endoscopic treatment of obesity - (iagh) > home · obesity associated disorders , unsuccessfully...
TRANSCRIPT
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