The use of gastric balloon for weight loss

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Introduction

Gastric balloons (also known as intra-gastric balloons) are one method to reduce obesity. The procedure consists of placing a silicone balloon in the stomach and then filling it with air or saline. The balloon then floats freely in the stomach for several months. The idea is that the balloon reduces the stomach volume and therefore increases satiety [1]. Gastric balloons are indeed successful are lowering weight; patients lose 25-40% of their excess weight after six months [2]. However, the precise mechanism by which gastric balloons cause weight loss is unknown.

It is thought that the balloon’s weight stimulates baroceptors in the gastric wall, which in turn stimulates satiety. Though it is also thought that the balloons increase satiety via decreased ghrelin secretion and decreased gastric emptying [3].

 

 

Surgical procedure

The procedure for gastric balloon insertion is as follows: First, the physician checks that the stomach is free of abnormalities using an endoscope. Once the physician is happy to go ahead, he places the balloon into the patient’s mouth and down into the stomach using gastrectomy. The physician then fills the balloon with saline using a catheter and endoscope. A small amount of methylene blue is usually added as well. This dye alerts the patient to leaking because a leak makes the patient’s urine turn blue (7).

When the balloon is filled, its diameter is roughly 10cm and it weighs around 700g [4]. The physician removes the catheter and endoscope an

d then the balloon’s valve seals itself. This leaves the balloon floating freely in the stomach. Patients can usually go home immediately, but they must avoid solid foods for the first day after the operation. They must also follow a calorie restricted diet for the first few days after the operation. The physician usually prescribes medication like proton pump inhibitors to help reduce acid reflux. Then, just six months later, the physician removes the balloon. Balloons can only stay in the patient’s stomach for no more than six months because of risk of complications. This is because the risk of complications increases the longer a balloon is left in the stomach [4].

 

The history of gastric balloons

A physician named Davies first conceived the idea for a gastric balloon in 1921 [5]. He noticed that patients with stomach bezoars often experienced early satiety. This made him wonder if artificial bezoars could cure obesity. The first artificial bezoar, now called a gastric balloon, dates to 1984. It was named the Garren-Edwards bubble (GEB) [6]. It was made of polyurethane and filled with air. Early balloons like this soon became a popular way for patients to lose weight for surgery. However, these early balloons damaged easily, had rough surfaces, and often caused complications [7]. One complication was spontaneous deflation. The deflated balloon risks passing into the small bowel and causing bowel obstruction, which can be lethal [8].

In the late 1980s and early 1990s, studies questioned the usefulness of gastric balloons. The studies also criticised the balloons because of their complications and ineffectiveness [9, 10]. Gastric balloons fell out of favour, until experts convened and realised that fluid-filled balloons would be more reliable [11]. So from then on, most gastric balloons were filled with fluid instead of air [4]. These fluid-filled balloons are safer and more effective than air-filled balloons [6]. Also, they are made from silicone, which makes them more robust and softer than polyurethane balloons.

 

Complications, postoperative problems

The most common side effects of gastric balloons are nausea, heartburn, vomiting and severe epigastric pain. Patients often describe the pain as a burning sensation [8]. These symptoms start a few hours after the operation and often last for weeks. For around 5% of patients, the symptoms are persistent and require early removal of the gastric balloon [12]. Physicians can also reduce the size of the balloon to reduce the patient’s symptoms. But for most patients, the symptoms either alleviate on their own or with protein pump inhibitors and spasmolytics.

Another common complication is spontaneous deflation of the balloon. Deflation occurs in between 3% [13] to 40% [14] of cases, depending on the findings of different studies. In the best case scenario, the deflated balloon passes harmlessly away in the stool. However, in the worst case scenario the deflated balloon obstructs the small bowel or gastric outlet and kills the patient. However, death is actually quite rare, and occurs in no more than 0.2% of cases [6]. Surgery usually saves the patient’s life by removing the deflated balloon before it causes damage.

Other dangers of gastric balloons include death by perforation of the stomach and even suffocation. Less harmful side effects are gastric ulceration (which occurs in 3% of patients [15]) and gastritis [8]. It should be noted that serious complications are actually extremely rare. However, the side effects of gastric balloons have certainly contributed to its relative unpopularity compared to other weight loss methods.

Advantages and disadvantages of gastric balloons

One advantage of gastric balloons is that they cause significant weight loss [16, 17], but a disadvantage of gastric balloons is that this weight loss is only temporary. This is because patients soon regain their lost weight after their balloon is removed [4]. Furthermore, removal takes place just six months after the operation, to limit the risk of side effects. This means gastric balloons are only a short-term solution to obesity. However, gastric balloons do have uses. They are useful as the first stage of a multi-stage procedure, since they can help patients lose weight until surgery is a safe option. Even super obese people are suitable for gastric balloons, because the balloons are easy to insert and remove, and less invasive than surgery [18]. Gastric balloons are also more effective than dieting, so they are suitable for unsuccessful dieters. However, gastric balloons are unsuitable for patients with gastroparesis, a condition where the stomach does not digest food properly. Physicians should perform a gastric emptying study on these patients to verify their suitability for a gastric balloon.

One of the main disadvantages of gastric balloons is their side effects and complications. Almost all patients experience severe stomach pain after the operation, and medication cannot entirely eliminate this pain. Many patients also experience spontaneous deflation of their balloon, which can block the intestine. Furthermore, physicians sometimes have difficulties inflating and deflating the balloon. Inflation and deflation difficulties occur in around 30% of patients [4].

 

References

  1. Genco, A., et al., Endoscopic Treatment: Intragastric Balloon, in Minimally Invasive Bariatric and Metabolic Surgery, M. Lucchese and N. Scopinaro, Editors. 2015, Springer International Publishing. p. 145-152.
  2. Korner, J., et al., Implantable gastric stimulator does not prevent the increase in plasma ghrelin levels that occurs with weight loss. Obesity, 2011. 19(10): p. 1935-1939.
  3. Mion, F., et al., Effects of intragastric balloon on gastric emptying and plasma ghrelin levels in non-morbid obese patients. Obesity surgery, 2005. 15(4): p. 510-516.
  4. Caglar, E., A. Dobrucali, and K. Bal, Gastric balloon to treat obesity: filled with air or fluid?Digestive Endoscopy, 2013. 25(5): p. 502-507.
  5. Nieben, O.G. and H. Harboe, Intragastric balloon as an artificial bezoar for treatment of obesity. The Lancet, 1982. 319(8265): p. 198-199.
  6. Korenkov, M., R. Merkle, and S. Abegg-Zips, Gastric balloon, in Bariatric Surgery. 2012, Springer. p. 187-194.
  7. Schapiro, M., et al., Obesity and the gastric balloon: a comprehensive workshop. Gastrointestinal endoscopy, 1987. 33(4): p. 323-327.
  8. Kannan, R.Y. and M. Nutt, Are intra-gastric adjustable balloon system safe? A case series. International journal of surgery case reports, 2013. 4(10): p. 936-938.
  9. Mathus‐Vliegen, E. and G. Tytgat, Intragastric balloons for morbid obesity: results, patient tolerance and balloon life span. British Journal of Surgery, 1990. 77(1): p. 76-79.
  10. Hogan, R.B., et al., A double-blind, randomized, sham-controlled trial of the gastric bubble for obesity. Gastrointestinal endoscopy, 1989. 35(5): p. 381-385.
  11. Matar, Z., et al., Small bowel obstruction due to air-filled intragastric balloon. Obesity Surgery, 2009. 19: p. 1727-30.
  12. Dumonceau, J.-M., Evidence-based review of the Bioenterics intragastric balloon for weight loss. Obesity surgery, 2008. 18(12): p. 1611-1617.
  13. Doldi, S., et al., Intragastric balloon: another option for treatment of obesity and morbid obesity. Hepato-gastroenterology, 2003. 51(55): p. 294-297.
  14. Forestieri, P., et al., Heliosphere® Bag in the treatment of severe obesity: Preliminary experience. Obesity surgery, 2006. 16(5): p. 635-637.
  15. Subei, I.M., et al., The effect of different types of intragastric balloons with and without a behavior modification program in morbid obesity. Saudi Journal of Gastroenterology, 1996. 2: p. 63-68.
  16. ETotté, E., et al., Weight reduction by means of intragastric device: experience with the bioenterics intragastric balloon. Obesity surgery, 2001. 11(4): p. 519-523.
  17. Alfalah, H., et al., Intragastric balloon for preoperative weight reduction in candidates
    for laparoscopic gastric bypass with massive obesity. Obesity surgery, 2006. 16(2): p. 147-150.
  18. Panel, N.O.E.I.E., Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. 1998.
Dr. Naif Alenazi

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