The current status and future perspectives of bariatric and metabolic surgery in the management of obesity and its co-morbidities / 中华外科杂志

Bariatric-metabolic surgery (BMS) has the potential of decreasing body weight and improving obesity-related metabolic syndrome by restricting food intake and malabsorption. Laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, biliopancreatic diversion with duodenal switch are four major BMS procedures. Sleeve plus surgery, one-anastomosis gastric bypass, intragastric balloon and endoscopic surgery are also arising and gaining popularity due to their specific efficacy. Currently, BMS is now experiencing an era with deeply integrated interdisciplinarity, optimizing and innovating of surgeries and well-illustrated clinical efficacy, as a result, more obese patients would benefit from BMS.

Significados en torno a la experiencia de someterse a una segunda intervención quirúrgica para bajar de peso / MEANING ABOUT THE EXPERIENCE OF SUBMITTING A SECOND SURGICAL INTERVENTION TO LOSE WEIGHT

Diversos motivos inciden en que los pacientes se sometan a cirugía bariátrica para hacer frente a la obesidad. Pese a ser el procedimiento más eficaz contra el exceso de peso, existe una alta tasa de pacientes que después de la cirugía, recuperan un porcentaje importante del peso perdido. Esta re-ganancia de peso genera consecuencias médicas, físicas y psicológico-emocionales; y en muchos casos lleva a que los pacientes vuelvan a someterse a intervenciones quirúrgicas con el objetivo de reactivar la pérdida de peso. No obstante, las re-operaciones no suelen tener la misma eficacia en términos de la pérdida de peso y su mantención. Esta investigación se centra en los significados psicológicos de la experiencia de someterse a más de una intervención quirúrgica para perder peso, con el objetivo de comprender lo que implica este proceso para los pacientes, así como también las repercusiones que trae consigo someterse a más de una intervención de este tipo. La metodología que se utilizó fue cualitativa con un enfoque desde la Teoría Fundamentada y con un alcance descriptivo para comprender lo que deben vivir estos pacientes. Para llevar a cabo esta investigación, se realizaron entrevistas semi-estructuradas a cuatro mujeres y un hombre, quienes previamente se habían sometido a una intervención quirúrgica para perder peso, y luego de unos años y de haber recuperado el peso perdido se sometieron a una cirugía bariátrica. La elección de la segunda intervención se asoció a la creencia que la recuperación de peso se debió principalmente a la técnica de la primera intervención, evaluación que cambia hacia una percepción de bajo control en la alimentación, tras la re-ganancia de peso post-segunda intervención. Se observa niveles importantes de frustración tras esta segunda re-ganancia.

There are several reasons why patients choose to undergo bariatric surgery to cope with obesity. Despite being the most effective procedure against excess weight, there is a high rate of patients who, after surgery, recover a significant percentage of the weight lost. This regain of weight generates medical, physical and psychological-emotional consequences; and in many cases it leads to patients re-undergo surgery with the aim of reactivating weight loss. However, re-operations are usually not as effective in terms of weight loss and weight maintenance. This research focuses on the psychological meanings of a patient's experience of more than one surgical intervention to lose weight, with the aim of understanding what this process implies for patients, as well as the repercussions of obtaining more than one intervention of this type. The specified methodology was qualitative with an approach from the Grounded Theory and with a descriptive scope to understand what these patients must live. To carry out this research, semi-structured interviews were conducted with four women and one man, who had previously undergone surgery to lose weight, and after a few years and having recovered the lost weight, underwent surgery. bariatric The choice of the second intervention was associated with the belief that weight recovery was mainly due to the technique of the first intervention, an evaluation that changes towards a perception of low control in the diet, after the post-weight gain second intervention. Significant levels of frustration are seen after this second regain

Avaliação de perda de peso após o uso de balão intragástrico não ajustável e ajustável / Assessment of weight loss after non-adjustable and adjustable intragastric balloon use

ABSTRACT BACKGROUND: Intragastric balloon (IGB) use is indicated for patients whose BMI precludes the option of bariatric surgery or who need to lose weight prior to undergoing surgery. It is a minimally invasive procedure and currently there are two main models of IGBs in use, the non-adjustable intragastric balloon (NIB), implanted for six months, and the adjustable intragastric balloon (AIB), implanted for up to 12 months. OBJECTIVE: Analyze clinical characteristics between patients receiving non-adjustable gastric balloon and the adjustable (prolonged implantation) intragastric balloon. METHODS: This was a cross-sectional study of 470 patients diagnosed as obese or overweight who had balloon implantation from October 2011 to July 2018. The associations between percentage excess weight loss versus clinical and demographic variables were calculated using the chi-squared test. Independent samples were submitted to the Student's t test to determine the quantitative variables, with a confidence interval of 95%. Calculation of excess weight was based on an estimated ideal weight that would correspond to a BMI of 24.99 kg/m2. RESULTS: A total of 414 patients completed the treatment achieving an average total body weight loss (%TBWL) of 15.4±7 with the NIB and 15.5±9.6 with the AIB. Overweight patients achieved higher excess weight loss (%EWL) values using AIBs (157.2±82.5) and obese patients did so with NIB use (56±29.7). Women achieved higher %EWL values (65.6±62.2) than men (48±27.1). Individuals who attended >4 consultations with a nutritionist (60.8%) achieved TBWL >18%. All of those P-values were <0.001. CONCLUSION: Obese individuals and women registered the greatest weight losses. Overweight patients achieved greater losses using AIB and obese patients did so using NIBs. NIB use was associated with higher EWL percentages. Nutritional accompaniment had a positive impact on the %TBWL.

RESUMO CONTEXTO: O uso do balão intragástrico (BIG) é indicado para pacientes cujo IMC contraindica a cirurgia bariátrica ou que necessitam perder peso antes da cirurgia. É um procedimento minimamente invasivo e atualmente existem dois modelos principais de BIG - o balão intragástrico não ajustável (BINA), implantado por seis meses, e o balão intragástrico ajustável (BIA), por até 12 meses. OBJETIVO: Analisar os fatores associados aos resultados clínicos comparando o uso de balão intragástrico não ajustável com o uso de balão intragástrico ajustável. MÉTODOS: Estudo transversal em 470 pacientes, com sobrepeso ou obesidade, submetidos ao tratamento entre outubro 2011 e julho de 2018. A associação entre as porcentagens da perda de excesso de peso (%PEP) e da perda do peso total (%PPT) com as variáveis demográficas e clínicas foram calculados com o teste qui-quadrado (P<0,05). Foi utilizado o teste t de Student para amostras independentes para comparar variáveis quantitativas, com IC 95%. O cálculo do excesso de peso foi estimado em peso ideal correspondente a um IMC de 24.99 kg/m2. RESULTADOS: Um total de 414 pacientes realizaram o tratamento até o final, com %PPT média de 15,4±7 no BINA e 15,5±9,6 no BIA. Os com sobrepeso apresentaram maiores %PEP no BIA (157,2±82,5) e os obesos maiores %PEP no BINA (56±29,7), com P<0,001. Mulheres (65,6±62,2) apresentaram maiores %PEP do que homens (48±27,1), com P<0,001. Os indivíduos que atenderam a >4 consultas com nutricionista obtiveram %PPT >18% (60,8%), com P<0,001. CONCLUSÃO: Obesos e mulheres tiveram maiores perdas ponderais. Maior perda de peso foi identificada em pacientes com sobrepeso que utilizaram BIA e em obesos os quais utilizaram BINA. O BINA esteve associado com maiores taxas de %PEP. O acompanhamento nutricional impactou positivamente na %PPT.

Intragastric balloon for weight reduction: rationale, benefits, risks and indications / 南方医科大学学报

Intragastric balloon (IGB) placement under endoscopy is a non-invasive method for weight loss.By placing a space-occupying balloon in the stomach, IGB treatment can achieve better effect of weight loss than medications.Herein we review the development of IGB, its effect on weight loss and the mechanism, and the eligible individuals for IGB treatment.We also examine the high-intensity postoperative management following IGB placement, which is important for maintaining long-term weight loss, and discuss the future development of IGB.The patients should understand that on the basis of ensuring a high safety, the weight-losing effect of IGB can be limited and relies heavily on postoperative management.Patients should make a decision on IGB placement after careful consideration of their own physical, economic, and psychological conditions, lifestyle and the line of work in addition to the indications of IGB.IGB placement combined with high-intensity postoperative management and active interventions of lifestyle and dietary habits help to achieve long-term effect of weight loss and improve obesity-related complications.

Esophageal intramural pseudodiverticulosis in a patient with food bolus impaction / Pseudodiverticulosis intramural esofágica en un paciente con impactación de bolo alimentario

Esophageal intramural pseudodiverticulosis is an uncommon esophageal benign disease. The typical finding during endoscopy is the presence of numerous pinhead-sized outpouchings along the esophageal wall. We reported a case of food bolus impaction secondary to esophageal intramural pseudodiverticulosis. A 67-year-old man presented with sudden-onset dysphagia. Multiple tiny orifices were revealed during upper endoscopy. In addition, there were an impacted food bolus and an esophageal web. The patient was treated with balloon dilatation and proton pump inhibitors. As a result the symptoms disappeared completely. Esophageal intramural pseudodiverticulosis is a rare cause of food bolus impaction and its treatment is directed towards the underlying associated conditions as well as the resolution of complications.

La pseudodiverticulosis intramural esofágica es una enfermedad benigna del esófago poco común. El hallazgo típico durante la endoscopia es la presencia de numerosos sáculos del tamaño de una cabeza de alfiler a lo largo de la pared esofágica. Reportamos un caso de impactación de bolo alimentario secundario a pseudodiverticulosis esofágica intramural. Un hombre de 67 años presentó disfagia de aparición repentina. Se encontraron múltiples orificios pequeños en la endoscopia superior. Además, hubo un bolo alimentario impactado y una red esofágica. El paciente fue tratado con dilatación con balón e inhibidores de la bomba de protones. Como resultado, los síntomas desaparecieron por completo. La pseudodiverticulosis intramural esofágica es una causa rara de impactación del bolo alimentario y su tratamiento se dirige a las condiciones asociadas subyacentes, así como a la resolución de complicaciones.

Endoscopic Removal of Inflated Transected Sengstaken–Blakemore Tube Using Endoscopic Scissors

Balloon tamponade using Sengstaken–Blakemore (SB) tube is employed as a bridging therapy in cases in which endoscopic therapy fails to control esophageal variceal bleeding. Although SB tube insertion can lead to successful hemostasis, it is accompanied by numerous complications, with SB tube transection being one of the rarest complications. A 53-year-old man with liver cirrhosis and hepatocellular carcinoma presented with massive esophageal variceal bleeding. Therapeutic endoscopic variceal ligation failed, and SB tube was inserted. The SB tube was unexpectedly disconnected because of the patient's irritability due to hepatic encephalopathy. The esophageal and gastric balloon of the SB tube remained inflated in the stomach. Whereas the use of other endoscopic instruments was ineffective, endoscopic removal was successfully accomplished using endoscopic scissors. In conclusion, we detected SB tube transection in a patient with hepatic encephalopathy and removed remnants of the inflated tube using endoscopic scissors.

Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience / Balões intragástricos em obesos de alto risco em um centro brasileiro: experiência inicial

ABSTRACT Objective: to assess the short-term efficacy, tolerance and complications in high-risk morbidly obese patients treated with an intragastric balloon as a bridge for surgery. Methods: we conducted a post-hoc analysis study in a Brazilian teaching hospital from 2010 to 2014, with 23 adult patients with a BMI of 48kg/m2, who received a single intragastric air or liquid balloon. We defined efficacy as 10% excess weight loss, and complications, as adverse events consequent to the intragastric balloon diagnosed after the initial accommodative period. We expressed the anthropometric results as means ± standard deviation, comparing the groups with paired T / Student's T tests, when appropriate, with p<0.05 considered statistically significant. Results: the balloons were effective in 91.3% of the patients, remained in situ for an average of 5.5 months and most of them (65.2%) were air-filled, with a mean excess weight loss of 23.7kg±9.7 (excess weight loss 21.7%±8.9) and mean BMI reduction of 8.3kg/m2±3.3. Complications (17.3%) included abdominal discomfort, balloon deflation and late intolerance, without severe cases. Most of the participants (82.7%) did not experience adverse effects. We removed the intragastric balloons in time, without intercurrences, and 52.2% of these patients underwent bariatric surgery within one month. Conclusion: in our center, intragastric balloons can be successfully used as an initial weight loss procedure, with good tolerance and acceptable complications rates.

RESUMO Objetivo: identificar a eficácia em curto prazo, a tolerância e as complicações em obesos mórbidos de alto risco, tratados com balão intragástrico como ponte para cirurgia. Métodos: estudo de análise post-hoc em um hospital acadêmico brasileiro durante o período de 2010 a 2014, de 23 pacientes adultos com IMC de 48kg/m2 que receberam um único balão intragástrico de ar ou líquido. Eficácia foi definida como perda de excesso de peso de 10%, e complicações como eventos adversos consequentes ao balão intragástrico diagnosticados após o período acomodativo inicial. Expressaram-se os resultados antropométricos com média ± desvio padrão, comparando os grupos com testes T Pareado / T de Student, quando apropriado, com p<0,05 considerado estatisticamente significante. Resultados: os balões foram efetivos em 91,3% dos pacientes, permaneceram in situ por em média 5,5 meses e a maioria deles (65,2%) era de ar, com perda média de excesso peso de 23,7kg±9,7 (perda de excesso de peso de 21,7%±8,9) e redução média de IMC de 8,3kg/m2±3,3. As complicações (17,3%) compreenderam desconforto abdominal, deflação do balão e intolerância tardia, sem casos graves. A maioria dos participantes (82,7%) não experimentou efeitos adversos, seus balões intragástricos foram extraídos em tempo, sem intercorrências e 52,2% desses pacientes submeteram-se à cirurgia bariátrica no intervalo de um mês. Conclusão: no nosso centro, balões intragástricos podem ser usados com sucesso como procedimento inicial de perda ponderal, com boa tolerância e taxas aceitáveis de complicações.

Gastric Ulceration and Bleeding with Hemodynamic Instability Caused by an Intragastric Balloon for Weight Loss

Obesity in the United States is a medical crisis with many people attempting to lose weight with caloric restriction. Some patients choose minimally invasive weight loss solutions, such as intragastric balloon systems. These balloon systems were approved by the Federal Drug Administration (FDA) in 2015–2016 and have been considered safe, with minimal side effects. We report a patient with a two-day history of melena, abdominal pain, hypotension, and syncope which developed five months after placement of an intragastric balloon. Esophagogastroduodenoscopy with balloon removal revealed a small 8-mm gastric ulcer in the incisura. This gastric ulcer probably developed secondary to mechanical compression of the stomach mucosa by the gastric balloon which contained 900 mL of saline. The FDA is now investigating five deaths since 2016 associated with these second-generation balloons. Clinicians should be aware of these complications when evaluating patients with gastrointestinal complications, such as bleeding.

Efficacy and safety of intragastric balloon in the treatment of obesity in adolescent females

BACKGROUND: The aims of this study are to evaluate the efficacy and safety of intragastric balloon (IB) to reduce the weight and body mass index (BMI) in severely obese adolescent females and to describe the changes in the liver enzymes and lipid and glucose metabolism biomarkers. METHODS: This study included 10 severely obese post-menarche adolescent females. We evaluated anthropometric data, lipid profile, glucose metabolism biomarkers, and liver enzymes before insertion and after removal of the IB. RESULTS: BMI and weight reduction were larger during the first month of intervention. Especially in the first week, there was a reduction of 1.74 ± 0.46 kg/m2(p= 0.004) and 6.46 ± 1.52 kg (p= 0,002), respectively. After 3 months, there wasan average BMI reduction of 4.29 ± 1.04 kg/m (p= 0.005) and weight reduction of 12.9 ± 3.08 kg (p= 0.004). From the initial moment to study conclusion, there was a statistically significant reduction in insulin levels (9.0 ± 2.8 U/mL; p=0.012) and in homeostatic model assessment-insulin resistance (2.0 ± 0.6;p= 0.009). Five patients reported, during the first week, epigastric pain; nausea and vomiting were observed in two patients. No adolescents presented dysphagia during IB use. CONCLUSION: IB use in adolescent females with severe obesity in association with a conservative multidisciplinary treatment had a positive impact in BMI reduction, with few adverse effects. There was also an improvement in insulin resistance.

Balão intragástrico como tratamento ponte para a cirurgia bariátrica / Intragastric ballon as bridge treatment for bariatric surgery

Introdução: a obesidade, uma doença crônica e degenerativa de causa multifatorial, é um problema crescente de saúde pública em todo o mundo, associada à alta morbiletalidade. O balão intragástrico (BIG) é um tratamento endoscópico temporário para a obesidade e pode ser aplicado aos pacientes com obesidade grave como uma ponte de tratamento, com intuito de reduzir os riscos cirúrgicos. Objetivo: avaliar o impacto da perda de peso com uso do BIG nos resultados cirúrgicos de pacientes obesas. Método: trata-se de um estudo retrospectivo em que foram avaliados as pacientes obesas submetidas à colocação de BIG e posteriormente operadas. Foram colhidos dados sociodemográficos, antropométricos, clínicos e cirúrgicos. Resultados: a média de idade das 12 pacientes foi de 36,6 ± 7,3 anos, altura média de 1,64 ± 0,06 m e o tempo médio de permanência do balão de 199,3 ± 9,6 dias. A média de peso antes da colocação do BIG era de 132,7 ± 17,7 kg e o IMC de 49,2 ± 7,7 kg/m2 e, após a retirada do balão, 120,3 ± 18,7 kg, com IMC de 44,7 ± 7,2 kg/m2 respectivamente (p<0,0001). Observou-se uma redução média de 9,4 ± 5,4% do peso corporal. Uma paciente (8,4%) realizou sleeve gástrico e as demais, cirurgias de Fobi-Capella. O tempo de internação pós-cirúrgico foi de 6 ± 2,1 dias, não havendo intercorrências transoperatórias ou complicações cirúrgicas no grupo. A média de peso seis meses após a cirurgia foi de 96,4 ± 2,0 kg e o IMC de 35,9 ± 8,6 kg/m2. A porcentagem de perda de peso média foi de 21,5 ± 6,1%. Conclusão: quando aplicado em instituições especializadas, com experiência no tratamento da obesidade, o BIG representa uma modalidade segura, mesmo em pacientes obesos de alto risco. E, embora temporária, representa uma maneira útil de reduzir o IMC e auxiliar no controle de comorbidades em pacientes extremamente obesos, podendo tratar-se de um tratamento ponte para a cirurgia bariátrica.

Introduction: obesity, a chronic and degenerative disease caused by multiple factors, is a growing public health problem worldwide, associated with high morbidity and mortality. The intragastric balloon (BIB) is a temporary endoscopic treatment for obesity and can be applied to patients with severe obesity as a bridge treatment with the aim of reducing the surgical risk. Objective: to evaluate the impact of weight loss with BIB's use in surgical outcomes of obese patients. Method: this is a retrospective study which evaluated obese patients undergoing placement of BIB and later operated. Sociodemographic, anthropometric, clinical and surgical data were collected. Results: the mean age of the 12 patients was 36.6 ± 7.3 years, mean height of 1.64 ± 0.06 m and the average length of balloon stay was 199.3 ± 9.6 days. Mean weight prior to placing the BIG was 132.7 ± 17.7 kg, BMI 49.2 ± 7.7 kg / m2 and, after removal of the balloon, 120.3 ± 18.7 kg, with BMI 44.7 ± 7.2 kg / m2 respectively (p<0.0001). There was a mean reduction of 9.4 ± 5.4% of body weight. One (8.4%) patient underwent sleeve stomach and other Fobi-Capella surgery. The time of postoperative hospital stay was 6 ± 2.1 days, there were no intraoperative complications or surgical complications in the group. The average weight six months after surgery was 96.4 ± 2.0 kg and BMI 35.9 ± 8.6 kg / m2. The percentage of average weight loss was 21.5 ± 6.1%. Conclusion: when applied in specialized agencies with experience in treating obesity, BIB is a safe mode even in high-risk obese patients. And although temporary, is a useful way to reduce BMI and assist in the control of comorbidities in extremely obese patients, can be treated as bridge treatment for bariatric surgery.

Utilização de balão intragástrico e perda de peso em pacientes em um centro de referência no Rio Grande do Sul / Use of intragastric balloon and weight loss in patients at a reference center in Rio Grande do Sul

Objetivo: Estudar a relação entre perda de peso e a utilização de balão intragástrico. Método: Estudo transversal prospectivo desenvolvido com 50 usuários de balão intragástrico em um centro de referência em aparelho digestório no Rio Grande do Sul. Foi calculado o índice de massa corporal (IMC), dividindo-se o peso (quilograma) pela altura (metro) elevada ao quadrado e considerado normal IMC<25; como sobrepeso 25-29,9;IMC 30-34,9 como obesidade grau I; IMC 35-39,9 como obesidade grau II e IMC>40 obesidade grau III, conforme Organização Mundial da Saúde (OMS)/2000. Resultados: Foram avaliados 50 pacientes com estado nutricional entre sobrepeso e obesidade grau III, conforme classificação da OMS/2000. Em relação à porcentagem de perda de peso, observou-se que 46% dos pacientes tiveram uma perda entre 10-15 kg, 24% perda menor que 10 kg, 22% perda entre 15-20 kg e 8% perda maior de 20 kg. Conclusão: Embora a perda média fique entre 15 a 20% do peso inicial, esta perda seja extremamente variável e dependa de vários fatores, como peso inicial, adaptação, volume de preenchimento, disposição emocional para mudanças, adesão ao controle clínico e nutricional, grau de atividade física, metabolismo basal, a motivação e a disciplina para implantar as mudanças são os grandes determinantes deste resultado. Contudo, podemos observar, no presente estudo, evidências sobre a eficácia do tratamento com balão intragástrico em pacientes obesos.(AU)

Objective: To study the relationship between weight loss and use intragastric balloon. Methods: A prospective cross-sectional study was carried out with 50 intragastric balloon users at a reference center in a gastrointestinal tract in RS. The body mass index (BMI) was calculated by dividing the weight (kilogram) by the height (meter) elevated squared and considered normal BMI <25; As overweight 25-29.9; BMI 30-34.9 as obesity grade I; BMI 35-39,9 as obesity grade II and BMI> 40 obesity grade III according to World Health Organization (WHO)/ 2000. Results: Fifty patients with nutritional status between overweight and grade III obesity were evaluated, according to WHO / 2000 classification. Regarding the percentage of weight loss, it was observed that 46% of the patients had a loss between 10-15 kg, 24% a loss less than 10 kg, 22% loss between 15-20 kg and 8% loss greater than 20 kg. Conclusion: Although the average loss is between 15 and 20% of the initial weight, this loss be extremely variable and depends on several factors such as initial weight, adaptation, filling volume, emotional disposition for changes, adherence to clinical and nutritional control, degree of physical activity, basal metabolism, motivation and discipline to implant the changes are the major determinants of this result. However, we can observe in the present study evidence on the efficacy of intragastric balloon treatment in obese patients.(AU)

Efficacy and future of endoscopic bariatric surgery in the treatment of obesity and metabolic diseases / 中华胃肠外科杂志

The emerging endoscopic technologies are proved to be effective treatments for obesity in selected patients and to offer the potential advantages of reduced invasiveness, reversibility and repeatability. From the view of operation principle, endoscopic technologies can be classified as restrictive procedure, malabsorption procedure and endoscopic revision of gastric bypass. Restrictive procedures include intragastric balloon, aspiration therapy, endoscopic sleeve gastroplasty (ESG) and transoral gastroplasty. Intragastric balloon employs space occupying, volume restriction and satiety mechanisms, which is superior to drugs and lifestyle change, but shorter than sleeve and bypass surgery. Aspiration therapy is similar to standard percutaneous endoscopic gastrostomy, while there are no available data regarding the obesity and metabolic improvement. Compared with traditional bariatric surgery, ESG does not excise gastric tissue with less complications and without weight regain, but it can not be used as an independent operation still now. Transoral gastroplasty is rarely applied clinically whose efficacy and long-term complications need further studies. Malabsorption surgery includes endoscopic duodenojejunal bypass sleeve (EDJBS) and endoscopic gastroduodenojejunal bypass sleeve(EGDJBS). EDJBS may have the similar mechanism like bypass reducing the blood glucose. Even with obvious effect of weight loss, EDJBS has high morbidity of complications and requirements of the skilled operators. EGDJBS, which imitates bypass anatomy changes and belongs to the mixed operation, should be superior to the above procedures in reducing weight theoretically, but due to the lack of clinical data, its short-term and long-term efficacy still need further clinical observation. As compared to the complexity and risks associated with telescopic surgical revision, endoscopic suturing has been confirmed as less invasive and safer for stomal revisions, while its long-term efficacy of reducing weight and improvement of diabetes are not yet clear. Even if long-term efficacy of reducing weight and morbidity of complication in endoscopic bariatric surgery are still indefinite, and clinical trial researches of large sample and long-term follow-up are absent, with the development of endoscopic skill and the gradual clinical application, endoscopic bariatric surgery will provide a new option for the patients of obesity and metabolic diseases.

Two hearts, one rhythm: A case report on thoracoomphalopagus twins / Philippine Journal of Obstetrics and Gynecology

A 21-year old woman, G1P0, was referred for further prenatal check-up with sonographic examination revealing conjoined twins at 29 weeks age of gestation. The fetuses were in breech presentation positioned face-to-face with fusion at the level of the thoraces and gastric bubble suggestive of thoracoomphalopagus twins. There was a definite communication between the two fetal circulations at the ventricular level as seen on fetal echocardiogram with a single cardiac rhythm shared between the two hearts. Close antenatal and fetal surveillance was done during the entire pregnancy duration. The patient was counseled about therapeutic options and explained of the complexity of their cardiac anatomy. The twins were delivered by cesarean section at 35 weeks due to preterm labor and a neonatal 2D-echocardiogram was done shortly after to re-assess their cardiac anatomy. Since the results revealed a shared ventricle, the twins were considered inseparable. The family was apprised of their poor prognosis and opted for natural death to occur.

Clinics in diagnostic imaging (165). Oesophageal rupture secondary to malposition of an SB tube gastric balloon

Oesophageal rupture is a life-threatening complication of balloon tamponade for bleeding oesophageal varices. We herein describe the clinical course and imaging findings in a 33-year-old Indian man who had a Sengstaken-Blakemore (SB) tube inserted for uncontrolled haematemesis, which was unfortunately complicated by malposition of the gastric balloon with resultant oesophageal rupture. The inflated SB tube gastric balloon was visualised within the right hemithorax on chest radiography after the SB tube insertion. Further evaluation of the thorax on computed tomography confirmed the diagnosis of oesophageal rupture associated with right-sided haemopneumothorax. It is crucial for both the referring clinician and reporting radiologist to recognise early the imaging features of an incorrectly positioned SB tube gastric balloon, so as to ensure prompt intervention and a reduction in patient morbidity and mortality.

Novel Endoscopic Management of Obesity

Endoscopic procedures have been well-documented in the obesity field, but have not yet reached a sufficient level of evidence as stand-alone methods for treating obesity. It is unclear if they should take over. Although expanding, the array of bariatric surgical techniques does not fully meet the current needs, and there are not enough resources for increasing surgery. Surgery is avoided by a majority of patients, so that less aggressive procedures are necessary. For the time being, relevant endoscopic methods include intra-gastric balloons, gastric partitioning (Endo-plication), and the metabolic field (Endo-barrier). Surgical novelties and basic research are also important contributors owing to their potential combination with endoscopy. Conditions have been listed for implementation of bariatric endoscopy, because innovation is risky, expensive, and faces ethical challenges. A scientific background is being built (e.g., hormonal studies). Some techniques require additional study, while others are not ready but should be priorities. Steps and goals include the search for conceptual similarities and the respect of an ethical frame. Minimally invasive bariatric techniques are not ready for prime time, but they are already being successful as re-do procedures. A time-frame for step-strategies can be defined, and more investments from the industry are mandatory.

Effect of weight loss induced by intragastric balloon therapy on cardiac function in morbidly obese individuals: a pilot study

The aim of the study was to investigate the effect of intragastric balloon therapy on left ventricular function and left ventricular mass in a cohort of morbidly obese patients. A prospective trial was performed in a cohort of 17 class II and class III morbidly obese individuals. The intragastric balloon was retained in the stomach for an average of 6 months. Conventional and tissue Doppler echocardiography were performed in all patients before and after the procedure. The mean age of the study participants was 36 +/- 10 years [range: 18-55]. The mean body mass index was significantly decreased following the intragastric balloon insertion procedure [44 +/- 8 vs. 38 +/- 5, p < 0.001]. The left ventricular mass index and left atrial volume index were significantly decreased following the procedure [112 +/- 21 vs. 93 +/- 17, p = 0.001 and 20 +/- 6 vs. 14 +/- 5, p = 0.02, respectfully]. In addition, the ratio of mitral peak early diastolic velocity to tissue Doppler-derived peak diastolic velocity and tissue Doppler echocardiography-derived left ventricular myocardial performance index were decreased significantly following the procedure [9.5 +/- 1.9 vs. 7.7 +/- 1.5, p = 0.002 and 0.57 +/- 0.11 vs. 0.46 +/- 0.06, p= 0.001, respectively].Intragastric balloon therapy resulted in significant weight reduction in morbidly obese patients. This weight reduction was associated with improved left ventricular function

Role of Gastroenterologists in Management of Obesity / 대한소화기학회지

Obesity is a serious disorder that increases morbidity and mortality. Primary intervention with life style modification and medication is not always effective for obese patients. Endoscopic management of obesity may be a less invasive, more cost-effective, and relatively safer option than bariatric surgery. Moreover, therapeutic endoscopy is considered to be the primary modality for managing complications that occur after bariatric surgery. In the near future, role of gastroenterologists will be more important in the management of obesity and its related problems.

Bariatric surgery – An update for the endocrinologist / Cirurgia bariátrica – Uma atualização para o endocrinologista

Obesity is a major public health problem, is associated with increased rates of mortality risk and of developing several comorbidities, and lessens life expectancy. Bariatric surgery is the most effective treatment for morbidly obese patients, reducing risk of developing new comorbidities, health care utilization and mortality. The establishment of centers of excellence with interdisciplinary staff in bariatric surgery has been reducing operative mortality in the course of time, improving surgical safety and quality. The endocrinologist is part of the interdisciplinary team. The aim of this review is to provide endocrinologists, physicians and health care providers crucial elements of good clinical practice in the management of morbidly obese bariatric surgical candidates. This information includes formal indications and contraindications for bariatric operations, description of usual bariatric and metabolic operations as well as endoscopic treatments, preoperative assessments including psychological, metabolic and cardiorespiratory evaluation and postoperative dietary staged meal progression and nutritional supplementation follow-up with micronutrient deficiencies monitoring, surgical complications, suspension of medications in type 2 diabetic patients, dumping syndrome and hypoglycemia. Arq Bras Endocrinol Metab. 2014;58(9):875-88.

A obesidade é um problema de saúde pública, está associada com aumento do risco de mortalidade e de desenvolver diversas comorbidades e diminui a expectativa de vida. A cirurgia bariátrica é o tratamento mais eficaz para pacientes com obesidade mórbida, reduzindo o desenvolvimento de novas comorbidades, a utilização dos cuidados de saúde e a mortalidade. A criação de centros de excelência com equipes interdisciplinares em cirurgia bariátrica vem reduzindo a mortalidade operatória no decorrer do tempo, melhorando a segurança e a qualidade cirúrgica. O endocrinologista faz parte da equipe interdisciplinar. O objetivo desta revisão é fornecer aos endocrinologistas, médicos e prestadores de cuidados de saúde elementos cruciais de boas práticas clínicas no tratamento de pacientes com obesidade mórbida candidatos à cirurgia bariátrica. Essas informações incluem indicações formais e contraindicações para as operações bariátricas, descrição das operações bariátricas e metabólicas habituais, bem como tratamentos endoscópicos, avaliação pré-operatória, incluindo avaliação cardiorrespiratória psicológica, metabólica e no pós-operatório, dieta com refeições progressivamente estagiadas e seguimento com suplementação nutricional e monitoramento de deficiências de micronutrientes, complicações cirúrgicas, suspensão de medicamentos em pacientes diabéticos tipo 2, síndrome de dumping e hipoglicemia. Arq Bras Endocrinol Metab. 2014;58(9):875-88.

Is endoscopic sphincterotomy plus large-balloon dilation a better option than endoscopic large-balloon dilation alone in removal of large bile duct stones? A retrospective comparison study.

Background: Several comparison studies have demonstrated that endoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) may be a better option than EST alone to manage large bile duct stones. However, limited data were available to compare this combination method with LBD alone in removal of large bile duct stones. Objective: To compare EST plus LBD and LBD alone for the management of large bile duct stones, and analyze the outcomes of each method. Patients and Methods: Sixty-one patients were included in the EST plus LBD group, and 48 patients were included in the LBD alone group retrospectively. The therapeutic success, clinical characteristics, procedure-related parameters and adverse events were compared. Results: Compared with EST plus LBD, LBD alone was more frequently performed in patients with potential bleeding diathesis or anatomical changes (P = 0.021). The procedure time from successful cannulating to complete stone removal was shorter in the LBD alone group significantly (21.5 vs. 17.3 min, P = 0.041). The EST plus LBD group and the LBD alone group had similar outcomes in terms of overall complete stone removal (90.2% vs. 91.7%, P = 1.000) and complete stone removal without the need for mechanical lithotripsy (78.7% vs. 83.3%, P = 0.542). Massive bleeding occurred in one patient of the EST plus LBD group, and successfully coagulated. Postoperative pancreatitis did not differ significantly between the EST plus LBD group and the LBD alone group (4.9% vs. 6.3%; P = 1.000). Conclusion: Endoscopic sphincterotomy combined with LBD offers no significant advantage over LBD alone for the removal of large bile duct stones. LBD can simplify the procedure compared with EST plus LBD in terms of shorten the procedure time.

Obesity and gastric balloon

The obesity epidemic, which is among the most common nutritional disorders, is rising rapidly worldwide. It leads to several health problems such as metabolic disorders, stroke, and even cancer. Efforts to control obesity with exercise and diet have a limited value in obese patients and different approaches to do this have been tried. In this paper, we share our experience with bioenteric intragastric balloon [BIB] in treating obesity: Its safety, tolerability, and its efficacy in weight reduction. From January 2009 to September 2012, a total of 190 gastric balloons was inserted on patients at the endoscopy unit in King Fahd Hospital of the University, Al-Khobar. This is an evaluation of the first 100 patients. All the patients had a body mass index of over 30 kg/m[2] and were within the age range of 17-55 with a mean age of 32 years. After consent, preballoon investigation tests and anesthesia evaluation, BIB was inserted under monitored anesthesia care sedation in the endoscopy suite. The balloon was filled with 500-700 mls of stained saline. All patients' were given an analgesic and antiemetic for a week and antisecretory proton pump inhibitor's for 6 months. Diet and the importance of the exercise were part of the preballoon insertion phase and protocol. The balloon was removed after 6-12 months. The weight loss response to BIB in the 100 patients are classified into four groups: In the uncooperative, noncompliant patients - the maximum weight loss was 7 kg, while in the most compliant patients the weight loss reached up to 39 kg. In addition, there was significant improvement into diabetes mellitus, hypertension, dyslipidemia, and fatty liveras. Its safety and tolerability were extremely acceptable. Our data indicates that in well-selected patients, BIB is an effective device, which with minimum complications helps to achieve body weight loss and resolve many obesity related morbidities in cooperative and dedicated obese patients