Spanish consensus document on bariatric endoscopy. Part 2: specific endoscopic treatments

The GIRO Guideline: a key tool to approach the obesity challenge and its impact on digestive health

The recently published second edition of the GIRO Guideline (Guía española de manejo integral de la obesidad) edited by the Sociedad Española para el Estudio de la Obesidad (SEEDO), whose preparation involved the participation of 35 representatives of different scientific societies, including the Sociedad Española de Patología Digestiva (SEPD), focuses on the cross-cutting and multidisciplinary nature of obesity, a condition experienced by many of our patients that decisively impact their health status, and that we must understand and manage adequately.

Spanish Intragastric Balloon Consensus Statement (SIBC): practical guidelines based on experience of over 20 000 cases

BACKGROUND

intragastric balloons (IGBs) are a minimally invasive, increasingly popular option for obesity treatment. However, there is only one worldwide guideline standardizing the technical aspects of the procedure (BIBC, SOARD 2018).

OBJECTIVES

to construct a practical guideline for IGB usage by reproducing and expanding the BIBC survey among the Spanish Bariatric Endoscopy Group (GETTEMO).

METHODS

a 140-question survey was submitted to all GETTEMO members. Twenty-one Spanish experienced endoscopists in IGBs answered back. Eight topics on patient selection, indications/contraindications, technique, multidisciplinary follow-up, results, safety, and financial/legal aspects were discussed. Consensus was defined as consensus ≥ 70 %.

RESULTS

overall data included 20 680 IGBs including 12 different models. Mean age was 42.0 years-old, 79.9 % were women, and the mean preoperative body mass index (BMI) was 34.05 kg/m². Indication in BMI > 25 kg/m², 10 absolute contraindications, and nutritional and medication measures at follow-up were settled. A mean %TBWL (total body weight loss) of 17.66 % ± 2.5 % was observed. Early removal rate due to intolerance was 3.62 %. Adverse event rate was 0.70 % and 6.37 % for major and minor complications with consensual management. A single case of mortality occurred. IGBs were placed in private health, prior contract, and with full and single payment at the beginning. Seven lawsuits (0.034 %) were received, all ran through civil proceeding, and with favorable final resolution.

CONCLUSIONS

this consensus based on more than 20 000 cases represents practical recommendations to perform IGB procedures. This experience shows that the device leads to satisfactory weight loss with a low rate of adverse events. Most results are reproducible compared to those obtained by the BIBC.

Mechanism of bariatric and metabolic surgery: beyond surgeons, gastroenterologists and endocrinologists

Bariatric-metabolic surgery is the safest, most effective and long-lasting treatment for obesity and its associated co-morbidities, whether they be metabolic (type 2 diabetes, hyperlipidemia non-alcoholic fatty liver disease) or cardiovascular (myocardial infarction, stroke). Due to the obesity pandemic, bariatric-metabolic surgery is the second most frequent intra-abdominal procedure and the gastroenterologist and the surgeon must be aware of the physiologic changes caused by the anatomic reconfiguration following surgery. Among the mechanisms of action, independent of the loss of weight and fat tissue, surgery leads to the release of gut hormones related to carbohydrate metabolism (the rapid and continuous release of insulin), appetite and degree of satiety (glucagon-like peptide 1, peptide Y-Y, grhelin). As a result, indications for surgery have been extended to earlier disease stages. Apart from the neurohormonal effects, changes in the metabolism of biliary acids and the microbiota have also been reported. The aim of this review is to describe the physiologic changes caused by bariatric-metabolic surgery.

Twisting of sleeve gastrectomy: two ways of clinic presentation

Laparoscopic sleeve gastrectomy is an increasingly widespread bariatric surgical technique thanks to its good outcomes and apparent simplicity. However, complications may arise, including hemorrhage, gastric fistula, and stenosis, which can be either organic or functional. Functional stenosis is caused by gastric tube twisting. We present two cases of patients who underwent laparoscopic sleeve gastrectomy and who were subsequently diagnosed with gastric twisting. Both cases required conversion to laparoscopic gastric bypass. Accompanying symptoms may vary but they commonly include early satiety, epigastric pain associated with food intake, gastroesophageal reflux and early vomiting. Although diagnose is mainly clinical, it requires high suspicion since endoscopy and gastrointestinal studies are not conclusive. The principal therapeutic options are endoscopic dilatations, serotomy and conversion to gastric bypass.