Endoscopic and surgical treatment of obesity

ENDOSCOPIC
AND SURGICAL
TREATMENT OF
OBESITY

Introduction and overview
Space occupying devices.
Gastric restrictive measures.
Malabsorptive endoscopic procedures.
Measures regulating gastric emptying.
Surgical management of obesity
Take home message.

Potential Roles
• Primary therapy of obesity.
• Treat metabolic diseases such as diabetes in obese patients.
• Bridge to surgical therapy.
• Revision of failed surgical bariatric procedures.
Christine Hill, et al Annals of New York Academy of Sciences Sep 2017

Space
Occupying
Devices
Intragastric
Balloons.
Transpyloric
Shuttle
Gastric
Restrictive
Measures
Transoral
Gastroplasty
Transoral
Endoscopic
Restrictive
Implant System.
Malabsorptive
Endoscopic
Procedures
Duodenal-
Jejunal
Bypass Liner
(DJBL).
Sati-Sphere
Regulating
Gastric
Emptying
Intragastric
Botulinum
Toxin
Injections
Gastric
Electrical
Stimulation

Indications-
• Weight loss in patients with BMI > 35 kg/m2 where bariatric surgery is
contraindicated due to numerous comorbidities, failed dietary or
pharmacotherapy- assisted weight loss.
• Prior to bariatric surgery to reduce intraoperative risk.
• Insertion risk such as active gastric inflammation or ulceration,
• Large hiatus hernia > 5 cm, severe cardiovascular or respiratory comorbidities,
and coagulopathy
Contraindications-

ORBERA
• Approved in USA in 2015
• FDA approved for use in adults with a BMI
between 30 and 40 kg/m2
• Single, spherical balloon composed of
• Preloaded onto a catheter, deployed into the
gastric fundus, then inflated with 450–700
saline solution.

ORBERA
• Inserted under light sedation on OPD
• Transitioning to solid foods may take up
weeks.
• Removed endoscopically after 6 months.
• Removal is generally performed under
• First puncturing the balloon with a needle
emptying the saline with a catheter
grasping forceps or a polypectomy
to remove the deflated balloon.

• A recent systematic review identified 7 studies (409 patients) which
reported weight loss at 6 months with a mean EWL of 16 kg.
• 80% of weight loss was found to occur in the first 3 months of therapy.
S. Gaur et al.
Gastrointestinal
Endoscopy, vol.
81, no. 6, 2015.
• The durability of this technique is questionable, as demonstrated by Dastis
et al ;- only a quarter of individuals maintained weight loss up to 30
months after procedure.
Dastis et al.
Endoscopy, vol.
41, no. 7, 2009
• Migration and gastric perforation : 1.4% and 0.1% with the 50% of the
perforations occurring in those with prior gastric surgery.
Christine Hll.
Ann. N.Y. Acad.
Sci. 2017

ReShape.
•Approved by the FDA in July 2015.
•Dual-balloon device.
•Two silicone balloons connected by
flexible catheter.
•Inserted endoscopically inflated
with up to 450 mL saline or
methylene blue in each balloon, up
900 mL total.

Participants (n = 326) with body mass index (BMI) 30-40 kg/m(2) were randomized to endoscopic
DBS treatment plus diet and exercise (DUO, n = 187) or sham endoscopy plus diet and exercise
alone (DIET, n = 139).
DUO weight loss was over twice that of DIET.
DUO patients had significantly greater %EWL at 24 weeks compared with DIET patients ( 27.9 %
vs 12.3 %)
DUO patients significantly exceeded the response rate.
Balloon deflation occurred in 6% without migrations.
Dual balloon system plus diet and exercise in the treatment of obesity is more
effective compared to diet and exercise alone with a low adverse event profile.

OBALON
•Gelatin capsule with attached catheter.
•Air filled to 250 ml.
•FDA Approved in 2016.
•Percentage EWL- 36 % at 3 months.
•Indwell time - 3 to 6 months.
•Capsule is swallowed, fluoroscopy to ensure gastric
•Gelatin dissolves, inflated with air via catheter (extends to
mouth) which is then detached.
•Up to 3 balloons can be swallowed depending on the
progress.
Gregory Pajot, MD. Curr Treat Options Gastro 2017

The multicenter U.S. pivotal trial (n = 387) compared the outcomes of patients with the
Obalon IGB and lifestyle counseling (n = 185) vs control group of sham capsules and
lifestyle counseling (n = 181).
At 24 weeks, significant improvements in SBP, FBS, LDLc,TGs were noted in the
treatment group but not in the control group.
The %TBWL was 6.81 ± 5.1% in the treatment group and 3.59 ± 5.0% in the control group
at 6 months from first balloon insertion (three balloons inserted at 0, 3, 9, or 12 weeks).
Non serious adverse events occurred in 89.9% of subjects
The most common of these events were nausea and abdominal cramping
The Obalon balloon seems to be well tolerated, with lower incidence of accommodative
symptoms compared to those observed with other fluid-filled balloons.

Spatz adjustable balloon system
•It has an attached catheter to prevent migration
and an extractable injection tube for volume
adjustment
•Allows for in situ volume adjustment,
•Approved for 12-month therapy outside of the
United States.
•Single IGB that is placed endoscopically
•Filled with 400–800 mL saline solution.

•A small pilot study (n = 18), found %EWL at 6 and 12 months to
be 26.4% and 38.8%, respectively.
•Adjustment feature to be useful for tolerability and weight loss
following plateaus; however, 39% of the IGBs were removed
prematurely because of various adverse events.
Machytka,
et al. 2011.
Obes.
Surg. 21: 14
99–1507.
•Brooks et al. reported results in 73 patients in the UK.
•In those with successful insertion (n = 70), the rate of early
removal was 30%, due to premature satisfaction (14), intolerance
refusing adjustment (4), and deflation (3).
•At 12 months (in 49 patients and <12 months in 21 patients
owing to premature removal), the % EWL was 45.7%
Brooks, J. et
al. 2014.
Obes.
Surg. 24: 81
13–819.

Elipse
•Balloon with gelatin capsule and attached
catheter
•No need for endoscopic procedure;
•Swallowable, self-draining, naturally
and excreted in stool.
•EWL- 12.4% at 6 weeks.
•The catheter opening remains outside the
mouth and is used to fill the balloon with
Machytka E, et al. Elipse, the first procedureless gastric balloon for weight loss: Endoscopy. 2017;.

Heliosphere bag
•Polymer balloon covered with silicone.
•Gas filled to 700 ml
•Air filled so may reduce risk of digestive
intolerance.
•High rates of spontaneous deflation.
•EWL - 24 ± 4.2%
•Dwell time- 4 months.
Trande P, et al. Efficacy, tolerance and safety of new intragastric air-filled balloon (Heliosphere BAG) for obesity: Obes Surg. 2010;20:1227–1230.

It is composed of silicone and consists of a large
spherical bulb connected to a smaller cylindrical
bulb by a flexible catheter.
After deployment into the stomach, theTPS
moves freely without any physical attachment
or invasive anchoring to the tissues.
The device is designed to self-position across
the pylorus during peristalsis intermittent
obstruction and gastric emptying, early
and prolonged satiety.
Jason Behary and Vivek Kumbhari Hindawi Publishing Corporation Gastroenterology Research and Practice Volume 2015

Twenty patients with a mean body mass index (BMI) of 36.0 kg/m(2) were assigned to
2 groups of 10 patients scheduled to have the device for 3 or 6 months.
Devices were deployed and retrieved in all patients with no complications.
Three-month patients had mean %EWL of 25.1%, mean %EBMIL of 33.1%, and mean
%WL of 8.9%.
Six-month patients had mean %EWL of 41.0%, mean %EBMIL of 50.0%, and mean
%WL of 14.5%.
Early device removal occurred in 2 patients due to symptomatic gastric ulcerations,
which resolved after device removal.
TheTPS is a promising technology that provides a, nonsurgical, ambulatory
method for weight loss.
EWL- Excess weight loss, EBMIL- excess BMI loss,WL- Weight loss

Space
Occupying
Devices
Intragastric
Balloons.
Transpyloric
Shuttle
Gastric
Restrictive
Measures
Transoral
Gastroplasty
Transoral
Endoscopic
Restrictive
Implant System.
Malabsorptive
Endoscopic
Procedures
Duodenal-
Jejunal Bypass
Liner (DJBL).
Sati-Sphere
Regulating
Gastric
Emptying
Intragastric
Botulinum
Toxin
Injections
Gastric
Electrical
Stimulation

Endoscopic Sleeve Gastroplasty
•FDA approved full thickness endoscopic suturing
system (Overstitch Apollo Endosurgery, Austin, TX,
USA)
•Reduce gastric volume by approximately 70%
•Not an FDA approved procedure.
•A series of endoscopically placed full-thickness
prepyloric antrum to GE junction.
•This technique reduces the entire stomach along the
greater curvature, creating a sleeve.

Prospective study of 91 patients (mean age, 43.86 ± 11.26 years; 68% female).
All patients had a body mass index (BMI) greater than 30 kg/m2 and had failed
noninvasive weight-loss measures or had a BMI greater than 40 kg/m2 and were not
considered as surgical candidates or refused surgery.
Patients had lost 14.4% of their total body weight at 6 months, 17.6% at 12 months, and
20.9% at 24 months after ESG.
At 12 months after ESG, patients had statistically significant reductions in levels of
HbA1c, SBP, waist circumference,ALT, and serum triglycerides.
ESG is a minimally invasive and effective endoscopic weight loss intervention.
In addition to sustained total body weight loss up to 24 months, ESG reduced markers
of hypertension, diabetes, and hypertriglyceridemia.

POSE
•POSE depends on an Incisionless Operating
Platform (IOP) to place full‐thickness
tissue‐anchor plications.
•FDA is examining it for safety and efficacy.
•Plications in 8–9 locations in the fundus and
3–4 in the distal body using specialized suture
anchors.
•The g-Prox and g-Lix Endoscopic Graspers
manipulators in the approximation of
gastrointestinal and other soft tissue.
• The procedure and associated recovery time is <24 h.
• Following the procedure, patients advance from a clear liquid diet to a soft
pureed diet during the first month and then to solid food by 6 weeks.

POSE was performed on 18 patients; mean age 39 years (34-44), BMI 36.
At 15 months (n = 15), meanTWL was 19.1 ± 6.6% (15.5; 22.8) and EWL was 63.7 ± 25.1%
(49.8; 77.6).
At 2 and 6 months (n = 18), intake capacity decreased significantly from 901 to 473 and
574 kcal, respectively (p < 0.001).
At 2 months, Gastric emptying was delayed but returned to baseline levels at 6 mths.
Glucose/insulin ratio improved (p < 0.05).
Postprandial decrease in ghrelin was enhanced (p = 0.03) as well as postprandial increase
in PYY (p = 0.001).
• The POSE procedure was followed by significant sustained weight loss and improved
glucose homeostasis and satiation peptide responses.
• Weight loss following POSE may be mediated through changes in gastrointestinal neuro-
endocrine physiology.

TRANSORAL GASTROPLASTY
DEVICE
•The TOGA system enables the
creation of a stapled,
pouch along the lesser
curvature of the stomach.
•Not approved by FDA.
•By slowing the movement of
food and limiting the
expansion, early satiety is
achieved

Shi-Han, Yong- Jun wang Chinese medical journal 2018
• This mechanism creates a restrictive pouch (analogous to gastric banding) and a 10‐mm
channel for food to pass through.
• This procedure is under clinical investigation for the treatment of both obesity and
gastroesophageal reflux disease (GERD)

Endolumina
• Teflon covered, impermeable.
• Proximal end in duodenal bulb and distal end in
jejunum.
• Length- 65 cm and can remain in situ for 3–
12 months.
• Prevents contact between food and the mucosa.
• Allows pancreaticobiliary secretions to travel
along the outside of the device to the jejunum,
which results in food reaching the mid‐jejunum
earlier.

Modified DJBS
• Similar mechanism as the Endolumina.
• Length- 120 cm, and is secured at the
GE junction.
• This modification causes the sleeve to
bypass the stomach in addition to the
duodenum and proximal jejunum.
• Mimics the effects of RYGB and
reducing the capacity for intake.
Fateh Bazerbachi Clin Endosc 2017

SatiSphere
• 1mm nitinol wire with pigtail
several mesh spheres mounted
its course.
• Multiple mesh spheres reduce
flow of chyme – prolongs the
time – activation of CCK
release anorectic neuropeptides.
• The soft spheres stimulate
mechanoreceptors --- satiety
• Drawback - distal migration.

Duodenal mucosal resurfacing
•Specifically designed catheter to
deliver hot water into the
for circumferential mucosal lift.
•This is followed by inflation of a
2.0‐cm balloon with heated water
(T- 90‘C) for ablation of duodenal
mucosa.
•Resets duodenal endocrine cells
thus improve insulin signaling.

A total of 39 patients with type 2 diabetes (screening HbA1c 9.5%; BMI 31 kg/m2).
28 had a long duodenal segment ablated (LS; ∼9.3 cm) and 11 had a short segment
ablated (SS; ∼3.4 cm treated).
Three patients experienced duodenal stenosis treated successfully by balloon dilation.
HbA1c was reduced by 1.2% at 6 months in the full cohort (P < 0.001).
LS cohort experienced a 2.5% reduction in mean HbA1c at 3 months postprocedure vs.
1.2% in the SS group (P < 0.05) and a 1.4% reduction at 6 months vs. 0.7% in the SS
group (P = 0.3). ADA Diabetes Care 2016 Dec; 39(12): 2254-2261
Single-procedure DMR elicits a clinically significant improvement in hyperglycemia in
patients with type 2 diabetes in the short-term, with acceptable safety and tolerability.
Long-term safety, efficacy, and durability and possible mechanisms of action require
further investigation.

Space
Occupying
Devices
Intragastric
Balloons.
Transpyloric
Shuttle
Gastric
Restrictive
Measures
Transoral
Gastroplasty
Transoral
Endoscopic
Restrictive
Implant System.
Malabsorptive
Endoscopic
Procedures
Duodenal-
Jejunal Bypass
Liner (DJBL).
Sati-Sphere
Regulating
Gastric
Emptying
Intragastric
Botulinum
Toxin Injections
Gastric
Electrical
Stimulation

Intragastric Botulinum Toxin
Injections
• Botulinum toxin A (BTA) – inhibits ACh
at the neuromuscular junction,
delaying gastric emptying and
ghrelin secretion.
• Because BTA is accessible and not
with adverse events, it is an attractive
for the treatment of obesity.
• Both the antrum and fundus need to be
treated for optimal results.

Twenty obese patients (BMI >28 kg/m2) were randomized into two groups:
Group 1 (200 U BTX-A) and Group 2 (300 U BTX-A).
For each patient, 20 puncture sites were selected into the gastric wall.
Body weights and BMIs were recorded and gastric emptying times were
determined before treatment and 1, 4 and 12 weeks after treatment.
Both groups showed significant body weight (>5%) and BMI decrease
(p<0.05) with decreasedTG levels
A significant decrease in fasting ghrelin levels in all 19 obese patients was
found after BTX-A administration 4 weeks later.
Endoscopic multi-punctures of BTX-A including fundic injections may decrease
body weight and BMI by delaying the gastric emptying time.
The effect of BTX-A on ghrelin levels may also be involved in the reduction of
appetite.

Gastric Electrical Stimulation
•Gastric electrical stimulation has been
in patients with gastroparesis; however, its
use in obesity is currently being
•Several trials have shown that gastric
electrical stimulation results in significant
amounts of weight loss due to reduced
gastric accommodation, delayed gastric
emptying and increased intestinal transit.

Aspiration Therapy
• Endoscopic placement of a
tube (A-tube) and the AspireAssist
assembly to aspirate gastric
minutes after meal consumption.
• FDA approved for age 21 years or
with a BMI between 35 and 55
• The most common adverse events
peristomal pain, stoma granulation
formation, irritation, and infection.

Surgery for Obesity and Related Diseases (2016)

SURGICAL
TREATMENT
FOR
OBESITY
Gastric
volume
Reduction
Gastric
Bypass
1) Laproscopic adjustable gastric
banding
2) Sleeve Gastrectomy
The absorption of calories in small
intestine is decreased.
Ex- Biliopancreatic diversion
Roux-en-Y gastric Bypass
It is a combination of both restrictive and malabsorptive procedure

The Initial Phase
(1950–1970)
Small Bowel Bypass
The Middle Phase
(1970–1990)
Stomach Stapling
The Current Phase (1990 -
Present) Laparoscopic
Procedures.
• Jejunoileal bypass (JIB).
• The proximal 35 cm of
jejunum was joined end-
to-side to the last 10 cm
of ileum.
• Serious side-effects.
• Abandoned by the
1970s.
• Roux-en-Y gastric bypass
(RYGB)- 1970
• Biliopancreatic diversion
procedure (BPD)- 1976
• Vertical banded
gastroplasty (VBG)- 1982
• Duodenal switch variant
(BPD-DS)- 1990
• Laparoscopic adjustable
gastric band (LAGB)-
1993
• Sleeve Gastrectomy.
• Gastric imbrication
• Laparoscopic BPD or its
DS variant has remained
clinically challenging.
De Groot LJ, Chrousos G Surgical Treatment of Obesity - Endotext - NCBI Bookshelf Jan 2016

Nature Reviews | Gastroenterology & Hepatology Volume 8 | August 2011
Unsuccessful weight loss with dietary and exercise interventions, and one of the following:
1) BMI ≥40 kg/m2
2) BMI 35–39.9 kg/m2 with ≥1 comorbidities such as type 2 diabetes mellitus,
hypertension, or obstructive sleep apnea
3) BMI 30–34.9 kg/m2 with type 2 diabetes mellitus and failure to achieve glycemic
treatment targets with an optimal medical regimen.
Acceptable operative risk
Psychosocially stable with no active depression, psychosis, or substance abuse
Well-motivated patient, able to adhere to postoperative dietary restrictions

Laparoscopic adjustable gastric
banding (LAGB)
•The band- within 1 cm of GE junction.
•The access port - in the subcutaneous layer of
the anterior abdominal wall.
•Satiety- achieved for the LAGB patient by
adding or removing of fluid from the system to
change the degree of compression of the band.
•Satiation - is the resolution of hunger with
eating. Each bite is squeezed across by
esophageal peristalsis, generating increased
pressure on that segment of the gastric wall.

Sleeve gastrectomy
• Excision of approximately 80% of the stomach.
• The antrum is preserved to maintain gastric
emptying.
• Gastric imbrication is a non-resectional variant
of the sleeve gastrectomy.
• The greater curve vascular pedicles are ligated
and then the gastric wall is imbricated using two
rows of sutures to create a narrow lumen, similar
in size to the sleeve gastrectomy.
• The costs are reduced by avoiding the use of
multiple firings of stapling devices.

Roux-en-Y gastric bypass
• The stomach is divided completely by 2 rows of
staples.
• Small gastric pouch of 50ml + large residual
stomach.
• A Roux limb of jejunum (50cm from DJ flexure)
anastomosed with the small gastric pouch.
• Single anastomosis Gastric Bypass (SAGB)
simpler and safer than RYGB.
• Similar outcomes for effects on the metabolic
syndrome and quality of life.
Vest et al Bariatric Surgery for the Treatment of Obesity 2015

Biliopancreatic Diversion (BPD)
• The restrictive component is a partial
gastrectomy leaving a large proximal gastric
segment of between 200 and 500ml.
• The malabsorptive component consists of
division of the small intestine, usually at 250cm
proximal to the ileocecal valve, anastomosis of
the distal side of this division to the gastric pouch
• End-to-side anastomosis of the proximal side of
the division to the terminal ileum, usually at 50cm
proximal to the junction with the cecum.

Nature Reviews | Gastroenterology & Hepatology Volume 8 | August 2011

www.healthierweight.co.uk/obesity-surgery/procedure-comparison/

Intragastric balloons may represent an effective therapeutic strategy for
weight loss in the short term and are typically used in the super obese to
achieve a safe weight in patients prior to definitive bariatric surgery.
The Obera, ReShape Duo, and Obalon IGB have been approved by the
FDA, and the Ellipse and Spatz balloon have also been approved for
European use.
The majority of balloons have a volume of 500 ml and are left in place
for 6 months

TheTOGA system enables the creation of a stapled, restrictive
pouch along the lesser curvature of the stomach causing satiety.
Transpyloric shuttle is a promising technology that provides a,
nonsurgical, ambulatory method for weight loss
Endoscopic sleeve gastroplasty in addition to weight loss it reduces
the markers of hypertension, diabetes, and hypertriglyceridemia.
The POSE procedure causes significant sustained weight loss and
improved glucose homeostasis and satiation peptide responses.

TERIS creates a restrictive pouch (analogous to gastric banding) and a
10‐mm channel for food to pass through leading to satiety.
Duodenal-jejunal bypass liner (DJBL) prevents contact between food and
the mucosa leading to decreased absorption of food.
Single-procedure DMR elicits a clinically significant improvement in
hyperglycemia in patients with type 2 diabetes in the short-term, with
acceptable safety and tolerability.
Endoscopic multi-punctures of BTX-A including fundic injections may
decrease body weight and BMI by delaying the gastric emptying time.

Bariatric surgery has an important role in the treatment of severe and complex obesity.
RYGB, Laparoscopic adjustable gastric band (LAGB), SleeveGastrectomy, Gastric
imbrication, Laparoscopic BPD or its DS variant are the important bariatric procedures
done in the current practice.
There is no difference between RYGB and LAGB but a better weight is achieved with
biliopancreatic diversion.
All the surgical procedures have the potential for perioperative complications and death but
achieve substantial weight loss, improved health and quality of life and a longer life

VBG, vertical band gastroplasty; RYGB, Roux-en-Y gastric bypass;
DS, duodenal switch; BPD, biliopancreatic diversion.
Hyuk Soon Choi Clin Endosc 2017;50

Endoscopic and surgical treatment of obesity

Endoscopic and surgical treatment of obesity

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