Sun-Chuan Dai, MD, from the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania, USA presents this VideoGIE “Intragastric balloons: an introduction and removal technique for the endoscopist.”
This is a video presentation of a 40-year-old female who had requested removal of an intragastric weight-loss balloon that had been placed 2 months to her presentation. She had experienced a 10 kilogram weight loss but was suffering from daily inability to tolerate oral intake, and computed tomography images had demonstrated gastric outlet obstruction from the balloon. Going into her endoscopic procedure we did not have any other information regarding her intragastric balloon as it had been placed in Dubai.
During her procedure we identified a Bioenterics Intragastric Balloon from Allergan that was partially obstructing the body of her stomach. Our initial attempt to decompress the balloon with a 25 gauge sclerotherapy needle and 60 cc syringe was time-consuming, so we switched to a 19 gauge fine needle aspiration needle with a 60 cc suction syringe. The larger caliber needle and stronger suction proved to be effective, as we were able to deflate the balloon within minutes and remove it with a grabbing forceps. Besides superficial erosions from balloon compression, the rest of the patient’s stomach was normal. We discharged the patient on omeprazole with the intention of seeing her in follow-up, but she returned to Dubai.
Obesity and its downstream complications are a growing global epidemic. In the United States, treatment options predominantly revolve around lifestyle modifications and surgery, but intragastric weight loss balloons are used frequently in the rest of the world. At the time of this case, these devices were not approved for use by the U.S. Food and Drug Administration and we thought sharing our experience would be helpful should they be encountered and require removal.
Since our experience in the past year, the FDA has approved 2 intragastric balloons for obesity, the ReShape Integrated Dual Balloon System (ReShape Medical, San Clemente, California) and the Orbera Intragastric Balloon System (Apollo Endosurgery, Austin, Texas). These systems have proprietary removal mechanisms but in the event these accessories are unavailable to the endoscopist, we demonstrate a safe and effective method of balloon removal using conventional endoscopic devices.
Besides removal technique, it is also important for endoscopists to understand how intragastric balloons work, as patients may frequently request endoscopic placement in light of their recent FDA approval. The primary mechanism of intragastric balloons is to generate satiety by occupying space in the stomach. Intragastric balloons are inflated with 400-700 ccs of saline, while ReShape’s product will require a larger cumulative volume as it is a dual balloon system. Balloon placement is recommended for 6 months with concurrent lifestyle modifications, and a roughly 13% total body weight loss can be expected in this period of time. The weight loss is sustained up to 12 months after balloon placement (or 6 months after removal) with continued lifestyle modifications.
While adverse event rates of intragastric weight loss balloons may be less than 1.5%, patients should be advised that risks may necessitate early removal and include esophagitis, balloon migration, balloon rupture, gastric perforation, ulcers or in our patient, gastric outlet obstruction.
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