Bariatric Artery Embolization for Obese Patients. An Up-to-Date Review.

Overweight and obesity are one of public health's major problems in the world. Conservative treatment with exercise, diet and pharmacotherapy is often ineffective, especially in the long term. Bariatric surgery is the gold standard method for a sustained long-term weight loss. Recently the endovascular technique of bariatric artery embolization (BAE) has been studied as an obesity and overweight treatment, with promising results. The goal of this article is to analyze the rationale behind BAE and to provide an up-to-date analysis of its strengths and limitation in comparison with bariatric surgery as a treatment for obesity.

Left Gastric Artery Pseudoaneurysm Complicating Chronic Calcifying Pancreatitis in a Child.

A left gastric artery pseudoaneurysm is a rare complication of pancreatitis and is associated with significant morbidity and mortality. We report a 14-year-old male with severe abdominal pain and a palpable upper abdominal mass, earlier diagnosed as chronic idiopathic calcifying pancreatitis, and awaiting surgical intervention. Computed tomography showed a pseudocyst and a pseudoaneurysm in the lesser sac near the left gastric artery. The patient underwent successful angiographic coiling of the left gastric artery and definitive pancreatic surgery weeks thereafter. The early detection and interventional radiologic management of the vascular complication averted a life-threatening hemorrhage without emergency surgery in a pediatric patient.

Histopathological and immunohistochemical changes of gastric fundus and duodenum after bariatric embolization in the New Zealand rabbits / 中华放射学杂志

Objective:To investigate the histopathological and immunohistochemical changes of gastric fundus and duodenum after bariatric embolization of left gastric artery and gastroduodenal artery in obesity New Zealand rabbit models.Methods:Twenty obesity New Zealand rabbit models were successfully established and divided into two groups using stratified randomization. Left gastric artery and gastroduodenal artery were embolized with gelatin sponge (350-560 μm) in experimental group, left gastric artery and gastroduodenal artery were perfused with normal saline in control group. All animals were sacrificed for pathological, immunohistochemical examination and Western Blot analysis 4 weeks post embolization, the density of ghrelin producing cells and the gray ratio of ghrelin protein band were measured and compared by the independent sample t test. Results:Macropathological examination showed ulceration in the anterior wall of the gastric body in one rabbit, histopathological examination showed mucosa ulceration in the gastric body in 3 rabbits in experimental group. Immunohistochemical examination showed that the ghrelin producing cells of gastric fundus and duodenum in the experimental group were significantly less than those in the control group (10.0±5.1 vs.27.7±3.4, t=12.35, P<0.05;5.6±2.6 vs. 12.3±2.1, t=4.73, P<0.05). Western Blot analysis showed that the gray ratio of ghrelin bands of gastric fundus and duodenum in the experimental group were significantly lower than that in the control group (0.65±0.05 vs.1.12±0.09, t=9.62, P<0.05;0.55±0.03 vs. 0.94±0.08, t=7.98, P<0.05). Conclusions:Immunohistochemical and Western Blot analysis showed that the ghrelin-producing cells of gastric fundus and duodenum in the experimental group were significantly less than those in the control group after bariatric embolization, histopathologic analysis indicated that bariatric embolization was a safe technique.

Verification of thrombus formation just after endoscopic injection sclerotherapy with ligation for esophagogastric varices by venous phase of left gastric arteriography.

Management of hepatic venous pressure gradient (HVPG) is important in the treatment of portal hypertension. We report a case that was treated by a hybrid procedure combining endoscopic injection sclerotherapy with ligation (EISL), left gastric artery embolization (LGE), and partial splenic artery embolization (PSE) based on a new concept ``splanchnic caput Medusae.'' The venous phase of left gastric arteriography just after EISL demonstrated thrombus formation in the gastric varices and the cardiac branch of the left gastric vein. The para-esophageal vein and lesser curvature branch of the left gastric vein were not affected. HVPG decreased from 14 to 11 mmHg immediately after LGE and PSE. 3D-CT reconstruction portal image revealed that the portal system reversed to almost normal form. This is the first case report in which thrombus formation in gastric varices and cardiac branch just after EISL could be demonstrated by the venous phase of left gastric arteriography.

Gastric necrosis and perforation following treatment of Dieulafoy's lesion with embolization of multiple gastric arteries: A case report.

Diagnosis, management, and treatment of Dieulafoy's lesion have been complicated since its first mention in 1884. With increased awareness over the decades, Dieulafoy's lesions are being managed differently based on the physician's expertise. Herein, we report a case of a 58-year-old female who was found to have a Dieulafoy's lesion on endoscopy, with her treatment complicated by gastric necrosis and perforation after multiple embolizations and limited surgical resection.

Effect of left gastric artery embolization on obesity and ghrelin/leptin levels in pigs.

OBJECTIVE: To investigate the influence of left gastric artery embolization (LGAE) on obesity and Ghrelin/Leptin levels in pigs. METHODS: Healthy female Wuzhishan piglets aged 3-4 months were allocated into obesity + LGAE group, obesity group, control group (fed with a normal diet; n=8 for each group). Body weight, serum Ghrelin, Leptin, glucose and insulin levels were compared before surgery, 1 month and 3 months after surgery. RESULTS: Piglets in obesity group and obesity + LGAE group were heavier than those in control group before and 1 month after surgery (P<0.001), and in obesity group were heavier than those in obesity + LGAE group 1 month after surgery (P<0.05). A significant decrease in body weight was observed in obesity + LGAE group 3 months after surgery (P<0.05), and the obesity group showed heavier weight than the other two groups (P<0.001). Ghrelin levels in obesity group and obesity + LGAE group were higher than those in control group before and 1 month after surgery (P<0.001), and in obesity group were higher than those in obesity + LGAE group 1 month after surgery (P<0.05). They showed an evident decrease in obesity + LGAE group 3 months after surgery (P<0.05), and in obesity group were higher than that in the other two groups (P<0.01). Leptin levels in obesity group and obesity + LGAE group were higher than those in control group before surgery (P<0.01) and 1 month after surgery (P<0.05). They decreased significantly in obesity + LGAE group 3 months after surgery (P<0.01), and in obesity group were higher than those in the other two groups (P<0.01). CONCLUSION: LGAE greatly contributes to weight loss possibly by reducing the secretion of Ghrelin and Leptin.

Left gastric artery embolization for obesity treatment: a systematic review and meta-analysis of human and animal studies.

PURPOSE: The main purpose of this systematic review was to reflect on recent literature on bariatric LGA embolization for obesity treatment and to compare this new procedure in human and animal studies. METHODS: A systematic search of Scopus, MEDLINE, Web of Science, Embase, and Google Scholar was performed to identify human and animal studies employing bariatric LGA embolization to treat obesity. As well, Cochrane's Q test and the I2 statistic were utilized to determine heterogeneity. RESULTS: Nine human and four animal studies recruiting a total of 118 cases (n = 78 patients and n = 40 animals) were included in analysis. All assessments on body mass index (BMI), weight, and ghrelin levels had been fulfilled based on before-after (human studies) and intervention-control designs (animal studies) using bariatric LGA embolization. The findings suggested that bariatric LGA embolization had significantly decreased BMI (mean difference (MD): - 2.66, 95% confidence interval [CI] - 3.74, - 1.58, P < 0.001) and weight (MD: - 8.69, 95% CI - 10.48, - 6.89, P < 0.001) in humans. Although overall pooled estimate showed no significant changes in ghrelin levels following this procedure (Hedges' g statistic: - 0.91, 95% CI - 1.83, 0.01, P = 0.05) in humans, a significant reduction was observed in animal studies (MD: - 756.56, 95% CI - 1098.79, - 414.33, P < 0.001) along with a significant drop in weight (MD: - 7.64, 95% CI - 13.73, - 1.54, P < 0.001). CONCLUSION: The present study concluded that ghrelin levels in humans had not been affected, although bariatric LGA embolization might significantly improve BMI and weight.

Future of Bariatric Embolization: A Review of Up-to-date Clinical Trials.

Obesity is a significant health issue with an overall rise in mortality; it has multiple risk factors, including hormonal effects, which play a significant role in the balance of food intake and weight gain. Ghrelin is an anabolic hormone secreted from stomach fundus and plays a significant role in this regulation. Management of obesity involves multiple interventions, including lifestyle adjustment, pharmacotherapy, and bariatric surgery. Bariatric embolization is a relatively new procedure; several animal studies show that embolization of the left gastric artery reduces serum ghrelin and induces weight loss.  Also, several clinical studies were conducted in the past ten years which have shown bariatric embolization's effectiveness in inducing weight loss: a meta-analysis of 47 patients included in six different clinical studies of left gastric artery embolization resulted in 8% total weight loss from baseline body weight. Many studies also show this procedure's effect on lowering the HgA1C level and lipid profile. Clinical studies mostly reported minor adverse effects such as transient abdominal discomfort, nausea and vomiting, gastric ulcers, and major adverse effects were uncommon, suggesting the procedure is well tolerated. It may be an alternative line of management in patients who are not suitable candidates for bariatric surgery. Although future clinical studies will provide an answer to several questions like the exact effects of the procedure on diabetes and metabolic syndrome, future studies are also needed to establish particular guidelines to match different patient characteristics with their optimal procedural techniques and pre- and post-procedure evaluation tests.

Body composition changes after left gastric artery embolization in overweight and obese individuals.

PURPOSE: To determine the effects of left gastric artery embolization (LGAE) on computed tomography (CT) body composition change. MATERIALS AND METHODS: Sixteen overweight or obese patients who had abdominal CT scans before and after LGAE for gastric bleeding were retrospectively reviewed. Body composition analysis was performed with semiautomated imaging processing algorithms (MATLAB 13.0, Math Works, MA). Adipose tissue and lean skeletal muscle were measured using threshold attenuation values. Total body fat index (BFI), subcutaneous fat index (SFI), visceral fat index (VFI), intramuscular fat index (IMFI), and skeletal muscle index (SMI) were determined ([tissue area (cm)]2/[height (m)]2). Excess body weight (EBW) was determined based on the Lorentz formula for ideal body weight. RESULTS: Mean follow-up was 1.5 ± 0.8 months. Following LGAE, patients experienced significantly decreased body weight (p = 0.003), BMI (p = 0.005), EBW (p = 0.003), BFI (p = 0.03), SFI (p = 0.03), and SMI (p < 0.001). Changes in VFI and IMFI did not significantly change (p = 0.13 and p = 0.83, respectively). CONCLUSIONS: Patients who underwent LGAE had significant unintended weight loss as a result of decreased body fat and skeletal muscle. Body composition analysis can readily assess the extent of fat loss and identify muscle wasting.

Bariatric Left Gastric Artery Embolization for the Treatment of Obesity: A Review of Gut Hormone Involvement in Energy Homeostasis.

OBJECTIVE: The global population is becoming more overweight and obese, leading to increases in associated morbidity and mortality rates. Advances in catheter-directed embolotherapy offer the potential for the interventional radiologist to make a contribution to weight loss. Left gastric artery embolization reduces the supply of blood to the gastric fundus and decreases serum levels of ghrelin. Early evidence suggests that this alteration in gut hormone balance leads to changes in energy homeostasis and weight reduction. The pathophysiologic findings and current evidence associated with the use of left gastric artery embolization are reviewed. CONCLUSION: The prevalence of obesity continues to increase at an alarming rate, and, thus far, advances in medical management have been relatively ineffective in slowing this trend. Lifestyle modifications such as diet and exercise are effective initially, but most patients regain the weight in the long term. Bariatric surgery is the most effective strategy for achieving long-term weight loss; however, as with all surgical procedures, it has potential complications.

Minimally invasive percutaneous endovascular therapies in the management of complications of non-alcoholic fatty liver disease (NAFLD): A case report.

Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disorders from simple steatosis to inflammation leading to fibrosis, cirrhosis, and even hepatocellular carcinoma. With the progressive epidemics of obesity and diabetes, major risk factors in the development and pathogenesis of NAFLD, the prevalence of NAFLD and its associated complications including liver failure and hepatocellular carcinoma is expected to increase by 2030 with an enormous health and economic impact. We present a patient who developed Hepatocellular carcinoma (HCC) from nonalcoholic steatohepatitis (NASH) cirrhosis. Due to morbid obesity, she was not an optimal transplant candidate and was not initially listed. After attempts for lifestyle modifications failed to lead to weight reduction, a transarterial embolization of the left gastric artery was performed. This is the sixth such procedure in humans in literature. Subsequently she had a meaningful drop in BMI from 42 to 36 over the following 6 months ultimately leading to her being listed for transplant. During this time, the left hepatic HCC was treated with chemoembolization without evidence of recurrence. In this article, we wish to highlight the use of minimally invasive percutaneous endovascular therapies such as transarterial chemoembolization (TACE) in the comprehensive management of the NAFLD spectrum and percutaneous transarterial embolization of the left gastric artery (LGA), a novel method, for the management of obesity.

The Global Nonalcoholic Fatty Liver Disease Epidemic: What a Radiologist Needs to Know.

Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disorders from a benign steatosis to hepatocellular carcinoma (HCC). Metabolic syndrome, mainly obesity, plays an important role, both as an independent risk factor and in the pathogenesis of NAFLD. With the progressive epidemics of obesity and diabetes mellitus, the prevalence of NAFLD and its associated complications is expected to increase dramatically. Therapeutic strategies for treating NAFLD and metabolic syndrome, particularly obesity, are continuously being refined. Their goal is the prevention of NAFLD by the management of risk factors, prevention of progression of the disease, as well as management of complications, ultimately preventing morbidity and mortality. Optimal management of NAFLD and metabolic syndrome requires a multidisciplinary collaboration between the government as well as the health system including the nutritionist, primary care physician, radiologist, hepatologist, oncologist, and transplant surgeon. An awareness of the clinical presentation, risk factors, pathogenesis, diagnosis, and management is of paramount importance to a radiologist, both from the clinical perspective as well as from the imaging standpoint. With expertise in imaging modalities as well as minimally invasive percutaneous endovascular therapies, radiologists play an essential role in the comprehensive management, which is highlighted in this article, with cases from our practice. We also briefly discuss transarterial embolization of the left gastric artery (LGA), a novel method that promises to have an enormous potential in the minimally invasive management of obesity, with details of a case from our practice.