ENDOSCOPIC TREATMENT OF OBESITY - Dr hossein Ajdarkosh GILDRC , TUMS

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

  ValenTx T    EndoBarrier

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