Endoscopic treatment: The past, the present and the future

doi:10.1016/j.bpg.2014.07.009

Best Practice & Research Clinical Gastroenterology

Volume 28, Issue 4, August 2014, Pages 685-702

https://doi.org/10.1016/j.bpg.2014.07.009 Get rights and content

Abstract

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.

Section snippets

Intragastric balloon treatment

Intragastric balloons have been used for over 35 years. Although being available for 3 decades, intragastric balloon treatment is not covered by the existing evidence-based guidelines. This is partly the result of ineffective and hazardous balloons in the 1980s such as the FDA approved Garren-Edwards Gastric Bubble (GEGB). In GEGBs, deflations occurred in 31% which needed surgical interventions in 2.3%. Gastric ulcers were seen in 26% and the balloon was not tolerated in 7% [12].

With the

The duodenojejunal bypass sleeve or duodenojejunal bypass liner (DJBS or DJBL)

The bypass of duodenum and proximal jejunum by the duodenojejunal bypass sleeve is a totally different concept which, in addition to early satiety and delayed gastric emptying, aims at creating a duodenojejunal bypass. By endoscopy a guide-wire is introduced into the duodenum. The device which consists of a capsule at the distal end, holding the sleeve and the anchor, is advanced into the small bowel under fluoroscopy. First, the impermeable 60-cm Teflon sleeve is deployed by pushing the inner

Botulinum Toxin A (BTA) injection

Botulinum Toxin A (BTA) is produced by Clostridium botulinum. It inhibits acetylcholine release at the neuromuscular junction and selectively inhibits the activity of cholinergic nerves and smooth and striated muscles. When injected in the antrum it delays gastric emptying and induces satiety by means of a pharmacologically induced gastroparesis. When injected in the fundus, BTA was hypothesized to decrease gastric accommodation and ghrelin secretion and to induce an early sensation of satiety

SatiSphere

SatiSphere is a new endoscopically implantable device designed to delay transit time of nutrients through the duodenum [98]. It consists of a 1 mm nitinol wire with several mesh spheres mounted along its course. It is released in the duodenum and made to stay in place by pigtail endings in the antrum and down to the ligament of Treitz, mimicking the anatomy of the duodenal C loop configuration. Thirty-one patients were included, 21 in the device group and 10 in the control group, with scheduled

Aspiration therapy

Endoscopic aspiration therapy involves the placement of a gastrostomy tube via the pull technique for PEG placement and an AspireAssist siphon assembly to aspirate gastric contents 20 minutes after a meal [99]. Exclusion criteria, additionally to those mentioned in Table 1, consisted of eating disorders, major depression, a history of gastrointestinal diseases or previous gastric surgery that increased the risk of gastrostomy placement. Eighteen obese subjects were randomised to 1-year of

Endoscopic bariatric treatment

In contrast to the previously discussed endoscopic options to treat obesity, which are mostly at the disposal of and practicable by endoscopist but have the disadvantage of limited durability, the gastric volume reduction devices require high endoscopic skills and time and are in its infancy of development. The endoscopic procedures may mimic bariatric surgical interventions such as the vertical banded gastroplasty, sleeve gastrectomy and the gastric band.

Summary

Because of the obesity epidemic and the obesity-associated diseases a large number of individuals will need treatment. Endoscopic bariatric therapy will fill the gap between medical treatment, which consists of intensive lifestyle treatment and pharmacotherapy at the one side and bariatric surgery on the other. There are endoscopic options such as balloons, duodenojejunal bypass sleeve and aspiration therapy, which are all at the disposal of and practicable by endoscopist but have the

Conflicts of interest

None.

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The rise of obesity and associated fatal diseases has taken a massive toll worldwide. Despite the existing pharmaceuticals and bariatric surgeries, these approaches manifest limited efficacy or accompany various side effects. Therefore, researchers seek to facilitate the prolonged and specific delivery of therapeutics. Or else, to mimic the essential part of “gastric bypass” by physically blocking excessive absorption via less invasive methods. To achieve these goals, polymeric biomaterials have gained tremendous interest recently. They are known for synthesizing hydrogels, microneedle patches, mucoadhesive coatings, polymer conjugates, and so forth. In this Review, we provide insights into the current studies of polymeric biomaterials in the prevention and treatment of obesity, inspiring future improvements in this regime of study.
Epidemiology of the surgical management of obesity
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Surgical interventions for obesity have quintupled in the world in 15 years (140,000 in 2003 vs. 720,000 in 2018), however growth has slowed since 2011. This progressive increase varies by country and from 2008 through 2018, 6.5 million people have undergone bariatric surgery. Growth was strongest in the Asia/Pacific region. Belgium is the country performing the most operations per number of inhabitants: (127 operations per 100,000). France is in 7th place with 72 operations per 100,000 and 70% of patients are operated in surgical services that perform more than 100 procedures per year. The sleeve gastrectomy (SG) is the most commonly performed intervention while the adjustable gastric band (AGB) has practically disappeared. Along with the intragastric balloon, novel endoluminal procedures are being evaluated. A real management policy is needed to respond to this evolution of both epidemiology and techniques.
Intragastric balloon placement in the treatment of overweight and obesity: Experience at a Mexican referral center
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El balón intragástrico es una terapia de mínima invasión temporal para inducir pérdida de peso. Cualquier balón con un volumen de 400 ml induce saciedad y retraso del vaciamiento gástrico. El objetivo de este estudio es demostrar su seguridad y su eficacia.
Analizamos la efectividad y la seguridad en la pérdida de peso en 128 pacientes con balón. Se compararon subgrupos mediante la prueba t de Student, ANOVA y chi cuadrado dependido del tipo de variables y del número de grupos evaluados, tomando una significancia estadística ≤ 0.05 para evaluar la pérdida de peso.
La pérdida de peso promedio después de la terapia con balón fue de 10.7 kg, con únicamente 2 casos de complicaciones por intolerancia a la vía oral. La permanencia promedio fue de 8 meses, sin haber complicaciones después de los 6 meses, pero tampoco mayor pérdida de peso (p = 0.540). La pérdida de peso final vs inicial fue significativa (p = 0.000). Los pacientes del grupo que acudían a una cita bimestral de control perdieron más peso que los que no tuvieron cita: 12.7 vs 7.26 kg (p = 0.000).
Comparando estos resultados con la literatura, la tasa de eventos adversos, como intolerancia y complicaciones, es muy baja en nuestro trabajo: 1.6% vs 4.7% y 0% vs 3%, respectivamente. La colocación del balón intragástrico tuvo mejores resultados cuando el paciente acudió a su cita de control. El balón intragástrico es un método seguro y eficaz para disminuir el peso de pacientes con sobrepeso y obesidad.
Intragastric balloon therapy is a temporary, minimally invasive method for inducing weight loss. Any balloon with a volume of 400 mL induces satiety and delayed gastric emptying. The aim of the present study was to demonstrate its safety and efficacy.
We analyzed the safety and effectiveness of balloon placement in relation to weight loss in 128 patients. Subgroups were compared through the Student's t test, ANOVA test, and the chi-square test, depending on the type of variable and the number of groups evaluated. Statistical significance was set at a P ≤ .05 to evaluate weight loss.
Mean weight loss after balloon therapy was 10.7 kg, with only 2 cases of complications due to oral feeding intolerance. Mean length of time with the balloon was 8 months. There were no complications after 6 months, but no further weight loss either (P = .540). Final weight loss versus initial weight loss was significant (P = .000). There was greater weight loss in the group that attended the bimonthly control appointments than in the group that did not: 12.7 kg vs. 7.26 kg (P = .000).
The rates of the adverse events of intolerance and complications were very low in our study, compared with results in the literature: 1.6% vs. 4.7% and 0% vs. 3%, respectively. Intragastric balloon placement had better results when the patients attended the control appointments. Intragastric balloon therapy is a safe and efficacious method for reducing weight in patients with overweight and obesity.
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Citation Excerpt :
These devices induce satiety by reducing the gastric capacity and slowing gastric emptying. Stretching of the gastric wall may also be responsible for a vagally controlled reflex for causing satiety [10]. Additionally, the levels of different gut hormones and peptides are altered after placement of intragastric devices and could explain a neurohormonal mechanism of weight loss, early satiety and delayed gastric emptying [10].
Endoscopic treatment of obesity is an area of growing interest. These endoscopic treatment options are less invasive than traditional surgical operations and are considered more effective than available medical and life style modification options. Endoscopic interventions currently available work through several mechanisms including space-filling devices that reduce volume of food intake, reduction in the stomach volume with endoscopic suturing, mucosal liners that reduce absorption, and aspiration therapy to remove the ingested food before absorption. Other devices are on the horizon with other mechanisms. This article will review the mechanisms and data surrounding endoscopic devices and procedures currently approved by the FDA and those in development. Some of the devices have limited data available due to being early in their clinical application.
Intragastric Balloons in Clinical Practice
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About 20,000 such devices were implanted. In practice, spontaneous deflation occurred in 31% of cases and gastric ulcers were seen in 26%.5 Adverse events including gastric perforations and intestinal obstructions requiring surgical extraction eventually led to the withdrawal of the device.
Novel endoscopic bariatric therapies: A glimpse into the future
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Historically, intragastric balloons have been in use for more than 30 years. Although the air-filled Garren-Edwards gastric bubble was the first to gain FDA approval in 1985, it, along with many of the other first generation balloons, was eventually withdrawn from the market because of a failure to demonstrate efficacy, significant complications, and new consensus on ideal balloon designs [6,7]. Recent consensus guidelines suggest intragastric balloons be (1) constructed from a smooth, durable material with low ulcerogenic and obstructive potential, (2) incorporate a radiopaque marker to allow appropriate follow-up in case of deflation, and (3) possibility to adjust to a variety of sizes [8].
The management of obesity generally consists of lifestyle interventions, which are often inadequate, or invasive surgery, that carries a high cost and strict eligibility requirements. The recent rise of endoscopic bariatric interventions has the potential to provide a minimally invasive, cost-effective, and reversible option for patients. Although a few of these therapies have already gained Food and Drug Administration (FDA) approval, many more are in various stages of development and clinical trials. These methods use a wide array of techniques, including reducing gastric capacity, limiting absorption, duodenal mucosal resurfacing, and creating intestinal diversion. This review focuses on these newer, nonFood and Drug Administration approved approaches, which have the potential to drastically change the landscape of bariatric interventional options in the near-term future.

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12Endoscopic treatment: The past, the present and the future

Abstract

Section snippets

Intragastric balloon treatment

The duodenojejunal bypass sleeve or duodenojejunal bypass liner (DJBS or DJBL)

Botulinum Toxin A (BTA) injection

SatiSphere

Aspiration therapy

Endoscopic bariatric treatment

Summary

Conflicts of interest

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Am J Clin Nutr

Am J Clin Nutr

Gastrointest Endosc

Am J Clin Nutr

Am J Clin Nutr

Am J Gastroenterol

Chest

Gastrointest Endosc

Surg Obes Relat Dis

Surg Obes Rel Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Gastrointest Endosc

Surg Obes Relat Dis

Gastroenterology

Obesity: preventing and managing the global epidemic

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults- the evidence report

Obes Res

Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children

Metabolic/bariatric surgery worldwide 2011

Obes Surg

The future of bariatrics: endoscopy, endoluminal surgery, and natural orifice transluminal endoscopic surgery

Endoscopy

Obesity and bariatrics for the endoscopist: new techniques

Ther Adv Gastroenterol

Endoscopic approaches for the treatment of obesity: fact or fiction?

Nutr Clin Pract

Current endoscopic techniques in the treatment of obesity

Rev Esp Enferm Dig

The role of endoscopy in bariatrics: past, present, and future

J Laparoendosc Adv Surg Tech A

Survey of gastric bubble usage in the United States

Clinical trial of silicone-rubber gastric balloon to treat obesity

Int J Obes

Fasting and meal-induced CCK and PP secretion following intragastric balloon treatment for obesity

Obes Surg

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

Obes Surg

Gastric emptying of solids in morbid obesity

Int J Obes Rel Metab Dis

Gastric emptying and intragastric balloon in obese patients

Eur Rev Med Pharmacol Sci

Effects of intragastric balloon on gastric emptying and plasma ghrelin levels in non-morbid obese patients

Obes Surg

Tolerance and efficacy of an air-filled balloon in non-morbidly obese patients: results of a prospective multicenter study

Obes Surg

Intragastric balloon-induced satiety is not mediated by modification in fasting or postprandial plasma ghrelin levels in morbid obesity

Obes Surg

Five percent weight lost in the first month of intragastric balloon treatment may be a predictor for long-term weight maintenance

Obes Surg

Intragastric balloon for obesity

Cochrane Database Syst Rev

Intragastric balloon treatment for obesity: what does it really offer?

Dig Dis

Evidence-based review of the bioenterics intragastric balloon for weight loss

Obes Surg

Safety and effectiveness of the intragastric balloon for obesity. A meta-analysis

Obes Surg

BioEnterics Intragastric Balloon (BIB): a short-term, double-blind, randomised, controlled, crossover study on weight reduction in morbidly obese patients

Int J Obes (Lond)

Intragastric balloon insertion increases the frequency of erosive esophagitis in obese patients

Obes Surg

Role of CCK(A) receptors in postprandial lower esophageal sphincter function in morbidly obese subjects

Dig Dis Sci

Intragastric balloon and binge eating

Obes Surg

12
Endoscopic treatment: The past, the present and the future