Dark Side of The Balloon · Intragastric Balloons –The Basics •Primary endoscopic bariatric...
Transcript of Dark Side of The Balloon · Intragastric Balloons –The Basics •Primary endoscopic bariatric...
Dark Side of The Balloon
•Mati Shnell
Vignette
• 25 years old female
• Obesity, no chronic Rx
• Presented to the ER with abdominal pain and nausea
• Accidental foreign body ingestion
Endoscopy
???
What’s Next?
• What is the foreign body?
• Remove?
• Call a surgeon?
Body Packing - Leave and Let Live
• ESGE recommends close observation in asymptomatic individuals who have concealed packets of drugs by swallowing
• We recommend against endoscopic retrieval
• We recommend surgical referral in cases of suspected packet rupture, failure of packets to progress, or intestinal obstruction
Birk M, Endoscopy 2016
The Nylon Thickens
• Upon inspection the bag ruptured
• Successful endoscopic removal
• The authorities were notified
Home Made Intragastric Balloon*
* Patent pending
Intragastric Balloons –Adverse Events
Case Records of The Bariatric Endoscopy Unit
Intragastric Balloons
• Introduction
• Cases - complications
• Discussion
Intragastric Balloons – The Basics
• Primary endoscopic bariatric treatment
• Renewed interest due to recent FDA approval for 3 models
• 6-12 months
• ~15% total body weight loss
Mechanisms of Action
• Restriction
• Delayed gastric emptying
• No effect on fasting or post-prandial ghrelin concentrations
Geliebter A, Am J Clin Nutr. 1988Gomez V, Obesity 2016Mathus-Vliegen EM, Obes Surg. 2014
Endoscopic IGB Models
• Shapes
• Water/fluid filled
• Duration
Orbera
ReshapeHeliosphereSpatz3
Case 1 – Outpatient Clinic
• 26 years old female
• No chronic medical treatment
• Spatz3 – 7 months (France)
• Lost 10 Kg
• Abdominal pain, nausea and vomiting
Case 1 - Imaging
• Positional contrast passage
Case 1 - Endoscopy
• Inflation tube serves as transpyloric anchor
• Successful endoscopic removal
Case 2 – ER Visit
• 41 years old female
• No chronic medical treatment
• Spatz3 – 7 months
• Lost 15 Kg
• Abdominal pain
Case 2 - Imaging
• Deep ulcer – anterior gastric wall
• Inflation tube embedded in the ulcer
Case 2 - Endoscopy
• Inflation tube causes deep gastric ulceration
• Successful endoscopic removal
Case 3 – Surgery Consultation
• 20 years old female
• No chronic medical treatment
• Spatz3 – 10 months
• Lost 6 Kg
• Severe abdominal pain
Dayan D, Obes Surg 2016
Case 3 - Imaging
• Free air
• No contrast extravasation
Dayan D, Obes Surg 2016
Case 3 - Laparoscopy
• Fibrin covered stomach
• Suspected microperforation
• Successful endoscopic removal
Dayan D, Obes Surg 2016
Case 4 - D.E.
• 54 years old female
• Major depression – Venlafaxine
• BMI 32
• Endball – 2 weeks
• General deterioration
Case 4 – Work Up
• No nausea\vomiting
• Normal Lab
• No response to diet modification
• No response to change in medication
• Depression exacerbation – refractory to Tx
Case – Concluded
• Successful endoscopic removal of balloon
• Referred to electroconvulsive therapy
Complications
Early removal
• Severe intolerance 0.44%
• Gastric perforation 0.19%, 40% mortality
• Gastric dilatation acute 0.08%, delayed 0.76%
• Spontaneous deflation 0.36%
Conservative
• Esophagitis – 1.27%
• Gastric ulcer – 0.2%
Genco A, Obes Surg 2005
Overall adverse events 3.3%
IGB – US RCTs
• Early removal 10-18.8%
• Serious adverse events 10%• 75% hospitalization for intolerance
• 10% gastric ulcer
• 0.5-0.8% perforation
FDA. Summary of Safety and Effectiveness Data 2015
Complications - Rare
• Acute balloon spontaneous over-inflation
• Pancreatitis
FDA Alert, Feb 2017
Conclusions
• Effective EBT
• Patient selection
• Early vs late complications
• Avoid home made balloons
• Prepare yourself – OTC balloons are coming
Future Perspectives
• Obalon
• Elipse
Thank You For Listening