This document discusses endoscopic management of obesity, known as endobariatrics. It can be used as primary therapy, bridging therapy before surgery, or revisional therapy after surgery. Primary endoscopic therapies include intragastric balloons, tissue apposition techniques, and nutrient diverting therapies. Secondary endoscopic therapies include transoral outlet reduction, revision obesity surgery procedures, and argon plasma coagulation. Several studies on intragastric balloons and other primary therapies show promising results with 20-50% excess weight loss. Endobariatrics aims to bridge the gap between medical and surgical obesity treatment.

1. Endoscopic Management Of
Obesity
(Endobariatrics)
Dr.Santosh M Narayankar
Department Of Gastroenterology
Yashoda Hospital

2. Bridge the gap between medical therapy
& surgical management.
• It may be used as
Primary Therapy
Bridging Procedure
Revisional Procedure

4. • Preoperative Endoscopy
• Post Operative Endoscopic
Management Of Surgical
Complications
• Endoscopic Treatment Of Obesity

5. PRIMARY THERAPY
• Intra Gastric Balloons
• Tissue Apposition Techniques
• Nutrient Diverting Therapies

6. Secondary Therapy
• Trans oral outlet reduction
• Revision Obesity Surgery Endoscopic
• Argon Plasma Coagulation

7. INTRAGASTRIC
BALLOONS

8. Intra Gastric Balloons
• Orbera Balloon –Fluid Filled
• Reshape Duo –Fluid Filled
• Spatz Ballon-Fluid Filled Adjustable
• Obalon Balloon-Gas Filled
• Elipse Balloon-Fluid filled
• TransPyloric Shuttle
FDA Approved in 2015-ReShape and Orbera

9. Orbera Balloon
• Most Studied And widely used –
Introduced in 1991
• Single,Spherical & made of silicone
• Placed Endoscopicaly
• Inflated with 400-700ml saline+2 to 10ml
Methylene blue
• Approved in 2015 by FDA

12. • The ASGE Bariatric Endoscopy Task Force
systematically reviewed 82 studies in 2015.
• These patients averaged a 25.4% EWL, with
a 95% confidence interval (CI) of 21.5% to
29.4%.
• Only 3 studies had adequate control
groups, with Orbera patients losing an
average of 26.9% more weight than control
patients , with 95% CI of 15.6% to 38.2%.
• A large RCT-results have not yet been
published

14. ReShape Duo
• The ReShape Integrated Dual Balloon System is
an endoscopically placed device consisting of 2
equal-sized silicone balloons connected by a
flexible shaft

15. • Each balloon is filled separately with either
375 or 450 mL of saline + methylene blue
• For a total volume of 750 or 900 mL
depending on the height of the patient.
• The device is removed endoscopically at 6
months.
• ReShape was approved by the FDA for
treatment of obesity in 2015.
ReShape Duo

16. • The ReShape IGB was evaluated in the
REDUCE Trial
• The completed study At 24 weeks, Duo
subjects had an average %EWL of 25.1%
compared with 11.3% in Diet patients(P= .
004) on intention-to-treat analysis.
• An average of 66% of weight lost at time of
balloon removal was maintained 24 weeks
later.

17. • Endoscopically placed, saline-filled single
intragastric balloon.
• Attached inflation tube -extracted out
through the mouth to adjust the balloon
volume during therapy to improve tolerance
or efficacy.
• Not approved by the FDA but is approved in
Europe for 12 months of therapy.
Spatz -Adjustable Balloon

18. Spatz Adjustable Balloon

19. • At present, there are limited safety and
efficacy data on the Spatz IGB.
• A study of 73 patients in the United
Kingdom showed a 45.7% EWL.

20. Obalon-Gas Filled Balloon
• Enclosed in a gelatin capsule, which is
swallowed by the patient under fluoroscopic
visualization.
• The capsule has an attached catheter that
extends through the esophagus and out of the
mouth, and is used to inflate the balloon with
250 mL of a nitrogen-mix gas.

21. Obalon-Gas Filled Balloon

22. • Pilot study - 17 patients was undertaken in
Europe, with up to 3 balloons given per patient,
swallowed individually at 4-week intervals, and
removed endoscopically at 12 weeks.
• Average EWL at 12 weeks was 36%, with no
serious adverse events reported.
• Most patients experienced transient abdominal
pain and nausea after balloon administration
Obalon-Gas Filled Balloon

24. • Enclosed within a capsule with an attached
catheter and swallowed under radiographic
guidance.
• 550ml fluid & remains in stomach for 4
months.
• Degrades over 4 months.
Elipse-Fluid filled swallowed
balloon

25. Elipse-Fluid filled swallowed
balloon

26. • An 8-patient pilot study using a
prototype demonstrated no adverse
events and patients lost an average of
12.4% of excess weight over 6 weeks.
• Results of a small multicenter study ,
yet to be published.
Elipse-Fluid filled swallowed
balloon

27. TransPyloric Shuttle
• Consists of a spherical bulb attached by a
flexible cord to a smaller cylindrical bulb
• Placed endoscopically and assembled in the
stomach.
• The large bulb rests in the antrum, with the
smaller bulb crossing into the duodenum.
• Intermittent obstruction at the pylorus leading
to delayed gastric emptying and longer periods
of satiety.

29. • One study of 20 participants showed
promising results, with mean EWL of 25%
at 3 months and 41% at 6 months
• Gastric ulcers in 50% of patients with
early device removal in 2 patients due to
symptomatic gastric ulcers.
• The ENDObesity II multicenter study is
currently underway, with no results yet
published.
TransPyloric Shuttle

31. Tissue Apposition
Techniques

32. • Gastric volume is reduced by using
endoscopically placed sutures to create a
gastric sleeve similar to a sleeve gastrectomy.
Endoscopic Sleeve
Gastroplasty

33. Overstitch endoscopic suturing device
(Apollo Endosurgery),an FDA-approved
commercial device for the purposes of tissue
apposition compatible with a double-channel
therapeutic gastroscope

35. • In 2015, midterm results of an open-label trial
were reported, with 25 patients (BMI 35.5)
enrolled.
• All ESGs remained intact by endoscopic
evaluation at 3 months, and patients had lost
an average of41%of excess body weight at 20
months
Endoscopic Sleeve
Gastroplasty

36. Primary Obesity Surgery
Endoluminal(POSE)
• Over tube style incision less operating platform (USGI
Medical, San Clemente, California) with 4working
channels and accommodates a slim endoscope along
with specialized instruments that are FDA-approved
for tissue apposition
• Transmural tissue anchor plications –
• To reduce accommodation of the gastric fundus
• Additional plications in the distal gastric body to delay
emptying.

37. Primary Obesity Surgery
Endoluminal

38. • Feasibility and safety were demonstrated in
a single-center , open-label prospective trial
in Spain with 45 patients evaluated, with
49% EWL average at 6 months.
• Physiologic changes –
• Decreased intake capacity
• Initially delayed gastric emptying that returned to
baseline by 6 months
• Improved insulin sensitivity
• Enhanced postprandial decrease in ghrelin.
ESSENTIAL, MILEPOST
Results have been presented in abstract form, but have not been published

39. Nutrient Diversion
Therapy

40. Aspiration therapy
• New endoscopic approach - Placement of a
large per cutaneous silicone gastrostomy tube
(A-Tube) that is subsequently connected with
a skin port to an Aspire Assist device (Aspire
Bariatrics, King of Prussia, Pennsylvania)
• The patient uses this system to siphon off a
portion of the ingested meal, typically one-
third of the volume.

41. Aspiration therapy

42. • In a small pilot study published in 2013,
patients in the aspiration group lost an
average of 49% of excess weight, compared
with 14.9% in the lifestyle therapy group.
Weight loss was maintained at 2-year follow-
up.
• No serious adverse effects were observed, and
no binge eating episodes occurred.
• Similar results were obtained in a single-arm
prospective trial in Sweden.

43. Duodenal–Jejunal Bypass
Liner
• Endobarrier (GI Dynamics, Lexington,
Massachusetts) is a 65 cm Teflon sleeve
that is anchored in the duodenal bulb by a
barbed nitinol crown .
• The device is placed under endoscopic and
fluoroscopic guidance.
• Removed endoscopically at 12 months.

44. EndoBarrier

45. • Efficacy has been assessed over several
studies, with EWL ranging from 30% to47%
at 52 weeks.
• A recent meta-analysis found that patients
had an average of 12.6% EWL with
EndoBarrier compared to dietary
modification, with an average of 0.9% change
in HbA1c that failed to meet statistical
significance

47. Gastroduodenal Bypass Liner
• Long 120 cm fluoropolymer sleeve has been
developed (ValenTx, Hopkins, Minnesota) .
• Secured at the GE junction - Endoscopic +
Laparoscopic approach.
• The device bypasses the stomach, duodenum,
and proximal jejunum.
• It is also left in place for 12 months and
retrieved endoscopically.

48. Gastroduodenal Bypass Liner

49. • A 1-year prospective series with 12 patients
enrolled showed an average EWL of 35.9%.
• 2 patients had the device removed due to
dysphagia and odynophagia, and 4 patients
had partially detached devices at 12 months,
with inferior weight loss results.
• No bowel erosions, ulcerations, or cases of
pancreatitis were observed.
• A modification device - does not require
laparoscopic assistance is being developed.

50. Incisionless Anastomosis System
• Endoscopically deliver magnets to adjacent
GI lumens, creating entero-enteral bypass
anastomoses by magnetic compression.
• IAS(GI Windows,Boston, Massachusetts),
previously known as self-assembling magnets
for endoscopy (SAMSEN), consists of smart
magnets that are delivered endoscopically in
a linear configuration and form an octagonal
shape intra luminally

51. Incisionless Anastomosis
System

52. • For bariatric use, this device may induce
ileal break with decreased food intake and
improved diabetic control.
• This system has recently been evaluated
in people in a feasibility study in Europe,
but the results have not been published
yet.
Incisionless Anastomosis System

53. Mucosal Resurfacing
• The Revita duodenal mucosal resurfacing procedure
(Fractyl Laboratories, Cambridge,Massachusetts)
• Involves the use of RFA following saline lift to induce
mucosal remodeling .
• Result in changes in enteroendocrine cells improving
diabetic control.
• A pilot study has been completed, and a multicenter
clinical trial is currently underway in Europe.

54. Mucosal Resurfacing-Revita
catheter

55. Secondary Therapy

56. Transoral Outlet Reduction
• Endoscopic Suturing technique
• Endoclinch
• Apollo Overstictch
• Associated - Decreased incidence of
• Dumping syndrome
• Bile reflux &
• Weight regain.

58. Revision Obesity Endoscopic
Surgery(ROSE)
• Uses the Incisionless Operating Platform
(IOP, USGI Medical) to place durable tissue
anchors in the gastric lumen to create
placations.
• In 2009, a multicenter prospective single- arm study of 116
patients ,reported 69% of patients experienced increased
satiety; 88% of patients stopped weight regain at 6 months,
and 53% of patients achieved an EWL of at least 20%, with
a mean 11.3 kg weight loss at 6 months. No significant
complications occurred

59. Argon Plasma Coagulation
• Used with 65 to 75 W and 2-3 L/m flow can be
used on the mucosa in the GJ anastomosis.
• Leading to fibrosis of gastric mucosa and
subsequent reduction of the GJ stoma.

60. • In a study of 215 patients by Sander and
colleagues , APC was used to decrease the
diameter of the GJ stoma by almost 50%
using an average of 1.36 sessions.
• Patients experienced on average 13.8 kg weight
loss after the final APC session.
• However, 69 patients (32.1%) did not achieve the
target stoma diameter.
• Main complication - Symptomatic stenosis in
16.3% of patients, necessitating balloon dilation.
Argon Plasma Coagulation

61. Thank You