Endoscopic gastric reduction with an endoluminal suturing device: a multicenter prospective trial with 1-year follow-up

BACKGROUND

Obesity is the pandemic disease of this century. Surgery is the only effective treatment but cannot be offered to every patient. Endoscopic sutured gastroplasty is a minimally invasive technique that may potentially fill the gap between surgery and behavioral therapy. In this study, we prospectively investigated the efficacy and safety of a novel suturing device.

METHODS

After a pre-bariatric multidisciplinary work-up, class 1 and 2 obese patients were included. Using a simple triangulation platform, transmural sutures with serosa-to-serosa apposition were performed in the gastric cavity. Patients were followed according to the same routines as those performed for bariatric procedures.

RESULTS

Between November 2015 and December 2016, 51 patients were included across three European Centers. Mean body mass index at baseline was 35.1 kg/m² (SD 3.0). Excess weight loss and total body weight loss at 1 year were 29 % (SD 28) and 7.4 % (SD 7), respectively, for the whole cohort (45 patients). At follow-up gastroscopy, 88 % of sutures were still in place (30 patients). No severe adverse events were observed.

CONCLUSIONS

Endoscopic sutured gastroplasty using this novel device is safe and achieved weight loss results in line with criteria expected for these endoluminal techniques. Further prospective studies vs. placebo or nutritional support are needed.

Transoral gastroplasty for morbid obesity: a multicenter trial with a 1-year outcome

BACKGROUND

Bariatric surgery is associated with specific complications and mortality. Transoral gastroplasty (TOGA) is a transoral restrictive bariatric procedure that might offer the benefits of surgery with a reduced complication rate.

OBJECTIVE

To evaluate the safety and efficacy of TOGA at 12-month follow-up.

DESIGN

Prospective, multicenter, single-arm trial.

SETTING

Two tertiary-care referral medical centers.

PATIENTS

This study involved 67 patients (average age 41.0 years, 47 women, baseline body mass index [BMI] 41.5 kg/m(2); 20 patients with BMI <40).

INTERVENTION

The TOGA procedures were performed by using 2 stapling devices that were used to create a small, restrictive pouch along the lesser gastric curvature. The pouch is designed to give the patient a sustained feeling of satiety after small meals.

MAIN OUTCOME MEASUREMENTS

Excess weight loss, excess BMI loss, safety, and improvements in quality of life, obesity-related comorbidities, and medication use.

RESULTS

Fifty-three patients were available at the 12-month follow-up. Excess BMI loss was 33.9%, 42.6%, and 44.8% at 3, 6, and 12 months, respectively. At 12 months, excess BMI loss was 52.2% for patients with a baseline BMI of <40.0 and 41.3% for patients with a baseline BMI of ≥ 40.0 (P < .05). At 12 months, hemoglobin A(1c) levels decreased from 7.0% at baseline to 5.7% (P = .01); triglyceride levels decreased from 142.9 mg/dL to 98 mg/dL (P < .0001); high-density lipoprotein levels increased from 47.0 mg/dL to 57.5 mg/dL (P < .0001). Two complications occurred: a case of respiratory insufficiency and an asymptomatic pneumoperitoneum treated conservatively.

LIMITATIONS

Small number of patients. Short-term follow-up. Twenty-one percent of patients were not available for the 12-month follow-up.

CONCLUSION

The TOGA procedure allowed a substantial weight loss 1 year after the operation without severe complications. A long-term evaluation is needed before definitive conclusions can be drawn.

Single vs repeated treatment with the intragastric balloon: a 5-year weight loss study

BACKGROUND

Saline-filled intragastric balloons (IB) may be inserted for 6 months to promote weight loss. We aimed to assess potential benefits of repeating IB therapy.

METHODS

One hundred eighteen consecutive subjects (median body mass index, 34.0 kg/m(2); interquartile range [IQR], 31.2-36.9) treated with IB were included in a prospective non-randomized multicenter study.

RESULTS

Nineteen (16%) subjects had repeat IB therapy at their own request, either to prolong first treatment (n = 8) or after a IB-free interval (n = 11). Higher weight loss 3 months after first IB insertion independently predicted repeat therapy (P = 0.008). Median weight loss in subjects who had repeat therapy was lower with second vs first IB (9.0 vs 14.6 kg; 30.4% vs 49.3% excess weight [EW]; P = 0.003). Compared to subjects with single treatment (n = 99), those with repeat treatment (n = 19) had greater weight loss at first IB extraction (14.6 vs 11.0 kg; 49.3% vs 30.7% EW; P = 0.026) and 1 year later (12.0 vs 6.0 kg; 40.9% vs 20.8% EW; P = 0.008) but the difference became less than 2 kg starting at 3 years. At final follow-up (4.9 years; IQR, 3.4-6.7), the whole subject population had lost a median of 2.0 kg (IQR, -3.0 to 10.3) or 6.2% EW (IQR, -8.1 to 31.6) and identical proportions of subjects with single/repeat treatment had >or=10% baseline weight loss (26%) or bariatric surgery (32%).

CONCLUSION

Higher weight loss at 3 months independently predicted repeat IB therapy; weight loss with the second IB was lower compared to first IB. Repeat treatment had no effect on proportions of subjects with >or=10% baseline weight loss or bariatric surgery at final follow-up.

Intragastric balloon for weight loss: results in 100 individuals followed for at least 2.5 years

BACKGROUND AND STUDY AIMS

To determine long-term outcome after treatment with an intragastric balloon for 6 months, with no structured weight maintenance program offered after balloon removal.

PATIENTS AND METHODS

100 consecutive overweight/obese individuals (mean body mass index [BMI] 35.0 +/- 5.6 kg/m (2)) were prospectively followed after endoscopic implantation of a saline-filled intragastric balloon; 97 completed final follow-up at a mean of 4.8 +/- 1.6 years. Successful intragastric balloon therapy was defined as weight loss at 6 months of > or = 10 % of weight at baseline, that remained > or = 10 % until 2.5 years, without bariatric surgery. All analyses followed intention-to-treat principles.

RESULTS

At 6 months, mean weight loss was 12.6 +/- 8.3 kg, 63 individuals had > or = 10 % baseline weight loss; no severe morbidity was detected. During the first and second years following intragastric balloon removal, mean body mass increased by 4.2 +/- 6.8 and 2.3 +/- 6.0 kg, respectively ( P < 0.001 for both year-on-year comparisons). At 2.5 years, intragastric balloon therapy had been successful in 24 participants. At final follow-up (4.8 +/- 1.6 years), 28 had > or = 10 % baseline weight loss, 35 had undergone bariatric surgery (60 % had preoperative mass higher than baseline), and 3 were lost to follow-up; the 34 remaining had lost 1.5 +/- 5.8 kg compared with baseline. During follow-up, 13 had a second intragastric balloon implanted and 13 took sibutramine for short periods.

CONCLUSION

Intragastric balloon therapy was relatively innocuous and associated with successful weight loss and maintenance at 2.5 years in a quarter of participants. It represents a valid option for weight loss.

Safety, feasibility and weight loss after transoral gastroplasty: First human multicenter study

OBJECTIVE

To evaluate the safety and feasibility in human subjects of a new transoral restrictive procedure for the treatment of obesity.

METHODS

The protocol was approved by the institutional review boards (IRBs) of both centers involved, and all patients gave informed consent. Patients met established inclusion criteria for bariatric surgery. The TOGa system (Satiety Inc., Palo Alto, CA), a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curve of the stomach. Patients were hospitalized overnight for observation and underwent barium upper gastrointestinal (UGI) the next morning. Post procedure, all patients were placed on a liquid diet for 1 month and asked to begin an exercise program. Follow-up was carried out at 1 week and 1, 3, 4, 5, and 6 months.

RESULTS

Twenty one patients were enrolled [17 female, age 43.7 (22-57) years, BMI 43.3 (35-53) kg/m(2)]. Device introduction was completed safely in all patients. There were no serious adverse events (AEs). The most commonly reported procedure or device related adverse events were vomiting, pain, nausea, and transient dysphagia. At 6 month endoscopy, all patients had persistent full or partial stapled sleeves. Gaps in the staple line were evident in 13 patients. Patients lost an average 17.6 pounds at 1 month, 24.5 pounds at three months, and 26.5 pounds at 6 months post-treatment [excess weight loss (EWL) of 16.2%, 22.6%, and 24.4%, respectively].

CONCLUSIONS

There is great interest in new procedures for morbid obesity that could offer lower morbidity than current options. Early experience with the TOGa procedure indicates that this transoral approach may be safe and feasible. Further experience with the device and technique should improve anatomic and functional outcomes in the future. Additional studies are underway.

[Strategy and critical analysis of bariatric surgery]

Bariatric surgery has considerably developed during the last 20 years in Belgium. The increase of prevalence of the morbid obesity and the development of multiple surgical procedures widened the spectrum of treatment. If a rigorous selection and a multidisciplinary approach of the patients are inescapable, the various decision-making algorithms plunge the practitioner into a certain confusion. The purpose of this paper is to clarify the advantages and the inconveniences of the different surgical treatments in light of the evolution of the principles and the objective results of the literature. Among the techniques proven and validated in the long run, one can mention the Silastic Ring Vertical Gastroplasty according to Mac Lean by minilaparotomy, the laparoscopic adjustable ring and the more recent gastric by pass. The evaluation of laparoscopic sleeve gastrectomy, and of duodenal switch is on course. The bilio-pancreatic by-pass according to Scopinaro remains strongly controversed. A meta-analysis of the literature confirms the success of the gastric bypass. Regarding to the long term follow-up, the adjustable gastric banding deceives. The sleeve gastrectomy should be analyzed in the long term. The preliminary results of a epidemiologic and financial study within a private hospital of Brussels reveals that the cost effective ratio is in favor the Silastic Ring Vertical Gastroplasty and the laparoscopic adjustable banding, as well in terms of public health support than the charge for the private insurance and the patient. The projection beyond 5 years reverses the tendency to plead in favor of the gastric by-pass. First with the hit-parade of comfort, food diversification, tolerance, gastro-esophageal reflux, and undoubtedly of the rate of recurrence, it supplants the others techniques for sweet eaters. The volume eaters can profit from a sleeve gastrectomy which undoubtedly supplants the Silastic Ring Vertical Gastroplasty responsible for late annular stenoses and reccurences.

Social protection sustainability, prolongation of working life and greater participation of women in the labour market

One of the greatest problems of European societies is the financial sustainability of social protection systems in Europe. Together with Japan, Europe has the highest levels of ageing population in the world. This concern explains the reiterated insistence of the European Commission and the OECD regarding the reforms that governments should undertake. In this paper, reference is made to two of these reforms: prolonging of working life and a greater participation of women in the labour market.

Results of silastic ring vertical gastroplasty more than 6 years after surgery: analysis of a cohort of 214 patients

BACKGROUND

Among the different techniques of surgical treatment for morbid obesity, silastic ring vertical gastroplasty (SRVG) is an alternative, effective and easily reproducible technique. The aim of this study is to evaluate a cohort of patients >6 years after SRVG for morbid obesity.

METHODS

From 1991 to 1996, 273 consecutive patients were eligible for SRVG. The evaluation criteria included weight loss, evolution of co-morbidities, long-term morbidities, satisfaction of patients and quality of life.

RESULTS

Among these 273 patients, 1 patient died in the postoperative period (0.4%). Postoperative morbidities occured in 27 patients (10%). The long-term follow-up involved 213 patients (78%). Late postoperative complications consisted of outlet stoma stenosis (14%), staple-line dehiscence (5.6%) and incisional hernia (8.5%). 23 patients (10%) needed a re-do operation. Co-morbidities drastically improved. BMI fell from 45.3 to 30.7. Failure of SRVG was statistically associated with male gender and super-obese patients. 69% of the patients were satisfied, and 73% would recommend this operation.

CONCLUSION

SRVG is very effective in a selected group of morbidly obese patients.

[The treatment of morbid obesity with gastroplasty]

Morbid obesity is related to a severe decrease in life expectancy. No medical or dietary treatment offers an alternative to control hypertension, apnea syndrome, orthopedic diseases, ..., caused by overweight. With respect to a serious preoperative evaluation and a severe selection (psychologic, dietetic, ...) Silastic Ring Vertical Gastroplasty is considered in our experience (more than 300 cases) and in the literature as the gold standard for surgical treatment of obesity. The long term follow-up (24-66 months) of 100 consecutive operated patients shows a positive response on hypertension (96%), apnea syndrome (92%), diabetes (85%), gastroesophageal reflux (76%), orthopedic diseases (74%) and cardiorespiratory insufficiency (74%). Considering our experience in the medical and surgical management of patients operated in our department or referred from other centers for complications after different procedures, we actually propose SRVG as the treatment of choice for morbid obesity.

Bacterial mutagenic evaluation of Luxabendazole, a new broad spectrum anthelmintic, with the Salmonella typhimurium His- and the Escherichia coli Tryp- reversion tests

Luxabendazole is a new benzimidazole carbamate chemotherapeutic agent, which has proved to be effective against adult and immature stages of the major gastrointestinal nematodes, trematodes and cestodes. The mutagenic properties of Luxabendazole were investigated in the in vitro Ames Salmonella and E. coli tests. The product was tested at concentrations of 0.5, 5, 50, 500, 1250 and 2500 micrograms/plate in the TA1535, TA1538, TA98 and TA100 strains of Salmonella typhimurium, and 0.5, 5, 50 and 500 micrograms/plate in the WP2, WP2uvrA- and its pKM 101-containing derivative CM891 (WP2 uvrA- pKM101) strains of Escherichia coli, with and without S9 microsomal activation (post-mitochondrial liver fraction from Wistar rats pretreated with Aroclor(R)). Positive and negative controls were included in each experiment. From the present study it can be concluded that Luxabendazole, over a dose range of 0.5-2500 micrograms/plate, is unlikely to present a mutagenic hazard, as demonstrated by the Ames test.

[Genotoxic study of commercial dyes with tartrazine base in S. typhimurium his- and E. coli trp-]

We study the genotoxic character of 21 food dyes samples with tartrazine in different trade-marks. Two homologated assays "in vitro" of reverse mutation in S. typhimurium and E. coli are used, with metabolic activation. There is no evidence of mutagenic character in any sample.