Intragastric Balloons for Treatment of Obesity

1. Intragastric Balloons
for Treatment of Obesity
Hossam Ghoneim, MD

2. OBESITY is a chronic disease
WHO statement 1996

3. What is Obesity?
BMI .. Height(m2
)/wt (kg)
• Normal Range:
– BMI : 20 < 25
• Overweight:
– BMI : > 25 < 30
• Obese:
– BMI : > 30
• Morbid Obese:
– BMI : > 40
• Super Obese:
– BMI : > 50

4. Risk Assessment in Obesity
Waist circumference (cm)
• Assess risk of developing
obesity related comorbidities
• MEN
– Healthy range < 94cm
– Risk range 94 - 102cm
– High risk > 102cm
• WOMEN
– Healthy range < 80cm
– Risk range 80 - 88cm
– High risk > 88cm

5. Treatment Options
• Surgical treatment
• Non-surgical treatment

6. Surgical Treatment for Obesity
• Reduction of Absorption
– Gastric Bypass
– Biliopancreatic diversion
• Reduction of Intake
– Gastric Banding
• LAP-BAND®-System
– VBG
– Sleeve gastrectomy

7. Non Surgical treatment
• Weight Loss Programs
• Pharmaceutical Agents
• Gene therapy
• Intragastric Balloon

8. BMI
Treatment options

9. Intragastric Balloons
The BIB System

10. History of Intragastric balloons

11. Garren-Edwards Bubble
• 1984 Garren gastric bubble
publications
- Polyurethane
- Air Filled
- 220 ml
- Sharp edges
- Recommended placement: 3
months

12. Garren-Edwards Bubble (cont’d)
• Problems
– High complication rates associated with sharp edges
and can shape.
– Low effectiveness and frequent deflation attributed
to low fill volume and air filled.

13. Tarpon Springs
• 1987 Obesity Congress “Tarpon Springs” (USA)
–Scientific conference held with 75 international
experts from the fields of gastroenterology, surgery,
obesity, nutrition and DBM experts to develop a
general consensus on this technology/treatment
option.

14. Tarpon Springs Criteria
• Effective at promoting weight loss
• Filled with liquid ( not air )
• Capable of adjustment to various sizes
• Have smooth surface and low potential for causing ulcer
and obstructions
• Contain a radiopaque marker that allows proper follow-up
of the device if it deflates
• Be constructed of durable materials that DOES NOT LEAK

15. The BIB System
• Distinctive Physical Characteristics
- Perfectly round
- Silicone Elastomer
- Smooth surface
- Radiopaque marker
- 6 month life
- Saline filled, 400 - 700 ml

16. How does the BIB work?
• Nausea during starting period.
• Food stays in stomach longer ( gastric emptying)
• Promotes satiation and satiety.

17. Who will benefit from BIB ?
• Patient who can not abide by a strict diet program
• BMI not yet indicated for surgery
• Indicated for surgery but prefers a less invasive approach
• Well motivated patient with clear and realistic expectations
• Patients with metabolic syndromes not fit for surgery

18. Criteria for success
• Major criteria of success is a well informed patient
– Compliance
– Clear expectation
• Understanding of the possible nausea and vomiting within the first
few days
– Motivation
– Good follow up with team specialists

19. Pre-placement care
• NPO 6-8 hours before placement
• Always accompanying person present
• Revise Dietary program

20. Placement
• Fully equipped theatre
• Monitoring of vital signs during placement
• Deep sedation ( Propofol)
• Perform full endoscopy before placement
• BIB is filled with normal saline & 2,5 ml MB
• Post-op care in fully equipped recovery room, with qualified
nursing-staff

23. Post-placement care
• Patient is discharged when fully awake
• Patient is not allowed to drive after placement
• Limited social activities for 3-5 days after placement
• Medication:
– PPI (? maintenance therapy)
– Domperidon or Metoclopramide
– Antispasmodic & Pain killer at night
• Follow up starts directly in the first week
– Possibility of consultation by telephone or at the clinic
– Nutrition & dieting program

24. Teamwork
• GI specialist who handles the endoscopic part,
– Placement and removal of the system.
• Follow-up patients, assistance to change eating
pattern
Nutritionist / Dietician
• Centers with a complete obesity program or
willingness to establish this.

25. BIB removal
• Preparation: liquid diet 24 h before removal day
• Patient position & sedation is similar to placement
• Use BIB removal instruments
– common removal instruments inadequate

26. Balloon killer
BalloonBalloon ExtractorExtractor

28. Complications & their management
• Severe nausea
• Dehydration
• Deflation
• Obstructions

29. Severe nausea
• Frequent during adaptation period
– 80 % experience severe nausea combined with vomiting ( 3 to 4
days max 1 week )
• Propulsive medication
– Motilium, Primperan IV, or Zofran
• PPI for 1 month or 6 month if reflux
• Analgesics, Antispasmodics, Anxiolytics

30. Dehydration
• Standard procedure minimum 1 liter of normal
saline IV during admission clinic
• At discharge, provide information on liquid intake
and diet
• In case of severe dehydration, clinical hydration
(IV saline)

31. Deflation
• Use MB for early detection
• Maximum placement period of 6 months
• In case of doubt perform plain abdominal X-ray

32. Obstruction
• Only seen in case of previous open surgery or major
laparoscopic surgery
• Remove BIB always within 6 months

33. Contraindications
(Absolute)
• Inflammatory diseases
– Oesophagitis, gastric or duodenal ulceration (PUD)
– Crohn’s disease
• Potentially Bleeding conditions
– Oesophageal or gastric varices
– Telangiectasia
– Current use of anticoagulants, steroids or NSAID’s
• Pregnancy or breast feeding
• Previous gastric or duodenal surgery

34. Contraindications
(Relative)
• Large hiatus hernia
• psychiatric disorders
• Alcoholism or drug addiction
• Refuse of diet and behavior modification program
• BMI < 30
• Any kind of laparotomy in the past

35. Take Home Message
►Good patient selection and follow up is neededGood patient selection and follow up is needed
►BIB is part of treatment algorithmBIB is part of treatment algorithm
►Average weight loss ranging from 15 kg to 30 kgAverage weight loss ranging from 15 kg to 30 kg
►When used correctly a minimum of complicationsWhen used correctly a minimum of complications
►BIB is NOT magic, it’BIB is NOT magic, it’s a good helps a good help

36. THANK YOU