period from a baseline value of 110 to 98 kg with significant reduction of mean BMI from baseline value of 41.2 to 36.7 at 16 weeks after BTA injection (p < 0.001). The study was completed without major adverse events.

Conclusion

EUS-guided BTA injection into the antral subserosa and muscularis propria could be an effective technique for weight reduction, or as a bridge for surgery, which can be done safely with minimal complications.

Trial registration

NCT03901040

Diet approach before and after bariatric surgery

Bariatric surgery (BS) is today the most effective therapy for inducing long-term weight loss and for reducing comorbidity burden and mortality in patients with severe obesity. On the other hand, BS may be associated to new clinical problems, complications and side effects, in particular in the nutritional domain. Therefore, the nutritional management of the bariatric patients requires specific nutritional skills. In this paper, a brief overview of the nutritional management of the bariatric patients will be provided from pre-operative to post-operative phase. Patients with severe obesity often display micronutrient deficiencies when compared to normal weight controls. Therefore, nutritional status should be checked in every patient and correction of deficiencies attempted before surgery. At present, evidences from randomized and retrospective studies do not support the hypothesis that pre-operative weight loss could improve weight loss after BS surgery, and the insurance-mandated policy of a preoperative weight loss as a pre-requisite for admission to surgery is not supported by medical evidence. On the contrary, some studies suggest that a modest weight loss of 5-10% in the immediate preoperative period could facilitate surgery and reduce the risk of complications. Very low calories diet (VLCD) and very low calories ketogenic diets (VLCKD) are the most frequently used methods for the induction of a pre-operative weight loss today. After surgery, nutritional counselling is recommended in order to facilitate the adaptation of the eating habits to the new gastro-intestinal physiology. Nutritional deficits may arise according to the type of bariatric procedure and they should be prevented, diagnosed and eventually treated. Finally, specific nutritional problems, like dumping syndrome and reactive hypoglycaemia, can occur and should be managed largely by nutritional manipulation. In conclusion, the nutritional management of the bariatric patients requires specific nutritional skills and the intervention of experienced nutritionists and dieticians.

Response Rates with the Spatz3 Adjustable Balloon

BACKGROUND

Intragastric balloons (IGBs) have demonstrated efficacy; however, the percent of "responders" (> 25% estimated weight loss (EWL) or > 10% total body weight loss (TBWL)-as suggested by FDA) have been less reported. The Spatz3 adjustable intragastric balloon (AIGB) extends implantation to 1 year, decreases balloon volume for intolerance, and increases volume for diminishing effect.

AIM

The aim of this study is to determine the efficacy/responder rate of the Spatz3 AIGB.

METHODS

Implantations of Spatz3 in 165 consecutive patients (pts) in 2 centers were retrospectively reviewed. Mean BMI is 35.7, mean weight (wt) 99.1 kg, and mean balloon volume 495 ml (400-600 ml). Balloon volume adjustments were offered for intolerance and for wt loss plateau.

RESULTS

In total, 165 pts were implanted yielding mean wt loss of 16.3 kg, 16.4% TBWL, and 67.4% EWL. Response (> 25% EWL; 10% TBWL) was achieved in 146/165 (88.5%) of patients. Response rates differed for 136 pts with BMI < 40 (91.2%) and 29 pts with BMI > 40 (69%). Down adjustments in 20 patients (mean - 150 ml) allowed 16/20 (80%) to continue IGB therapy. Up adjustments in 64 patients (mean 5.4 months; mean + 260 ml) yielded additional mean wt loss of 5.7 kg. One gastric perforation (0.6%) occurred in a patient who experienced abdominal pain for 2 weeks. Five patients with small ulcers did not require balloon extraction.

CONCLUSIONS

(1) Within the limitations of a retrospective review, the Spatz3 balloon appears to be an effective wt loss balloon with better response rates in BMI < 40. (2) Up adjustments yielded a mean 5.7 kg extra wt loss. (3) Down adjustments alleviated early intolerance in 80% of patients. (4) These two adjustment functions may be instrumental in yielding a responder rate of 88.5%.

Bridging interventions before bariatric surgery in patients with BMI ≥ 50 kg/m2: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery on patients with body mass index (BMI) ≥ 50 kg/m², historically known as superobesity, is technically challenging and carries a higher risk of complications. Bridging interventions have been introduced for weight loss before bariatric surgery in this population. This systematic review and meta-analysis aims to assess the efficacy and safety of bridging interventions before bariatric surgery in patients with BMI ≥ 50 kg/m².

METHODS

MEDLINE, EMBASE, Web of Science, and Scopus were searched from database inception to September 2018. Studies were eligible for inclusion if they conducted any bridging intervention for weight loss in patients with BMI greater than 50 kg/m² prior to bariatric surgery. Primary outcome was the change in BMI before and after bridging intervention. Secondary outcomes included comorbidity status after bridging interventions and resulting complications. Pooled mean differences (MD) were calculated using random effects meta-analysis.

RESULTS

13 studies including 550 patients met inclusion criteria (mean baseline BMI of 61.26 kg/m²). Bridging interventions included first-step laparoscopic sleeve gastrectomy (LSG), intragastric balloon (IGB), and liquid low-calorie diet program (LLCD). There was a reduction of BMI by 12.8 kg/m² after a bridging intervention (MD 12.8, 95% CI 9.49-16.1, P < 0.0001). Specifically, LSG demonstrated a BMI reduction of 15.2 kg/m² (95% CI 12.9-17.5, P < 0.0001) and preoperative LLCD by 9.8 kg/m² (95% CI 9.82-15.4, P = 0.0006). IGB did not demonstrate significant weight loss prior to bariatric surgery. There was remission or improvement of type 2 diabetes, hypertension, and sleep apnea in 62.8%, 74.6%, and 74.6% of patients, respectively.

CONCLUSIONS

First-step LSG and LLCD are both safe and appropriate bridging interventions which can allow for effective weight loss prior to bariatric surgery in patients with BMI greater than 50 kg/m².

Acute Pancreatitis: A Complication of Intragastric Balloon

PURPOSE

This study was carried out because intragastric balloon (IGB) is a widely used method to combat obesity, and acute pancreatitis complicating IGB is rare and yet to be understood.

METHOD

This study was a retrospective analysis of all patients with a history of IGB insertion, who developed acute pancreatitis before balloon removal.

RESULTS

A total of 4 cases were found, with a mean age of 27±2.9 years. The mean duration of IGB insertion was 2.25±1.25 months, with an average body mass index of 37.7±3.4 kg/m. Abdominal computed tomography visualized signs of pancreatitis with the balloon compressing the pancreatic body. Pancreatitis resolved after endoscopic balloon extraction, with an average aspiration of 607.5±64.5 mL of the fluid used to fill the balloon.

CONCLUSION

Our study demonstrates that acute pancreatitis can complicate IGB and recommends the need to measure amylase and lipase in patients who have a history of IGB insertion and present with a picture suggestive of pancreatitis.

Obesity Treatment with Botulinum Toxin-A Is Not Effective: a Systematic Review and Meta-Analysis

The effectiveness of gastric injections of botulinum toxin-A (BTA) as primary treatment for obesity is not well known since results in literature are discrepant. Hence, we aimed to systematically review and meta-analyze the available data to assess the real effect of BTA therapy. We searched MEDLINE, Embase, Cochrane, SCOPUS, EBSCO, LILACS, and BVS. We considered eligible only randomized controlled trials enrolling obese patients comparing BTA versus saline injections. Our initial search identified 8811 records. Six studies fulfilled eligibility criteria. After critical appraisal, two articles were excluded and we meta-analyzed the remainder. The mean difference for absolute weight loss and BMI reduction were 0.12 [CI 95%, - 1.14, 1.38] and - 0.06 [95% CI, - 0.92, 0.81], respectively. Therefore, we concluded that treatment of obesity with BTA is not effective.

Impact of Intragastric Balloon Before Laparoscopic Gastric Bypass on Patients with Super Obesity: a Randomized Multicenter Study

BACKGROUND

Super obese patients are recommended to lose weight before bariatric surgery. The effect of intragastric balloon (IGB)-induced weight loss before laparoscopic gastric bypass (LGBP) has not been reported. The aim of this prospective randomized multicenter study was to compare the impact of preoperative 6-month IGB with standard medical care (SMC) in LGBP patients.

METHODS

Patients with BMI >45 kg/m² selected for LGBP were included and randomized to receive either SMC or IGB. After 6 months (M6), the IGB was removed and LGBP was performed in both groups. Postoperative follow-up period was 6 months (M12). The primary endpoint was the proportion of patients requiring ICU stay >24 h; secondary criteria were weight changes, operative time, hospitalization stay, and perioperative complications.

RESULTS

Only 115 patients were included (BMI 54.3 ± 8.7 kg/m²), of which 55 underwent IGB insertion. The proportion of patients who stayed in ICU >24 h was similar in both groups (P = 0.87). At M6, weight loss was significantly greater in the IGB group than in the SMC group (P < 0.0001). Three severe complications occurred during IGB removal. Mean operative time for LGBP was similar in both groups (P = 0.49). Five patients had 1 or more surgical complications, all in the IGB group (P = 0.02). Both groups had similar hospitalization stay (P = 0.59) and weight loss at M12 (P = 0.31).

CONCLUSION

IGB insertion before LGBP induced weight loss but did not improve the perioperative outcomes or affect postoperative weight loss.

Filling the Void: A Review of Intragastric Balloons for Obesity

Endoscopic bariatric therapies are predicted to become much more widely used in North America for obese patients who are not candidates for bariatric surgery. Of all the endoscopic bariatric therapies, intragastric balloons (IGBs) have the greatest amount of clinical experience and published data supporting their use. Three IGBs are FDA approved and are now commercially available in the USA (Orbera, ReShape Duo, and Obalon) with others likely soon to follow. They are generally indicated for patients whose BMI ranges from 30 to 40 mg/kg² and who have failed to lose weight with diet and exercise. IGBs have been shown to be safe, effective, and relatively straightforward to place and remove. Accommodative symptoms commonly occur within the initial weeks post-placement; however, major complications are rare. Gastric ulceration can occur in up to 10% of patients, while balloon deflation with migration and bowel obstruction occurs in <1% of patients. The effectiveness of the Orbera and ReShape Duo IGBs ranges from 25 to 50% EWL (excess weight loss) after 6 months of therapy. The use of IGBs is likely to grow dramatically in the USA, and gastroenterologists and endoscopists should be familiar with their indications/contraindications, efficacy, placement/removal, and complications.

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.

Gastric wall changes after intragastric balloon placement: a preliminary experience

ABSTRACT Objective : to evaluate the thickness of the gastric wall at the time of intra gastric balloon (IGB) placement, at the time of its withdrawal and one month after withdrawal. Methods : fifteen morbidly obese patients underwent the introduction of IGB under general anesthesia. In all patients, there was infusion of 500ml of distilled water in the balloon for the test. Measurements of the thickness of the gastric wall were made in the antrum, body and proximal body, using a radial echoendoscope with a frequency of 12MHz and maximum zoom, and its own balloon inflated with 5ml of distilled water. Results : the presence of IGB led to increased wall thickness of the gastric body by expanding the muscle layer. These changes were apparently transient, since 30 days after the balloon withdrawal there was a tendency to return of the wall thickness values observed before the balloon insertion. Conclusion : the use of intragastric balloon for the treatment of obesity determines transient increase in the wall thickness of the gastric body caused by expanded muscle layer.

In search of the ideal patient for the intragastric balloon - short- and long-term results in 70 obese patients

INTRODUCTION

Treating concomitant diseases in obese patients generates costs which are twice as high as the costs of the therapies in individuals with a normal weight. The conservative management of obesity involving lifestyle and dietary modifications and medical treatment shows only short-term efficacy and carries a 90% risk of recurrence. The intragastric balloon causes a permanent feeling of satiety, thus reducing the amount of food consumed by the patient.

AIM

To assess the early and long-term effect of intragastric balloon treatment in obese patients.

MATERIAL AND METHODS

In 2012, we performed 75 intragastric balloon procedures in obese patients. A total of 70 patients were enrolled in the study. The balloon was removed at 6 months. The patients were interviewed 2 years after removal.

RESULTS

Upon balloon removal, mean total weight loss (TWL) was 15.9 kg, and excess weight loss (EWL) was 41 ±19.6% (p < 0.001). Only one patient was classified as a non-respondent. Satisfactory results (> 10% TWL) were achieved in all other patients. The mean body mass index (BMI) reduction was 5.8 kg/m(2) (15.5%) (p < 0.001). Two years later 45 patients still maintained reduced weight, 7 returned to baseline body weight, whereas 18 subjects experienced a full yo-yo effect (mean gain of 2.7 kg). During 2 years following the balloon removal, mean total weight increased by 10.9 kg, and mean BMI increased by 3.9 kg/m(2) (12.5%). A satisfactory effect (> 10% TWL) was achieved in only 19 patients.

CONCLUSIONS

Obesity management with the intragastric balloon is a safe treatment method, which effectively induces weight loss. Poor tolerance and lack of response occurring in some individuals should be taken into consideration. The best results are achieved in women with class 1 obesity.

Effectiveness of intragastric balloon for obesity: A systematic review and meta-analysis based on randomized control trials

BACKGROUND

Obesity has become a worldwide epidemic, and many methods are currently used to reduce obesity. This systematic review shows the effectiveness of the intragastric balloon (IGB) method compared to the sham/diet (s/d) method.

OBJECTIVE

To demonstrate the effectiveness of the IGB method compared to the s/d method.

SETTING

Hospital das Clinicas da Universidade de São Paulo, Brazil, Public Hospital.

METHODS

After searching MEDLINE, Embase, Cochrane, Lilacs, Scopus, and CINAHL, only enrolled randomized control trials comparing IGB/diet with s/d were analyzed. For qualitative analysis, 12 studies were selected, and 9 of these were acceptable for quantitative analysis.

RESULTS

The IGB/diet is more effective than s/d when comparing body mass index (BMI) loss with a mean difference of 1.1 kg/m(2) by the Student's t test and 1.41 kg/m(2) by the meta-analysis, with significant differences in both. It is also more effective in weight loss (WL), with a mean difference of 2 kg by the Student's t test and 3.55 kg by the meta-analysis. In the qualitative analysis of % excess WL (%EWL), the mean %EWL is 14.0% in favor of the IGB group compared to the s/d group by the Student's t test; however, no significant difference was found between these groups by quantitative analysis.

CONCLUSION

Based on randomized control trial data alone, IGB>400 mL is more effective than sham/diet in achieving BMI loss, WL, and %EWL.

Very low-carbohydrate ketogenic diet before bariatric surgery: prospective evaluation of a sequential diet

BACKGROUND

We evaluated the effectiveness of a sequential diet regimen termed the obese preoperative diet (OPOD) in morbidly obese patients with and without type 2 diabetes mellitus (T2DM) scheduled for laparoscopic bariatric surgery.

METHODS

Fifty patients (body mass index 53.5 ± 8.4 kg/m(2)) scheduled for bariatric surgery, including 14 with T2DM, were prospectively enrolled and followed the OPOD regimen: a very low-calorie ketogenic diet for 10 days, followed by a very low-calorie diet for 10 days, and then a low-calorie diet for 10 days. Patients were evaluated at baseline (T0) and after 10 days (T1), 20 days (T2), and 30 days (T3).

RESULTS

Body weight, body mass index, waist circumference, and neck circumference were significantly lower at T1, T2, and T3 than at T0 in the 48 patients who completed the OPOD. Two patients discontinued the OPOD after 4-7 days. In patients with T2DM, fasting plasma glucose levels decreased significantly, enabling reduction of diabetic medications. Plasma and urine ketone levels increased at T1 but were all <1 mmol/L, and hunger decreased during the diet period.

CONCLUSIONS

OPOD, including 10 days of a VLCKD, was safe and effective in morbidly obese patients, and it seems to be promising in morbidly obese patients with and without T2DM scheduled for laparoscopic bariatric surgery.

Tolerance of intragastric balloon and patient's satisfaction in obesity treatment

Introduction

The dietary management of obesity is associated with a high failure rate. Methods which enable the long-term reduction of food intake have been developed. Patients treated with an intragastric balloon may experience some unwanted symptoms during therapy. The severity of these symptoms may result in poor tolerance of treatment, while patients who do not experience these symptoms may refuse to follow dietary modifications. In these cases, weight reduction at the end of treatment may be below expectations.

Aim

To assess the tolerance of intragastric balloon treatment in obese patients as well as their satisfaction with this treatment.

Material and methods

Fifty-seven gastric balloon procedures were performed in 51 females and 6 males aged 17 to 65 years (39.5 ±10.7 years). Baseline weight was 104 ±14.5 kg (78–140 kg), body mass index 37.2 ±4.1 kg/m² (29.8–48.1 kg/m²), mean excess body weight 41.2 ±11.5 kg (20.4–63.1 kg). The balloon was filled with 669 ±25.8 ml of saline solution (550–700 ml). Upon balloon removal 6 months later, the patients completed a 12-question survey.

Results

We obtained 57 surveys. The most common symptoms included vomiting, heartburn, abdominal pain and others. Twenty-two patients reported > 2 symptoms. Two patients were symptom-free. The mean duration of symptoms was 24.8 days. Patients reported better control of hypertension, diabetes and resolution of obstructive sleep apnoea and joint symptoms. Only 14 patients did not observe any significant improvement in their bodily function. Fifty-four patients expressed satisfaction after treatment, 6 patients were dissatisfied with the weight loss, and 5 patients would not opt for balloon re-treatment.

Conclusions

The balloon treatment is a safe and well-tolerated therapy with a low complication rate.

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.

Complications of laparoscopic versus open bariatric surgical interventions in obesity management

With the epidemic of obesity fast spreading its grasp throughout the world, the medical professionals of diverse facilities need to be called on for better management to prevent its further progression. In particular, the gastroenterologists have a major role to play in all aspects of obese patient care. They should be able to recognize and treat obesity and associated disorders through the understanding and assessment of the various benefits and risks linked with a particular type of obesity treatment option. While treating these problems, a better understanding of the physiologic and anatomic alterations that might be associated with the treatment procedure and the weight loss-linked problems in association with the method of surgical intervention need to be weighed. Morbid obesity has been efficaciously treated by bariatric surgery promoting weight loss considerably and reducing the obesity-associated risks such as certain cancers, diabetes, cardiovascular disease, and all-cause mortality. Bariatric surgery has been performed traditionally through open method or, the more recent and popular form, laparoscopically that involves only a small incision in the abdomen. The laparoscopic bariatric surgery has become the surgical method of choice since its introduction in 1993 and has immediately crossed open surgery in terms of popularity. Drastic numbers came out when the two methods were compared for their applicability during a 3-year period in the United States. Only 6,000 reported open gastric bypass surgeries were recorded, but the number soared to nearly 16,000 for laparoscopic gastric bypass surgeries. The laparoscopic method has been found to be associated with much reduced complications and hospital stay along with lower cases of mortality as suggested by small randomized controlled trials and observational studies. However, these facts need to be reassessed through large-sized controlled trials and population-based studies. In addition, the previously ignored complications associated with laparoscopic methods should be studied in detail. Since the cases of obesity have been ever increasing and bariatric surgery is also gaining in popularity, it is important that the safest procedure should be identified. The main objective of this review was to compare the benefits and risks associated with open versus laparoscopic mode of bariatric surgery with a greater focus on the laparoscopic method. Although there are few reviews that have compared the two methods, none have focused on the complications of the two approaches. All these aspects have been dealt in detail here.

Bowel perforation due to break and distal passage of the safety ring of an adjustable intra-gastric balloon: A potentially life threatening situation

A 45-year-old man of Middle Eastern origin, morbid obese, with a body mass index of 39 had an intra-gastric balloon, filled with 500 mL of saline/methylene blue and intended as definite therapy, inserted some 8 wk previously. He was admitted to the emergency department with abdominal cramps. An ultrasound of the abdomen was performed in ER which confirmed the balloon to be in place without any abnormality. He was discharged home on symptomatic medication. Patient remains symptomatic therefore he reported back to ER 2 d later. Computed tomography scan was performed this time for further evaluation which revealed a metallic ring present in the small bowel while the intra-gastric balloon was in its proper position. There was no clinical or radiological sign of intestinal obstruction. Patient was hospitalized for observation and conservative management. The following night, patient experienced sudden and severe abdominal pain, therefore an X-ray of the abdomen in erect position was done, which showed free air under the right dome of diaphragm. Patient was transferred to O.R for emergency laparotomy. There were two small perforations identified at the site of the metallic ring entrapment. The ring was removed and the perforations were repaired. Due to increasing prevalence of obesity and advances in modalities for its management, physicians should be aware of treatment options, their benefits, complications and clinical presentation of the known complications. Physicians need to be updated to approach these complications within time, to avoid life-threatening situations caused by these appliances.

Laparoscopic gastric bypass vs. sleeve gastrectomy in the super obese patient: early outcomes of an observational study

BACKGROUND

Super obesity [body mass index (BMI) > 50 kg/m2] can yield to higher morbidity/mortality in bariatric surgery, this could be related to patient's characteristics and/or surgeon's experience. In morbid obesity, both techniques proved to have a positive impact and sometimes comparable outcomes during the first 2 years. This has not been clearly analyzed in the super obese patient.

METHODS

Retrospective study comparing the records of 77 consecutive super obese patients (BMI: 50-59.9 kg/m2) submitted to either laparoscopic gastric bypass (LGBP, n = 32) or laparoscopic sleeve gastrectomy (LSG, n = 45) between 2010 and 2012 at a single institution. The primary objective was to analyze baseline demographics, comorbidities, operative outcomes, and early complications (<30 days). Secondarily, weight loss [BMI and % excess weight loss (%EWL)] was also described and compared during the first year.

RESULTS

Female sex comprised 72.7 % of all cases. Both groups had comparable BMI (52.7 ± 2.1 kg/m2 for LGBP vs. 53.87 ± 2.8 kg/m2 for LSG; p = 0.087) and homogeneous baseline characteristics. Operative time was lower for the LSG group (113.1 ± 35.3 vs. 186.9 ± 39 min for LGBP; p ≤ 0.001). Overall, early complications were observed in 16.8% of patients (LGBP 9% vs. LSG 22%; p = 0.217). There were four major complications (two in each group), with two reinterventions. Weight loss (%EWL) at 6, 9, and 12 months was significantly higher in the LGBP group (51.6 ± 12.9%, 56.5 ± 13%, 63.9 ± 13.3%, respectively) than in the LSG group (40 ± 12.8%, 45.1 ± 15.5%, 43.9 ± 10.4%, respectively).

CONCLUSIONS

Just like in morbid obesity, LGBP and LSG are effective and safe procedures in super obese patients. LGBP had better weight loss at 1 year.

One-year adjustable intragastric balloons: results in 73 consecutive patients in the U.K

BACKGROUND

Most intragastric balloons have 6-month approval. We report results with the Spatz Adjustable Balloon: approved for 12 months and adjustable.

METHODS

Seventy-three patients (mean: age 45.5; weight 114.5 kg; BMI 36.6 kg/m2) scheduled for 1-year implantation with Spatz balloon (mean volume 417 ml saline). Adjustments performed for early intolerance and weight loss plateau.

RESULTS

Three patients failed insertion. There were 21 early removals (4 intolerant refusing adjustment; 3 deflations; 14 satisfied patients) leaving 49 patients at 12 months. Results of 70 patients (49 patients at 12 months and 21 patients at <12 months) were a mean 21.6 kg weight loss; 19% weight loss; and 45.7% EWL (excess weight loss). Ten intolerant patients were adjusted and lost additional mean 13.2 kg. Fifty-one patients with weight loss plateau scheduled for adjustment: adjustments failed in 6 and non-response in 7. The adjusted 38 patients lost an additional mean 9.4 kg and at extraction had mean 40.9% EWL with 18.7% weight loss. Three catheter impactions required surgical extraction, and three deflated balloons didn't migrate beyond stomach.

CONCLUSIONS

The Spatz balloon is an effective procedure without mortality; however, it carries a risk of catheter impaction necessitating surgical extraction (4.1%). The failure rate--4.1%; intolerance without ability to adjust balloon--5.5%; major complications occurred in 3 (4.1%); minor (balloon deflations) in 3 (4.1%), and 2 asymptomatic gastric ulcers at extraction (2.7%). The longer implantation period and adjustment option combine to produce greater weight loss, albeit <10% weight loss beyond the pre-adjustment weight loss.

Development of minimally invasive techniques for management of medically-complicated obesity

The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this complex disorder. The development of new laparoscopic and minimally invasive treatments for medically-complicated obesity has made it essential that gastrointestinal physicians obtain a thorough understanding of past developments and possible future directions in bariatrics. New laparoscopic advancements provide patients and practitioners with a variety of options that have an improved safety profile and better efficacy without open, invasive surgery. The mechanisms of weight loss after bariatric surgery are complex and may in part be related to altered release of regulatory peptide hormones from the gut. Endoscopic techniques designed to mimic the effects of bariatric surgery and endolumenal interventions performed entirely through the gastrointestinal tract offer potential advantages. Several of these new techniques have demonstrated promising, preliminary results. We outline herein historical and current trends in the development of bariatric surgery and its transition to safer and more minimally invasive procedures designed to induce weight loss.

One year adjustable intragastric balloon: safety and efficacy of the Spatz3 adjustable balloons

Background: The Spatz3 Adjustable balloon system is approved for 1 year implantation and allows multiple changes in the balloon volume during the course of implantation.Other intragastric balloons are currently approved for 6 months and their balloon volumes cannot be adjusted after implantation.Aim: To determine the efficacy and safety of the Spatz3 adjustable balloon system.Methods:  Seventy seven consecutive patients (66 females and 11 males) in two medical centers were implanted with the Spatz3 adjustable balloon device and were followed prospectively. The patients’ mean BMI was 37.2; the mean weight was 108.7 kg; the mean age was 41 (16-68); the mean balloon volume was 469 ml (450-500 ml). Adjustments were made for intolerance or weight loss plateau.Results: The mean weight loss at 1 year was 17.2 kg with 15.9 % weight loss and 42.9 % Excess Weight Loss (%EWL). Eighteen patients underwent balloon volume adjustments: three downward adjustments of 100 -150 cc which alleviated early intolerance; 15 upward adjustments (mean 320 ml; range 200-500) at a mean 4.1 months (range 2-5 months) yielded additional mean wt loss of 8.2 kg (range 0-25 kg) after the adjustment. Three balloons were removed before the 1 year completion date due to intolerance and three others were removed for other reasons (pregnancy, gall bladder surgery, and alcoholism). There was one episode of gastric ulceration which required endoscopic therapy and balloon removal. There were no deflations or perforations.                                                                                                                                                            Conclusions: The Spatz3 adjustable balloon is a safe and effective treatment for weight loss. The adjustability function can yield greater weight loss for those who show weight loss plateau and can mitigate intolerance.

Endoscopic treatment: the past, the present and the future

The obesity epidemic asks for an active involvement of gastroenterologists: many of the co-morbidities associated with obesity involve the gastrointestinal tract; a small proportion of obese patients will need bariatric surgery and may suffer from surgical complications that may be solved by minimally invasive endoscopic techniques; and finally, the majority will not be eligible for bariatric surgery and will need some other form of treatment. The first approach should consist of an energy-restricted diet, physical exercise and behaviour modification, followed by pharmacotherapy. For patients who do not respond to medical therapy but are not or not yet surgical candidates, an endoscopic treatment might look attractive. So, endoscopic bariatric therapy has a role to play either as an alternative or adjunct to medical treatment. The different endoscopic modalities may vary in mechanisms of action: by gastric distension and space occupation, delayed gastric emptying, gastric restriction and decreased distensibility, impaired gastric accommodation, stimulation of antroduodenal receptors, or by duodenal exclusion and malabsorption. These treatments will be discussed into detail.

[Intraluminal/endoscopic procedures in the treatment of obesity]

Few effective therapeutic tools are currently available to fight the increasing prevalence of obesity and its associated comorbidities. Bariatric surgery is the only treatment with proven long-term effectiveness, but is associated to a high surgical risk and significant economic costs because of its technical complexity and the characteristics of patients. This is leading to development of new endoscopic procedures with less clinical risks and economic costs, while maintaining the benefits in terms of morbidity and mortality, which could even serve as a bridging element before surgery in cases where this is unavoidable, allowing for preoperative weight loss and control of comorbidities in order to improve anesthetic risks and possible complications. The purpose of this review was to analyze the most relevant and promising endoscopic techniques currently available.

Assessment of the knowledge of GPS considering the surgical treatment of obesity

Bariatric surgery is currently the only effective treatment option for morbidly obese patients. There has been observed a considerable disproportion between the number of procedures conducted in Poland and the number of patients requiring such treatment. There are no studies assessing bariatric knowledge among general practitioners who play crucial role in polish health care system. The aim of the study was to assess the knowledge of general practitioners regarding bariatric surgery.

MATERIAL AND METHODS

An anonymous questionnaire conducted among 282 general practitioners in 2010-2011 during local educational conferences. The questionnaire consisted of 10 questions relating to fundamental issues of bariatric surgery.

RESULTS

Only one twelfth (8.1%) of the general practitioners questioned knows the indications for bariatric surgery, can apply them, and has epidemiological awareness. 61.5% of general practitioners know the surgical procedures used for the treatment of obesity, whereas 58% of them show the knowledge of surgical technique in which they are performed. Only 23% of general practitioners were aware that bariatric surgery decreases cancer risk. 92% of the participants noticed a necessity of education regarding the surgical treatment of obesity.

CONCLUSIONS

Bariatric knowledge among general practitioners is not adequate to scientific research results published during the last years. Most general practitioners who participated in our study are aware of that and are awaiting for educational programmes focused on this issue.

Short- and long-term efficacy of intragastric air-filled balloon (Heliosphere® BAG) among obese patients

BACKGROUND

Obesity is an increasing health problem worldwide. The intragastric balloon as a temporary endoscopic treatment of obesity can play an important role among the aforementioned group of obese individuals. It can also be used as a preoperative test before subjecting patients to restrictive bariatric surgery. Furthermore, the intragastric device may be applied to patients affected by severe obesity as a "bridge treatment" before they undergo major surgery in order to reduce chances of operation-related risks. To date, there are insufficient data in the literature on the long-term results of the intragastric balloon.

METHODS

Our study includes an analysis of our experience with Heliosphere® BAG from 2006 through to 2010, concerning early weight loss and weight loss maintenance over at least 18 months since the device's removal. The 32 patients who completed the 6-month treatment had recorded a mean weight loss of 12.66 kg and a mean overweight loss of 24.37 % (SD, 12.74).

RESULTS

A total of 16 patients are subjected to an 18-month follow-up. Their pretreatment and long-term body mass index (BMI) were calculated: 6 months later, when devices were removed, they showed a mean weight of 99.75 kg (SD, 17.90; p < 0.001) and a mean weight loss of 13.62 kg and 26.14 % (SD, 12.79). 18 months after removing Heliosphere® BAG, the 16 patients' mean BMI was 37.28 kg/m² (SD, 5.41; p = 0.004), with a mean weight of 103.56 kg (SD 17.25; p = 0.0125), and a mean weight loss of 9.8 kg or 18.2 % (SD, 12.07).

CONCLUSIONS

Heliosphere® BAG enables modest short-term weight loss with little side effects, although mid/long-term follow-up may entail partial weight gain. We believe it can be considered a useful bridge treatment in bariatric surgery in order to reduce chances of preoperative risks.

Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient

OBJECTIVE

To provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS).

RESEARCH METHODS AND PROCEDURES

Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail.

RESULTS

We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well-defined postsurgical diet progression.

DISCUSSION

Obesity-related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short- and long-term risks include: comprehensive medical screening; appropriate pre-, peri-, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long-term nutrition education/counseling.

A review of unmet needs in obesity management

The prevalence of obesity continues to escalate in the USA; however, there is no consensus regarding the optimal therapy for obesity. For the vast majority of severely obese patients, conventional medical therapies (i.e., diet, exercise, behavioral counseling) often fail over the long term. Existing pharmacotherapy adjunctive to behavioral therapy has limited effectiveness and an imperfect safety record. In contrast, bariatric surgery has a high degree of weight loss efficacy, yet only a small fraction of the qualifying obese population undergoes these procedures because of the associated perioperative risks and potential late complications. In addition, the role of bariatric surgery is unclear in certain patient populations, such as patients with lower body mass index (BMI, 30-35 kg/m(2)), the high-risk super-super obese patients (BMI > 60), the morbidly obese adolescent, and obese patients requiring weight reduction in preparation for other procedures, such as orthopedic, transplant, or vascular surgeries. In these circumstances, there is a need for an effective but less invasive treatment to bridge the gap between medical and surgical therapy. This review examines current treatment outcomes, identifies prominent areas of unmet clinical needs, and provides an overview of two minimally invasive "temporary procedures for weight loss" that may eventually address some of the unmet needs in obesity management.

Prospective, randomized, multicenter study evaluating safety and efficacy of intragastric dual-balloon in obesity

BACKGROUND

Intragastric balloons are designed to occupy space within the stomach and induce satiety. The present study evaluated the safety and efficacy of an intragastric dual balloon as an adjunct to diet and exercise in obese patients compared with diet and exercise alone.

METHODS

After approval from the institutional review board, patients provided written consent and were randomized to the treatment group (TG) or control group (CG) in a 2:1 ratio. Three sites randomized a total of 30 patients to the TG (n = 21) or CG (n = 9). Patients randomized to the TG underwent endoscopic placement of the dual balloon. Both groups received similar diet and exercise counseling. After 24 weeks, the device was removed. Patient weight, adverse events, and quality of life data were evaluated throughout the 48-week study duration.

RESULTS

Our patient population included 26 women and 4 men aged 26-59 years. At 24 weeks, the mean excess weight loss in the TG and CG was 31.8% ± 21.3% and 18.3% ± 20.9%, respectively (P = .1371). At 48 weeks, 24 weeks after device removal, the TG maintained 64% of their weight loss. No deaths, unanticipated adverse effects, early removals, balloon deflations, or balloon migrations occurred. In the TG, 4 patients were readmitted for severe nausea, 1 had asymptomatic gastritis at balloon removal, and 1 patient experienced transient hypoxia during device removal.

CONCLUSION

In the present small study, the dual balloon proved easy to use, was associated with a trend toward greater weight loss than the CG, and demonstrated a good safety profile.

Preoperative weight loss with intragastric balloon decreases the risk of significant adverse outcomes of laparoscopic gastric bypass in super-super obese patients

BACKGROUND

Extreme obesity increases morbi-mortality in bariatric surgery. We previously showed that significant weight loss can be obtained within 3 months in super-super obese patients (BMI > 60 kg/m(2)) with an intragastric balloon (IGB). Here, we explored the potential benefit of preoperative IGB on the outcome of laparoscopic gastric bypass (LGBP) in super-super obese patients.

METHODS

In this case-control study, we compared the records of 60 consecutive super-super obese patients (66.5 ± 3.4 kg/m(2)) submitted to a LGBP between 2004 and 2009, with preoperative IGB (n = 23, cases) or without (n = 37, controls). We analyzed the clinical outcome of surgery and a composite end point of significant adverse events defined as the presence of at least one of the following conditions: conversion to laparotomy, intensive care unit stay for more than 2 days, and overall hospital stay superior to 2 weeks.

RESULTS

All baseline clinical and biological characteristics were homogenous between both groups. IGB was maintained during 155 ± 62 days and induced a loss of 5.5 ± 1.3 kg/m(2) (11.2 ± 3.2% of excess body mass index) at the time of LGBP, associated with a decrease in systolic blood pressure and gamma-glutamyl transpeptidase level (p < 0.05 vs. baseline). Operative time was lower in the IGB group (146 ± 47 vs. 201 ± 81 min in controls; p < 0.01). Significant adverse events occurred less frequently after LGBP in the IGB group (2 vs. 13 in controls; p < 0.05). All patients were alive at 1 year and overall weight loss was similar in both groups (52.4 ± 17.3 vs. 50.3 ± 12.7 percent of excess BMI loss in controls; NS).

CONCLUSIONS

IGB prior to LGBP in super-super obese patients significantly reduced excess BMI. It was associated with a shorter operative time and a lower overall risk of significant adverse outcomes.