ENDOSCOPIC

TREATMENT OF OBESITY

Dr hossein Ajdarkosh

GILDRC , TUMS

Firouzgar Hospital

Multidisciplinary approach Gastroenterologist/ Endoscopist Bariatric Surgeon Endocrinologist Cardiologist Dietetician Psychologist Psychiatrist Orthopedist Anesthesiologist Gynecologist Reconstructive surgery

What is the current role of endoscopy in

the management of obesity?

primary management of obesity;

management of obesity-related disorders such as

diabetes mellitus and infertility

management of postsurgical complications.

Balloons and prosthesis Orbera Intragastric Balloon

Ullorex Intragastric Balloon (Swallowable balloons)

Spatz Adjustable Intragastric Balloon

Heliosphere Bag

Semistationary Antral Balloon

Endogast-ATIIP (Adjustable Totally Implantable Intragastric

Prosthesis)

First intragastric balloons : used in the USA (Garren-Edwards

Bubble –1984 )

filled with air of 220-500 ml volume and could be left in the

stomach for3-4 months.

In 1987, during a scientific conference in Florida, it was

emphasized that a balloon should be filled with fluid

Between 1986 and 1989 clinical trials were conducted in the

USA with a first fluid-filled intragastric balloon

Indications for treatment with an

intragastric balloon

1) BMI < 35 with obesity associated disorders,

unsuccessfully treated medically for at least 3 years

contraindications to pharmacological treatment of obesity

2) BMI 35 to 39.9 :

obesity associated disorders , unsuccessfully treated medically

contraindications to bariatric surgery. do not agree for surgical treatment of obesity.

3)BMI 40 to 49.9.

to reduce perioperative risk , general surgery, cardiac and orthopedic surgery

4) Patients with BMI > 50 : may have the balloon inserted to undergo preliminary

qualification for restrictive bariatric surgery

Absolute contraindications

ü A history of gastric or intestinal surgery

ü A ddiction to alcohol or drugs

ü A ctive gastric or duodenal ulcer

ü Required continuous treatment with

anticoagulants or anti-inflammatory drugs

ü Collagen diseases

ü Inflammatory bowel disease

ü liver cirrhosis, chronic renal failure, pregnancy,

AIDS, a history of or current mental

Disorders and malignancies

Relative contraindications

ü Disorders predispose to potential gastrointestinal

bleeding

Esophageal varices

Teleangiectasias,

Congenital gastrointestinal anomalies

ü 3rd grade esophagitis

ü Barret’s esophagus

ü Ingestion of anti-inflammatory drugs

ü Hiatal hernia >5 cm.

laboratory tests is

recommended

ü CBC

ü Coagulogram

ü FBS

ü Electrolyte(Na, K)

ü Creatinine

ü Triglyceride,

ü Albumin level

othere

ü ECG

ü Chest X-ray

ü Spirometry

ü US imaging of the abdominal cavity

ü Psychological consultation

What complications are associated with

these procedures?

the most-studied of these devices—include :

ü Nausea ,vomiting

ü Balloon migration

ü Abdominal pain

ü Ulceration , perforation

ü Mallory-Weiss tears,

ü Balloon deflation

ü Weight gain.

In a study from Switzerland,

100 patients who had a mean BMI of 35 kg/m2 for 6 months

followed for approximately 4 years.

The investigators found that

The mean weight loss at 6 months was 12.6 kg,

63% of patients had lost > 10% of their baseline body weight.

Mean BMI increased by a mean of 4.2 kg/m2 and 2.3 kg/m2 in the first and second years of follow-up, respectively.

A total of 28 patients maintained their weight loss of more than 10% at the final follow-up (approximately 4 years).

Are repeat procedures necessary in these

patients?

In a study from Spain :

BIB in 714 patients for 6 months and then replaced it in 114 patients after 1 month later (ie, at 7 months).

Mean excess weight loss was 44.5%, and the mean BMI decreased from 37.6 kg/m2 to 32.9 kg/m2 at 6 months and then to 30.3 kg/m2 at 1 year.

This study suggests that repeat procedures appear to hold some benefit in continuing weight loss, although more research is needed on this issue.

Do these endoscopic weight reduction

procedures have any other uses? . Studies have shown that these devices : Reduce weight

waist circumference, and fat mass

improve liver Steatosis

restore some components of metabolic syndrome.

These devices have also been shown to :

Improve control of diabetes mellitus

In an Italian study, investigators

leads to fertility in obese infertile women

In another study,

in (BMI >60 kg/m2) a modest weight loss, facilitated definitive surgical procedures and decreased complications of surgery.

Botulinum toxin

intragastric injection of botulinum toxin :

hypothetically delays gastric emptying and inhibits ghrelin secretion

the main source of which is the gastric fundus.

Plasma levels of ghrelin increase during periods of fasting and

decrease after a meal.

This hormone accelerates gastric emptying and also stimulates

gastric motility during fasting .

In 2003, Rollnik at al (59) reported that four months after botulinum toxin

injection into the antrum of the stomach, an obese man lost 9 kg and his

daily caloric intake decreased by approximately 32.5%.

A study published two years later (60) showed that

intragastric injection of botulinum toxin was safe and well tolerated.

cont One study performed by an Italian group (64) reported a delay in

gastric emptying, early satiety and body weight reduction.

In analyzed studies :

, varying doses of butulinum toxin (from 100 to 300 IU)

perhaps more important than the dose of toxin, was the method of its application

the toxin was injected both into the antrum and the gastric fundus.

In the other it was only injected in the antrum, which likely explains the differences in results that were observed

the drug is expensive; furthermore, it will be difficult to perform studies with a large number of patients

the limitation of the drug : short duration of its effect ,must be repeated,.

Malabsorptives techniques

EndoBarrier

ValenTx T

Duodenal-jejunal bypass sleeve

Duodenal-jejunal bypass sleeve

an endoscopic method used to reduce jejunal absorption.

The bypass is a flexible, nutrient-impermeable 60 cm sleeve that is

anchored in the duodenal bulb and extended into the proximal jejunum

The catheter-based delivery system is introduced into the duodenal bulb

over the guide wire and deployed to the jejunum using dynamic

fluoroscopy.

The anchor – the distal tip of sleeve – is a self-expanding 5.5 cm nitinol

stent that enables fixation within the duodenal bulb

the sleeve is maintained for 12 weeks, after which time, it is removed

endoscopically.

study from Boston that evaluated endoscopically implanted

duodenojejunal bypass sleeves,

39 patients: 25 patients who had the sleeve and were on a low-fat

diet and 14 patients who were only on a low-fat diet

.At the end of the 12-week study period, mean excess weight loss

was 22% and 5%, respectively.

The device was explanted in 20% of patients due to bleeding,

migration, or obstruction. Long-term results are pending.

Have any studies looked at endoscopic

techniques versus existing surgical techniques

for management of obesity?

A recent study from Turkey :

compared laparoscopic gastric bypass with 2 consecutive intragastric balloon

placements.

A total of 32 patients were studied

. Sixteen patients underwent laparoscopic gastric bypass, and the other 16 patients underwent balloon placement for

6 months followed by placement of a second balloon for another 6 months.

Excess weight loss between the 2 groups at 6 months was not significantly different, but at 12 and 18 months, patients in the balloon group had significantly higher weight loss compared to the laparoscopic gastric bypass group.

According to this study, endoscopic management of obesity is at least comparable to surgical management. However, it remains to be

BIB TEST

The Adjustable Totally Implantable

Intragastric - Prothesis (ATIIP)

Endogast

a new, minimally invasive technique using surgical and endoscopic procedures for the treatment of obesity.

The device is inserted in the gastric corpus-fundus area using a method similar to percutaneus endoscopic gastrostomy.

The two main principles in this method are the permanent presence of an air-filled prothesis inside the stomach and the fixation of the stomach to the abdominal wall.

The aim of the ATIIP-Endogast device is :

to induce early satiety and a reduction in body weight.

an effect on gastric accomodation,

electrical activity and neurohormonal mechanisms

the ATIIP-Endogast device is feasible, reproducible, safe and is associated with a low risk of complications, especially for obese patients older than 60 years of age, and superobese patients with a BMI of greater than 50 kg/m2.

The TOGA system is an endoscopic full-thickness stapling device that

allows exclusion of much of the stomach by creating a narrow gastric

sleeve

It is composed of a flexible 18-mm shaft device that is introduced into the

proximal stomach over a guidewire.

the maneuvers are repeated to create an 80– to 90-mm sleeve,

approximately 19 mm in diameter extending from the esophagus along the

lesser curvature.

adverse events : transient epigastric pain, nausea, vomiting, dysphagia,

throat pain, esophagitis and superficial phlebitis. Most of these symptoms

resolved spontaneously or with pharmacological treatment

Endoluminal suturing has been evaluated in several studies.

In a study from Venezuela, investigators performed endoluminal vertical gastroplasty by continuous sutures and reported excellent results with this minimally invasive procedure.

This procedure was performed on 64 patients who were divided into 3 groups:

patients with a BMI of more than 40 kg/m2,

35–40 kg/m2,

less than 35 kg/m2

The mean excess weight loss percentages were 49%, 56%, and

85% at 12 months after the procedure for each of the 3

BMI groups, respectively.

There were no significant side effects from these procedures.

TERIS

creates a restriction analogous to gastric banding

The technique involves stapling plications into the gastric cardia with anchor placement and subsequent attachment of a restrictor diaphragm.

This results in a restrictive pouch with a 10-mm orifice . It is designed to be a permanent implant, removed or modified as needed.

In a preliminary study of 12 patients, the EWL was 12.3% and 22.2% at 1 and 3 months, respectively.

In 1 patient, gastric perforation ,

in 2 patients, pneumoperitoneum

Weight loss was reported to be comparable to that with laparoscopic gastric bandplacement.

PRE-OPERATIVE ENDOSCOPIC

EVALUATION

the presurgery evaluation for the bariatric patient may include :

upper endoscopic evaluation.

As with any patient presenting with :

refractory reflux symptom

gastric or duodenal ulcers

In asymptomatic patients who do not warrant pre-operative endoscopy,

Helicobacter pylori screening should be performed and treated if positive.

most surgeons advocate pre-operative EGD because it will provide them

with

important information

the endoscopic options for early

and late surgical complications

of bariatric surgery.

Surgical Primary Endoscopic Secondary Intervention Endoscopic Complication

Early Bleeding Endoclip Fibrin glue

Leak Covered stent Fibrin glue,

Fistula Covered stent Fibrin glue

Stomal or

Anastomotic Stricture Balloon or bougie dilation Stent

Late Fistula Covered stent Fibrin glue,

Leak Covered stent Fibrin glue

Stomal or

Anastomotic Stricture Balloon or bougie dilation Stent

Stomal Dilation

(weight regain) Plication, Sclerotherapy ROSE procedure

Gastric Band Slippage/Erosion Endoscopic Evaluation and Surgical Referral