Impact of preoperative weight loss achieved by gastric balloon on peri- and postoperative outcomes of bariatric surgery in super-obese patients: a retrospective matched-pair analysis

Comparative Analysis of Laparoscopic Sleeve Gastrectomy with and Without Prior Endoscopic Intragastric Balloon Insertion: Examining Stomach Volumetry, Histopathologic Changes, Hormonal Levels, and Postoperative Outcomes

BACKGROUND

The effects of prior intragastric balloon (IGB) placement on stomach volumetry, surgical technique, and outcomes in laparoscopic sleeve gastrectomy (LSG) patients are unclear.

METHODS

This prospective cohort study analyzed stomach histology, gastric volume, and hormonal markers in 90 LSG patients (45 with prior IGB, 45 without). We assessed stomach wall thickness, fibrosis, smooth muscle density, and ghrelin-positive cells, along with intraoperative parameters like stapler cartridge use and operative time. Postoperative outcomes, including weight loss and food tolerance (FT), were compared between groups at 6 months and 1 year.

RESULTS

In the 6th month and 1st year, the two groups had no differences in weight, BMI, and %TWL before and after the Inverse Propensity Score-Weighted adjustment. The IGB group had significantly increased muscular thickness, smooth muscle cell count, and fibrosis (p < 0.001) but similar mucosa thickness and inflammation. Preoperative stomach and resected specimen volumes were higher in the IGB group (p < 0.001). Both groups showed slight increases by 1 year, with no significant FT differences. Furthermore, no significant difference in postoperative complications was noted. Hormonal changes were observed, including lower leptin levels in the IGB group throughout.

CONCLUSION

While prior intragastric balloon (IGB) placement induces significant volumetry changes and hormone levels, it does not affect surgical outcomes-including postoperative complications, weight loss, resolution of associated medical problems, the duration of IGB placement, or the interval between IGB removal and LSG surgery-compared to those without IGB.

Intragastric Balloon as a Bridge Before Metabolic and Bariatric Surgery: A Systematic Review and Meta-analysis

The intragastric balloon (IGB) acts as a restrictive procedure with acceptable short-term weight loss outcomes and a low incidence of major complications. This systematic review and meta-analysis aimed to assess whether preoperative insertion of an IGB can reduce perioperative complications and improve weight loss outcomes following metabolic bariatric surgery (MBS). PubMed, Embase, Scopus, and Web of Science databases were searched using relevant keywords to include studies on IGB as a bridge before MBS. The main outcome of this study was to compare the weight loss results and complications after MBS between the IGB group and the control group. For the meta-analysis of variables with severe and non-severe heterogeneity, random-effects and fixed-effects meta-analyses were used, respectively. Eleven articles were included. The IGB and control groups included 318 and 501 patients, respectively. The pooled random-effects analysis of six studies showed that preoperative IGB insertion resulted in a body mass index (BMI) loss of 7.45 kg/m2 over a mean follow-up of 6.14 months. The major complication rate for IGB was 5%. The mean BMI change after MBS between the IGB and control groups was not significantly different after 15.06 months (mean difference - 4.08, p = 0.07). Additionally, a fixed-effects analysis of ten studies found no significant difference in post-MBS complication rates between the IGB and control groups (OR 0.66, p = 0.12). Even though using IGB as a bridging approach to subsequent MBS can result in significant reductions in preoperative BMI, this weight loss does not appear to positively impact the overall outcomes of MBS in patients in the long term.

Sleeve gastrectomy with antral resection provides more effective weight loss in patients with super obesity

BACKGROUND

Obesity is a growing health issue that contributes to numerous diseases and lowers quality of life. In patients with super obesity (BMI > 50 kg/m²), bariatric surgery, particularly laparoscopic sleeve gastrectomy (LSG), is a common treatment option. However, the role of antral resection (AR) in LSG remains unclear, especially in this high-risk population. This study aims to compare the effectiveness of LSG with antral resection (LSG-AR) and LSG with antrum preservation (LSG-AP) on weight loss and postoperative complaints in patients with super obesity.

METHODS

The medical records of patients with a BMI > 50 kg/m² who underwent LSG between 2016 and 2022 were retrospectively reviewed. Weight data were collected at admission, and at the first, second, and fifth-year follow-up. Patients were divided into two groups based on LSG-AR or LSG-AP procedures.

RESULTS

Seventy-two patients were included. No significant difference was found in postoperative vomiting complaints between the groups (p = 0.67). First-year outcomes showed no significant differences in weight, BMI, or % Total Weight Loss (%TWL). However, second and fifth-year %TWL values were significantly higher in the LSG-AR group (p = 0.003 for both).

CONCLUSION

LSG-AR provides more effective long-term weight loss in patients with super obesity. Early postoperative vomiting complaints diminish over time, suggesting LSG-AR as a viable one-stage procedure for this patient population.

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS)

The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for metabolic and bariatric surgery (MBS), replacing the previous guidelines established by the National Institutes of Health (NIH) over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams (MDTs), as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Intragastric Balloon as a First Step Before Metabolic Bariatric Surgery in Patients with BMI ≥ 50 kg/m2: are the Results After Balloon Related to Global Outcomes After Surgery?

INTRODUCTION

Patients with body mass index (BMI) ≥ 50 kg/m2, classified with obesity class IV/V, require complex treatments. Intragastric balloon (IGB) is a possible treatment before metabolic bariatric surgery (MBS) that may reduce peri-operative complications. This study evaluates IGB outcomes and complications before MBS in patients with Obesity IV/V, and subsequent MBS results, regarding weight loss and comorbidity resolution.

METHODS

Retrospective cohort study of all patients with BMI above 50 kg/m2 submitted to IGB before MBS between 2009 and 2023 in a high-volume center. Variables analyzed included weight loss after IGB and MBS, IGB complications, and comorbidity resolution. Suboptimal clinical responses were defined as %TWL < 5% for IGB, %TWL < 20% for MBS, and %TWL < 25% or BMI ≥ 35 kg/m2 for IGB + MBS.

RESULTS

Seventy-four patients (mean BMI 58.8 ± 8 kg/m2) were included. After IGB, the mean %TWL was 14.2 ± 8.5%, with a 21.6% complication rate, predominantly nausea and vomiting, and one death. Suboptimal clinical response of IGB affected 13.5% of patients, and 5.4% required early removal. Two years after MBS, the mean %TWL was 38.2 ± 11.6%, mainly due to MBS, yet approximately one-third of %TWL was attributed to IGB. No correlation was found between IGB and MBS outcomes. At 2-year follow-up, 45.1% patients had %TWL ≥ 25 and BMI < 35 kg/m2.

CONCLUSION

The IGB is a treatment option before MBS in patients with Obesity Class IV/V, with acceptable weight loss outcomes but not infrequent complications. A multidisciplinary approach is mandatory, and all treatments must be considered in this difficult subset of patients.

Challenges in the care and treatment of patients with extreme obesity

Obesity is a prevalent chronic disease. The management of extreme obesity - i.e., body mass index (BMI) ≥ 50 kg/m2 or obesity class IV and V - is still far from ideal. Individuals with extreme obesity have a high risk of surgical complications, mortality, comorbidities, and reduced weight loss following bariatric surgery. Although lifestyle changes and anti-obesity medications are recommended for all patients with extreme obesity as adjuvants to weight loss, these measures are less effective than bariatric surgery. As a first step, sleeve gastrectomy or an inpatient very-low-calorie diet should be incentivized to enhance weight loss before definitive surgery. Although malabsorptive procedures lead to greater weight loss, they are associated with an increased risk of early complications and malnutrition. Nonstandard techniques employed in clinical trial protocols, such as transit bipartition, may be performed as they maintain a weight loss potency comparable to that of the classic duodenal switch but with fewer nutritional problems. Anatomical causes should be investigated in patients with postoperative suboptimal clinical response or recurrent weight gain. In these cases, the initiation of anti-obesity drugs, endoscopic therapies, or a conversion procedure might be recommended. More studies are needed to address the specific population of patients with extreme obesity, as their outcomes are expected to be distinct from those of patients with lower BMI.

The current status and challenges of perioperative management of patients with a BMI of greater than or equal to 50 kg/m 2 undergoing bariatric surgery in China: a multicenter cross-sectional study

BACKGROUND

Performing bariatric surgery on patients with a BMI of over 50 kg/m 2 is challenging. This study aimed to explore the status and challenges related to the perioperative management of such patients in China.

MATERIALS AND METHODS

A prospective survey was designed to investigate the perioperative management of patients with a BMI of greater than or equal to 50 kg/m 2 undergoing bariatric surgery in China. The questionnaire of our survey included general information, preoperative management measures, surgical procedures performed, technical details regarding anaesthesia, and postoperative management measures. A response from only one attending physician per bariatric centre was accepted.

RESULTS

Physicians from a total of 101 hospitals responded to the questionnaire, and the questionnaire data from 98 hospitals were complete. These centres had completed a total of 44 702 bariatric surgeries since the launch of such surgery to December 2021. A total of 3280 patients had a BMI exceeding 50 kg/m 2 . The preferred surgical procedures for patients with super obesity were sleeve gastrectomy by 62 centres, Roux-en-Y gastric bypass by 11 centres, sleeve gastrectomy plus jejunojejunal bypass by 19 centres, one anastomosis gastric bypass by 1 centre, and duodenal switch by 1 centre. The most worrying issues were cardiopulmonary failure and difficulty in extubation. 91 centres believed that preoperative weight loss was beneficial. A low-calorie diet was the specific measure mainly implemented, only three centres considered using intragastric balloon placement. Postoperative management measures varied greatly.

CONCLUSION

Bariatric surgery has seen rapid development. Chinese physicians show significant differences regarding the perioperative management for patients with a BMI of over 50 kg/m 2 . The perioperative risks of these patients remain relatively high, making further development of clinical pathways is necessary.

Effect of preoperative intragastric balloon treatment on perioperative and postoperative outcomes after laparoscopic sleeve gastrectomy: A retrospective cohort study

<b><br>Introduction:</b> Intragastric balloon (IGB) insertion is used as a bridging therapy in patients with body mass index (BMI) ≥ 50 kg/m2 . We arranged a retrospective study to evaluate whether pre-operative IGB treatment influences perioperative and postoperative weight loss outcomes after laparoscopic sleeve gastrectomy (SG), and especially to evaluate the impact of post - IGB percentage of excessive weight loss (%EWL) on postoperative %EWL.</br> <b><br>Materials and methods:</b> Patients who underwent IGB placement followed by laparoscopic SG were divided into the following groups considering %EWL after IGB: Group 1 <=10.38%; Group 2 >10.38% and <=17.27%; Group 3 >17.27% and <=24.86%; Group 4 >24.86%. 1 year after SG data were collected. The following parameters were compared between groups: operative time, total blood loss, length of stay and weight, BMI, percentage of total weight loss (%TWL), %EWL.</br> <b><br>Results:</b> There were no statistically significant differences between groups in perioperative results. Post-SG %EWL was the highest in intermediate groups: 2 and 3. Post-treatment results were observed: body weight and BMI were the lowest in Group 4 and the highest in Group 1. Post-treatment %EWL was the highest in Group 4, the lowest in Group 1 and grew gradually in subsequent groups.</br> <b><br>Discussion:</b> The study confirmed the impact of weight loss on IGB on postoperative results. The study showed that %EWL after the IGB treatment influences %EWL after SG and most of all affects definitive %EWL after two-stage treatment and it could be a foreshadowing factor of these outcomes.</br> <b><br>Importance:</b> The importance of research for the development of the field %EWL after IGB influences the final BMI and final weight, which means that patients with the greatest %EWL after IGB are more likely to have the greatest postoperative weight loss and overall weight loss.</br>.

Intragastric balloons for obesity: critical review of device design, efficacy, tolerability, and unmet clinical needs

INTRODUCTION

Sustaining a healthy weight is a challenge and obesity, with associated risk of co-morbidities, is a major public health concern. Bariatric surgery has shown a great promise for many where pharmacological and lifestyle interventions failed to work. However, challenges and limitations associated with bariatric surgery has pushed the demand for less invasive, reversible (anatomically) interventions, such as intragastric balloons (IGBs).

AREAS COVERED

This review critically appraises IGBs used in the past, present, and those in clinical trials, discussing the device designs, limitations, placement and removal techniques, patient eligibility, efficacy, and safety issues.

EXPERT OPINION

Several intragastric balloons were developed over the years that brought excitement to patients and healthcare professionals alike. Albeit good efficacy, there had been several safety issues reported with IGBs such as spontaneous deflation, intestinal occlusion, gut perforation, and mucosal ulcerations. This led to evolution of IGBs design; device material, filling mechanism, fluid type, inflation volume, and further innovations to ease ingestion and removal of device. There are some IGB devices under development aimed to swallow like a conventional pill and excrete naturally through defecation, however, how successful they will be in clinical practice in terms of their efficacy and tolerability remains to be seen in the future.

Performance Characteristics of Endoscopic Sleeve Gastroplasty in Patients with Prior Intragastric Balloon: Results of a Propensity Score Matched Study

INTRODUCTION

The performance characteristics of endoscopic sleeve gastroplasty (ESG) for weight recurrence after intragastric balloon (IGB) are unknown.

METHODS

This is a retrospective propensity score matched study of ESG after IGB (IGB-to-ESG) vs ESG without prior IGB (ESG-only). The primary outcome was total weight loss (TWL) at 12 months. Secondary outcomes included TWL at 3 and 6 months, 12-month excess weight loss (EWL), procedural characteristics, and safety.

RESULTS

Thirty-nine adults underwent ESG from August 2020 to September 2022 after IGB explantation a median of 24 months (range 2-56 months) prior and a median post-IGB nadir weight increase of 100.0% (range 0 to 3200%). An ESG-only 2:1 age- sex- and BMI- propensity score matched cohort was derived from 649 patients (Pearson's goodness-of-fit: 0.86). TWL for IGB-to-ESG vs. ESG-only was 12.3 ± 13.5% vs. 12.4 ± 3.7% at 3 months (p = 0.97), 10.1 ± 7.1% vs. 15.4 ± 4.6% at 6 months (p < 0.001), and 8.7 ± 7.7% vs. 17.1 ± 5.7% at 12 months (p < 0.001). Twelve-month EWL for IGB-to-ESG vs ESG-only was 27.8 ± 46.9% vs 62.0 ± 21.0% (p < 0.001). There was no difference in mean procedural duration of ESG; however, more sutures were used with IGB-to-ESG vs. ESG-only (7 vs. 6, p < 0.0002). There were no serious adverse events in either cohort.

CONCLUSION

ESG after IGB produces safe, acceptable weight loss but with an attenuated effect compared to ESG alone. Further study is required to understand the factors driving this discrepancy.

Efficacy of Intragastric Balloon versus Liraglutide as Bridge to Surgery in Super-Obese Patients

INTRODUCTION

Bariatric surgery is a safe and effective treatment for obesity, although in super-obese patients (BMI ≥50 kg/m2) it can become challenging for anatomical and anesthesiologic issues. Several bridging therapies have been proposed to increase preoperative weight loss and decrease perioperative morbidity and mortality. The aim of this study was to compare the efficacy and safety of different two-stage approaches in super-obese patients: laparoscopic sleeve gastrectomy (LSG) following preoperative liraglutide therapy versus LSG with preoperative intragastric balloon (IGB) during a 1-year follow-up.

METHODS

Clinical records of 86 patients affected by super-obesity who underwent two-stage approach between January 2019 and January 2022 were retrospectively reviewed using a prospectively maintained database. Patients were separated into two groups: those managed with preoperative IGB and those with liraglutide 3.0 mg prior to LSG. Weight (kg), BMI (kg/m2), %EWL, and %EBWL were reported and compared between the two groups at the end of bridging therapy, at 6th month and 12th month postoperatively. Postoperative complications were recorded.

RESULTS

Forty-four patients underwent IGB insertion prior to LSG, while 42 were treated with liraglutide. There were no statistical differences in baseline weight and BMI. At the end of preoperative treatment, the group treated with IGB reported a significant reduction in BMI (47.24 kg/m2 vs. 53.6 kg/m2; p < 0.391) compared to liraglutide group. There were no differences recorded between the two groups concerning postoperative complications. At 6 months, the liraglutide group had lower %EWL (15.8 vs. 29.84; p < 0.05) and %EBWL (27.8 vs. 55.6; p < 0.05) when compared to IGB group. At 12 months, the IGB preserved with higher %EWL (39.9 vs. 25; p < 0.05) and %EBWL (71.2 vs. 42; p < 0.05).

CONCLUSION

A two-stage therapeutic approach with IGB prior to LSG in super-obese patients could be considered an attractive alternative to liraglutide as bridging therapy before bariatric surgery.