17 (2007) 545–557
1052-5157/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.giec.2007.05.008 giendo.theclinics.com
546 HASHIBA
Balloons insertion
Both balloons can be inserted under conscious sedation. This introduc-
tion is not controlled by endoscopy or radiograph. The balloon placement
assembly is inserted a distance from the incisor teeth and calculated so as
to be located 10 cm distal to the esophagogastric junction. The procedure
is easily performed, although the collapsed HB is more rigid. In both cases
a hand maneuver is needed to help the introduction in the hypopharynx.
The BIB usually is filled with a solution of methylene-blue (Fig. 1).
The balloons when filled adequately may cause some symptoms in the
postendoscopic period. It is important to observe the patient in the hospital,
because nausea, vomiting, and abdominal cramps are common. To control
these undesirable events, it is important to start symptomatic medications (an-
tiemetics and antispasmodics) immediately after insertion. These symptoms
are expected to last 72 hours, but, in few patients, they are uncontrolled and
the balloon needs to be removed. These events are less frequent and intense
with the HB [15]. On discharge, the patients are given a balanced diet of
around 1000 to 1500 kcal per day. Physical activity is also recommended.
Balloons removal
For balloon removal, as much fluid as possible should be removed in the
first step, using a needle or one catheter. The BIB balloon can be grasped
with a snare or a forceps. Finally, the endoscope and the balloon are removed.
Usually this procedure is easily performed. The same does not occur with the
HB. In this case, after the maximum aspiration of the balloon, a specific device
must be used. This device has two claws that catch the balloon in the valve
(Fig. 2). The HB always finds a resistance in the cardia and the operator has
to wait for the relaxation of the muscles of the esophagogastric junction
area. Sometimes the first maneuver is not successful and the balloon has to
be grasped again. In this case, the removal procedure conducted with snare
and basket usually results in important esophageal trauma.
Results
During the implant period, the rate of weight loss typically increases in
the first week, remains constant for 3 to 4 additional weeks, and finally de-
creases as patients presumably adapt to the device. Probably, the distended
stomach’s increased capacity might contribute to increased food intake and
therefore decrease the rate of weight loss [2]. The treatment is effective in
well-motivated patients as a method for losing around 1 kg per week.
Most published studies are on the BIB balloon. For one of them [16], pa-
tients were invited for a randomized, double-blind trial of balloon or sham
treatment of 3 months’ duration. Only patients who achieved weight loss
were given an additional 9-month treatment. Forty-three patients held an av-
erage body mass index (BMI) of 43.3. Balloon and sham groups had similar
mean weight loss during the first 3 months. Balloon/balloon patients lost
significantly less weight in months 3 to 6 than did sham/balloon patients, evi-
dencing the weight loss plateau effect. Patients who completed the study per
protocol lost 25.6 kg (20.5%) after 1 year and 14.6 kg (11.4%) after 2 years.
A double-blind, sham-controlled, randomized and crossover study con-
ducted by Genco and colleagues included 32 patients with BMI of 40 to
45 and lasted 6 months [17,18]. The balloon group had a significant
reduction in BMI from 43.5 to 38.0. The authors concluded that in associ-
ation with appropriate diet, the device is significantly effective in weight re-
duction as compared with sham procedure plus diet control.
At the Sı́rio Libanês Hospital (SLH) in São Paulo (Brazil), an open pro-
spective study included 41 patients who did not respond to medical therapy.
A dietitian instructed each subject to consume a diet with 1200 kcal. On the
first and second days after the insertion, the patients received liquids, 200
mL, 8 times a day. Only water was allowed in the intervals. From the third
to seventh days of the postoperative course they received 7 times, 200 mL
of a full liquid diet. Between the 8th and the 30th days the patients received
200 g or 200 mL of a soft solid diet. The patients remained in the hospital for
1 day. Antiemetic and antispasmodic medications were administered for
8 days. Acid suppressant drugs were given during all the treatment. Physical
activity was advised. There were no complications in the insertion and re-
moval procedures. The mean initial weight was 112.07 kg and the BMI,
38.7. The final results were 92.45 kg and 32.4, respectively. No balloons de-
flated during the treatment. Only three were removed early. In one case, the
patient revealed intolerance for a long time (10 days) and in the other two,
the patients lost weight strongly in a short time (1 month) and they were
afraid to get sick. The data on the HB are limited and the results seem to
be similar to the BIB [15].
Complications
The spontaneous deflation of the balloon occurs in about 2% of cases
[16]. Probably, this is the most important adverse event in the treatment.
When the deflation occurs, the device can remain in the stomach or can
migrate distally. In some cases of migration, the balloon had to be removed
surgically. However, it is important to emphasize that most balloons lost
their contents. Some studies showed that well-functioning balloons deflate
at a rate of 2 to 3 mL per day [17]. The rates of complication related to
insertion and removal are low [15,16], but unpublished data (Jermid Q
and Hashiba K, 2006) show that the HB is more difficult to remove with
the current design and it requires a special device to complete the removal
procedure after the puncture for deflation.
Other balloons
The described BIB and HB are the balloons available on the market in
some parts of the world. However, since the first well-studied attempt to
treat obesity with balloons, there were other devices and few studies with
them (Table 1).
Recently, some studies were performed with a novel balloon device. It is
the Adjustable Totally Implanted Intragastric Prosthesis (ATIIP) Endogast
[19] (Districlass Medical S.A., Corbas, France).
550 HASHIBA
Table 1
Overview of balloons
Name Material Approximate date Volume (mL) filling fluid Shape
Garren-Edwards Polyurethane Early 1980s 250 air Cylinder
Taylor Silicon 1989–1990 550 water Pear
W.Cook Polyurethane Early 1980s 300 air Pear
Ballobes Polyurethane 1980s 500 air Spherical
BIB Silicon Current 500–800 water Spherical
Heliosphere Silicon Current 900 air Spherical
Endogast Silicon Current 300–800 air Pear
This device has a tube like a gastrostomy tube that keeps the balloon in
place. There are two models, one in which the gastrostomy tube has a valve
and the second in which the tube is totally implanted subcutaneously. The
advantage is the significant migration reduction and the volume control
that can be increased or decreased by the patient.
However, the difficulties in making a gastrostomy in obese patients and
the complications of the placement of the gastrostomy opening in the
abdominal wall are well known. One open study performed in patients
with mean BMI of 48.4 showed progressive weight loss: first month,
11 kg; 3 months, 18 kg; and 6 months, 22 kg. Most of the early complica-
tions were a result of the gastrostomy procedure. No late postoperative
complications occurred [19].
The present results with BIB showed that it is not an alternative to suc-
cessful bariatric surgery and seems to be most appropriate as a temporazing
adjunct measure for bariatric surgery candidates. The ultimate goal would
be to provide adequate psychological motivation for patients to maintain
their modified diet, thus maximizing the benefits of the balloon. It seems
also to be a suitable treatment for not morbidly obese patients with comor-
bities. At present, there is now general agreement that the treatment should
focus on a sustained 10% to 15% weight loss to prevent or to reduce the risk
of cardiovascular and other obesity-related diseases [16]. Considering that
the balloon treatment is easily reversible, the balloons seem to be a very
interesting option to treat some selected obese patients. However, a strong
reliance on the placebo effect, the lack of compliance with a modified diet
and behavior, and the stigma surrounding the Garren-Edwards bubble fail-
ure prevent widespread acceptance of the concept.
A different kind of GVDD is the development of a device made with
polyethilene (Butterfly; Wilson-Cook Medical Inc., Winston Salem, North
Carolina) [20]. In the final design of the experimental phase, a 36-meter strip
was made (Fig. 3). This long strip was 75 m thick and 3 cm wide, folded in
the middle. The strip was divided into loops of 40 cm that are put together in
bundles of seven loops so as to facilitate the insertion (Fig. 4). The loop has
a hole, each 20 cm, to allow the passing of a thread to close the device be-
tween two drags in the thread ends. A 36-cm long, 1.6-cm diameter overtube
ENDOSCOPIC BARIATRIC PROCEDURES AND DEVICES 551
was used in all procedures. Canola oil was used as lubricant. The insertion
was performed in a left-side position and under general anesthesia. Intrave-
nous (IV) antibiotics were given immediately after the procedure.
The device is easily inserted and removed from the gastric lumen. Some
trauma always occurs during the insertion in the posterior wall, near the car-
dia, but it can be reduced if the stomach is kept distended. When the clinical
study started, it was difficult to compress the loops to obtain a compact
device. So, some distal loops released from the block and migrated distally
to the duodenum.
To have a compact plastic device, a 3-m long polyethylene flexible tube 75
m was used. This tube was compressed over a plastic tube used as a guide
and pusher. The compressed plastic tube has a plastic ring at every segment
of 15 cm (Fig. 4). The pusher holds the ring to insert the polyethylene tube in
a continuous movement, without the need to return to the mouth, as in the
previous design. To deploy this later generation device, it needs to come
back 15 cm to take the other segment to push. As the device has a drag
in the distal end of the central thread, when the insertion finishes, another
drag is placed in the proximal end and closes the device after a suitable com-
pression (Figs. 5 and 6).
This device seems to have some advantages over the balloons, because it
does not need to be inflated or to change in any shape to work and allows
for different sizes as needed. It does not have valves to keep fluids and the
migration seems to be limited. The mechanisms of action resulting in weight
loss can also differ from those of the balloons. While the ideal position for
the balloons in the stomach is the fundus/body, the described plastic device
can move in the gastric lumen and probably distend the stomach due to its
volume and the emptying delay. However, this action can be the same as the
majority of balloons, because most of them lose their contents during the
treatment [17].
Further studies will show the real usefulness of the device to treat obese
patients.
Fig. 5. The shape of the present Butterfly after the insertion maneuvers.
ENDOSCOPIC BARIATRIC PROCEDURES AND DEVICES 553
Gastric reduction has also been performed in live animals using another
endoscopic suturing device [22]. The 2-0 stitches were placed in the gastric
fundus, 5 cm below the gastroesophageal junction. Differently, the suture
was closed using extracorporeal knots. The authors needed 10 to 12 stitches
to obtain a gastric pouch with 30 mL at the end of the procedure. There was
no follow-up in this study.
Certainly, there are many reasons why this procedure has not become
more widely attempted. One of them is that the experience with endoscopic
sutures in GERD treatment showed that most patients (83%) lost the
stitches after 18 months [23]. Moreover, in cases of the open vertical-banded
gastroplasty, in the late postoperative course, a staple-line disruption
occurred in 30% of cases, allowing an abnormal communication between
the ‘‘stomachs’’ and subsequent weight gain [24]. Moreover, the studies
performed in Hospital Novo Atibaia Experimental Surgery Center (São
Paulo, Brazil) on vertical gastroplasty in pigs with a transmural device
[25] showed a suture disruption 1 month later.
Nevertheless, a recent published report [26] on 10 patients, showed weight
loss between 15 to 49 kg after endoscopic vertical gastroplasty. The Bard
Endocinch was used in this study (Figs. 7 and 8). The BMI of patients
ranged between 25 and 35. Only one plication had to be repeated after 9
months because of rupture of the suture. All patients complained of sore
throats for 2 days. No complications occurred in any procedures performed
under general anesthesia. Laboratory tests demonstrated clinical significant
reductions in cholesterol and triglycerides.
Thus, it appears that endoscopic gastric reduction is technically feasible.
With the development of new endoscopic suturing devices, more preclinical
554 HASHIBA
Fig. 7. Endoscopic view of the gastric restriction with Endocinch. (Courtesy of Dr. Roberto
Fogel, Caracas, Venezuela.)
research and new clinical studies will evaluate whether an endoscopic proce-
dure can achieve long-lasting results and determine its clinical impact.
Fig. 8. Radiographic study of the stomach after the Endocinch suture. (Courtesy of Dr. Rob-
erto Fogel, Caracas, Venezuela.)
ENDOSCOPIC BARIATRIC PROCEDURES AND DEVICES 555
Fig. 9. GISleeve placed into the duodenum. The arrows show the sleeve. (Courtesy of Dr. Man-
oel Galvão Neto, São Paulo, Brazil.)
Summary
The development of endoscopic treatments for obesity offers gastroenter-
ologists, surgeons, and endoscopists an exciting and highly desirable less-
invasive therapeutic modality as compared with bariatric surgery. At
present, preliminary results cannot compare with those offered by surgical
treatment, but in selected patients, all endoscopic procedures have afforded
important improvements in patient health by reducing the comorbidities as-
sociated with morbid obesity. With the development of new techniques, the
possibility of a combined procedure can offer an interesting therapeutic
556 HASHIBA
Acknowledgments
I thank Mr. Vihar Surti for helping me with the preparation of the text
and Ms. Alvamar H.C.A. Lamparelli for helping me with the manuscript
revision.
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