Obesity is a global health epidemic with considerable economic burden.Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk.Sleeve gastrectomy ...Obesity is a global health epidemic with considerable economic burden.Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk.Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease(GERD)has been a topic of debate.GERD,including erosive esophagitis,is highly prevalent in the obese population.The role of pre-operative endoscopy in bariatric surgery has been controversial.Two schools of thought exist on the matter,one that believes routine upper endoscopy before bariatric surgery is not warranted in the absence of symptoms and another that believes that symptoms are poor predictors of underlying esophageal pathology.This debate is particularly important considering the evidence for the association of laparoscopic sleeve gastrectomy(LSG)with de novo and/or worsening GERD compared to the less popular Roux-en-Y gastric bypass procedure.In this paper,we try to address 3 burning questions regarding the inter-relationship of obesity,GERD,and LSG:(1)What is the prevalence of GERD and erosive esophagitis in obese patients considered for bariatric surgery?(2)Is it necessary to perform an upper endoscopy in obese patients considered for bariatric surgery?And(3)What are the long-term effects of sleeve gastrectomy on GERD and should LSG be done in patients with pre-existing GERD?展开更多
Obesity is a chronic,progressive,and relapsing disease of excess adiposity that contributes to more than two hundred medical conditions and is projected to affect more than half the adult population of the United Stat...Obesity is a chronic,progressive,and relapsing disease of excess adiposity that contributes to more than two hundred medical conditions and is projected to affect more than half the adult population of the United States by the year 2030.Given the limited penetrance of traditional bariatric surgery,as well as the cost and adherence barriers to anti-obesity medications,there is growing interest in the rapidly evolving field of endoscopic bariatric therapies(EBTs).EBTs are minimally invasive,same-day,per-oral endoscopic procedures and include endoscopic sleeve gastroplasty,intragastric balloons,and endoscopic bariatric revisional procedures.This field represents an exciting and innovative subspe-cialty within gastroenterology.However,building a successful endoscopic bariatric practice requires intentional,coordinated,and sustained efforts to overcome the numerous obstacles to entry.Common barriers include acquisition of the technical and cognitive skillset,practice limitations including the availability of nutrition counseling,facility capabilities,direct-to-consumer marketing,and financial pressures such as facility and anesthesia fees.As the highest-volume center for metabolic and bariatric endoscopy in the United States,we provide insights into successfully establishing an endoscopic bariatric program.展开更多
The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy(EGD) because of technical difficulty in intubating at EGD the postoperatively excluded st...The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy(EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass(RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status postRYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.展开更多
The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this ...The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this complex disorder. The development of new laparoscopic and minimally invasive treatments for medically-complicated obesity has made it essential that gastrointestinal physicians obtain a thorough understanding of past developments and possible future directions in bariatrics. New laparoscopic advancements provide patients and practitioners with a variety of options that have an improved safety profile and better efficacy without open, invasive surgery. The mechanisms of weight loss after bariatric surgery are complex and may in part be related to altered release of regulatory peptide hormones from the gut. Endoscopic techniques designed to mimic the effects of bariatric surgery and endolumenal inter-ventions performed entirely through the gastrointestinal tract offer potential advantages. Several of these new techniques have demonstrated promising, preliminary results. We outline herein historical and current trends in the development of bariatric surgery and its transition to safer and more minimally invasive procedures designed to induce weight loss.展开更多
Background:Bariatric surgery represents an important treatment option for severely obese patients with nonalcoholic fatty liver disease(NAFLD).However,there remains inadequate data regarding the effects of different b...Background:Bariatric surgery represents an important treatment option for severely obese patients with nonalcoholic fatty liver disease(NAFLD).However,there remains inadequate data regarding the effects of different bariatric procedures on various NAFLD parameters,especially for histological outcomes.Thus,this meta-analysis aimed to compare the effects of restrictive bariatric procedures and foregut bypass on the metabolic,biochemical,and histological parameters for patients with NAFLD.Methods:Medline and Embase were searched for articles relating to bariatric procedures and NAFLD.Pairwise meta-analysis was conducted to compare efficacy of bariatric procedures pre-vs.post-procedure with subgroup analysis to further compare restrictive against foregut bypass procedures.Results:Thirty-one articles involving 3,355 patients who underwent restrictive bariatric procedures(n=1,460)and foregut bypass(n=1,895)were included.Both foregut bypass(P<0.01)and restrictive procedures(P=0.03)significantly increased odds of fibrosis resolution.Compared to restrictive procedures,foregut bypass resulted in a borderline non-significant decrease in fibrosis score(P=0.06)and significantly lower steatosis score(P<0.001).For metabolic parameters,foregut bypass significantly lowered body mass index(P=0.003)and low-density lipoprotein(P=0.008)compared to restrictive procedures.No significant differences were observed between both procedures for aspartate aminotransferase(P=0.17)and alkaline phosphatase(P=0.61).However,foregut bypass resulted in significantly lower gamma-glutamyl transferase than restrictive procedures(P=0.01)while restrictive procedures resulted in significantly lower alanine transaminase than foregut bypass(P=0.02).Conclusions:The significant histological and metabolic advantages and comparable improvements in biochemical outcomes support the choice of foregut bypass over restrictive bariatric procedures in NAFLD management.展开更多
The prevalence of obesity continues to rise,and along with it comes a multitude of health-related consequences.The healthcare community has consistently struggled with providing treatment options to obese patients,in ...The prevalence of obesity continues to rise,and along with it comes a multitude of health-related consequences.The healthcare community has consistently struggled with providing treatment options to obese patients,in part due to the reluctance of patients in pursuing the more effective(yet invasive)surgical approaches such as sleeve gastrectomy and Rou-en-Y gastric bypass.On the other hand,the less invasive approach such as lifestyle/behavioral interventions and pharmacotherapy(Orlistat,Phenteramine,Phentermine/Topiramate,Locaserin,Naltrexon/Buproprion,and Liraglutide)have very limited efficacy,especially in the morbidly obese patients.Despite our best efforts,the epidemic of obesity continues to rise and pose enormous costs on our healthcare system and society.Bariatric endoscopy is an evolving field generated to combat this epidemic through minimally invasive techniques.These procedures can be performed in an ambulatory setting,are potentially reversible,repeatable,and pose less complications than their invasive surgical counterparts.These modalities are designed to alter gut metabolism by means of space occupation,malabsorption,or restriction.In this review we will discuss different bariatric endoscopic options(such as intragastric balloons,endoscopic sleeve gastroplasty,endoscopic aspiration therapies and gastrointestinal bypass sleeves),their advantages and disadvantages,and suggest a new paradigm where providers may start incorporating this modality in their treatment approach for obese patients.展开更多
Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated ... Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents(SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwenta computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.展开更多
A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate fo...A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the longterm impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a longterm approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees' prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicate展开更多
Endoscopic bariatric therapy may be a useful alternative to pharmacological treatment for obesity, and it provides greater efficacy with lower risks than do conventional surgical procedures. Among the various endoscop...Endoscopic bariatric therapy may be a useful alternative to pharmacological treatment for obesity, and it provides greater efficacy with lower risks than do conventional surgical procedures. Among the various endoscopic treatments for obesity, the intragastric balloon is associated with significant efficacy in body weight reduction and relief of comorbid disease symptoms. Anatomically, this treatment is based on gastric space-occupying effects that increase the feeling of satiety and may also affect gut neuroendocrine signaling. The simplicity of the intragastric balloon procedure may account for its widespread role in obesity treatment and its applicability to various degrees of obesity. However, advances in device properties and procedural techniques are still needed in order to improve its safety and cost-effectiveness. Furthermore, verification of the physiological outcomes of intragastric balloon treatment and the clinical predictive factors for treatment responses should be considered. In this article, we discuss the types, efficacy, safety, and future directions of intragastric balloon treatment.展开更多
Endoscopic sleeve gastroplasty(ESG)is a minimally invasive procedure used in the treatment of obesity,with a complication rate of less than 2%of cases.There have been only two reported cases worldwide of gallbladder i...Endoscopic sleeve gastroplasty(ESG)is a minimally invasive procedure used in the treatment of obesity,with a complication rate of less than 2%of cases.There have been only two reported cases worldwide of gallbladder injuries as a major complication of ESG.CASE SUMMARY We present the case of a 34-year-old patient who developed a complication after ESG.The patient experienced epigastric and right hypochondrium pain 12 h after the procedure,and a positive Murphy’s sign was identified on physical examination.Laboratory results showed a leukocyte count of 17×10^(3)/μL,and computed tomography indicated the presence of free fluid in the pelvic cavity and perihepatic recesses as well as a possible suture in the wall of the Hartmann’s pouch toward the anterior surface of the stomach.A diagnostic laparoscopy was performed,revealing plication of the Hartmann’s pouch wall to the anterior stomach wall.Laparoscopic cholecystectomy and lavage were carried out.The patient had a stable recovery and was discharged 72 h after surgery,tolerating oral intake.CONCLUSION Gallbladder plication should be suspected if signs and symptoms consistent with acute cholecystitis occur after ESG.展开更多
Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication o...Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early(< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late(> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.展开更多
The most effective and durable treatment for obesity is bariatric surgery.However,less than 2% of eligible patients who fulfill the criteria for bariatric surgery undergo the procedure. As a result,there is a drive to...The most effective and durable treatment for obesity is bariatric surgery.However,less than 2% of eligible patients who fulfill the criteria for bariatric surgery undergo the procedure. As a result,there is a drive to develop less invasive therapies to combat obesity. Endoscopic bariatric therapies(EBT) for weight loss are important since they are more effective than pharmacological treatments and lifestyle changes and present lower adverse event rates compared to bariatric surgery. Endoscopic sleeve gastroplasty(ESG) is a minimally invasive EBT that involves remodeling of the greater curvature. ESG demonstrated favorable outcomes in several centers,with up to 20.9% total body weight loss and 60.4% excess weight loss(EWL) on 2-year follow-up,with a low rate of severe adverse events(SAE). As such,it could be considered safe and effective in light of ASGE/ASMBS thresholds of > 25% EWL and ≤ 5% SAE,although there are no comparative trials to support this. Additionally,ESG showed improvement in diabetes mellitus type 2,hypertension,and other obesity-related comorbidities. As this procedure continues to develop there are several areas that can be addressed to improve outcomes,including device improvements,technique standardization,patient selection,personalized medicine,combination therapies,and training standardization. In this editorial we discuss the origins of the ESG,current data,and future developments.展开更多
Obesity is the abnormal accumulation of fat or adipose tissue in the body.It has become a serious health problem in the world in the last 50 years and is considered a pandemic.Body mass index is a widely used classifi...Obesity is the abnormal accumulation of fat or adipose tissue in the body.It has become a serious health problem in the world in the last 50 years and is considered a pandemic.Body mass index is a widely used classification.Thus,obese individuals can be easily classified and standardized.Obesity is the second cause of preventable deaths after smoking.Obesity significantly increases mortality and morbidity.We thought of preparing a publication about routine procedures for the preoperative evaluation of obesity.The question that we asked as bariatric and metabolic surgeons but which was not exactly answered in the literature was“Is esophagogastroduodenoscopy(EGD)necessary before bariatric surgery?”We found different answers in our literature review.The European Association of Endoscopic Surgery guidelines recommend EGD for all bariatric procedures.They strongly recommend it for Roux-en-Y gastric bypass(RYGB).As a result of a recent study by the members of the British Obesity&Metabolic Surgery Society,preoperative EGD is routinely recommended for patients und-ergoing sleeve gastrectomy,even if they are asymptomatic,but not recommended for RYGB.It is recommended for symptomatic patients scheduled for RYGB.According to the International Sleeve Gastrectomy Expert Panel Consensus Statement,preoperative EGD is definitely recommended for patients scheduled for sleeve gastrectomy,but its routine use for RYGB is controversial.However,a different view is that the American Society for Gastrointestinal Endoscopy recom-mends endoscopy only for symptomatic patients scheduled for bariatric surgery.In the literature,the primary goal of EGD recommended for sleeve gastrectomy has been interpreted as determining esophagitis caused by gastroesophageal reflux.In the light of the literature,it is stated that this procedure is not necessary in America,while it is routinely recommended in the European continent.Considering medicolegal cases that may occur in the future,we are in favor of performing EGD before bariatric surgery.In conc展开更多
alcohol as the leading cause of cirrhosis in the Western world.There remains to be a licensed pharmacological treatment for NAFLD.Weight loss is advised for all patients with NAFLD.Many patients however,struggle to lo...alcohol as the leading cause of cirrhosis in the Western world.There remains to be a licensed pharmacological treatment for NAFLD.Weight loss is advised for all patients with NAFLD.Many patients however,struggle to lose the recommended weight with lifestyle modification alone.Many drugs have either failed to show significant improvement of steatosis or are poorly tolerated.Bariatric surgery has been shown to reduce liver steatosis and regress liver fibrosis.The pathophysiology is not fully understood,however recent evidence has pointed towards changes in the gut microbiome following surgery.Novel endoscopic treatment options provide a minimally invasive alternative for weight loss.Randomised controlled trials are now required for further clarification.展开更多
There is no consensus when it comes to the necessity of an oeso-gastroduodenal fibroscopy(OGDF) before and after bariatric surgery. Many reports expressed the preoccupations about a gastroesophagal reflux disease(an a...There is no consensus when it comes to the necessity of an oeso-gastroduodenal fibroscopy(OGDF) before and after bariatric surgery. Many reports expressed the preoccupations about a gastroesophagal reflux disease(an acute risk of Barrett's esophagus) and its consequences after a sleeve gastrectomy(SG) and the risk of leaving a premalignant lesion in an excluded stomach after a Roux-en-Y gastric bypass. The International Federation for the Surgery of Obesity and Metabolic Disorders recommends a surveillance endoscopy, routinely after a SG. After review of the literature, we set out the arguments in favor of performing a systematic preoperative and post-operative OGDF.展开更多
Obesity is a chronic,relapsing,multifactorial pandemic defined as the excessive or abnormal accu・mulation of body fat due to genetic,biological,microbial,and environmental factors that promote a positive energy balanc...Obesity is a chronic,relapsing,multifactorial pandemic defined as the excessive or abnormal accu・mulation of body fat due to genetic,biological,microbial,and environmental factors that promote a positive energy balance mainly associated with increased intake and reduced consumption.1-3 Obesity is the consequence of enormous multisystem disorders,in eluding cardiovascular disease,4 type 2 diabetes,5 tumors,&sleep apnea,7-10 etc.,significantly increases mortality rate,11-13 and accounts for substantial elevation in health expenditures.14 Compared with Western countries.展开更多
The fast increase in the number of patients undergoing bariatric surgery has led to the emergence of bariatric endoscopy as a therapeutic interface for minimally invasive treatment of complications. These techniques h...The fast increase in the number of patients undergoing bariatric surgery has led to the emergence of bariatric endoscopy as a therapeutic interface for minimally invasive treatment of complications. These techniques have the potential to be safer, reversible and cost-effective, with decreased morbidity, because of their less invasive nature.展开更多
AIM:To determine if esophageal capsule endoscopy(ECE)is an adequate diagnostic alternative to esophagogastroduodenoscopy(EGD)in pre-bariatric surgery patients.METHODS:We conducted a prospective pilot study to assess t...AIM:To determine if esophageal capsule endoscopy(ECE)is an adequate diagnostic alternative to esophagogastroduodenoscopy(EGD)in pre-bariatric surgery patients.METHODS:We conducted a prospective pilot study to assess the diagnostic accuracy of ECE(PillCam ESO2,Given Imaging)vs conventional EGD in pre-bariatric surgery patients.Patients who were scheduled for bariatric surgery and referred for pre-operative EGD were prospectively enrolled.All patients underwent ECE followed by standard EGD.Two experienced gastroenterologists blinded to the patient’s history and the findings of the EGD reviewed the ECE and documented their findings.The gold standard was the findings on EGD.RESULTS:Ten patients with an average body mass index of 50 kg/m2were enrolled and completed the study.ECE identified 11 of 14(79%)positive esophageal/gastroesophageal junction(GEJ)findings and 14of 17(82%)combined esophageal and gastric findings identified on EGD.Fisher’s exact test was used to compare the findings and no significant difference was found between ECE and EGD(P=0.64 for esophageal/GEJ and P=0.66 for combined esophageal and gastric findings respectively).Of the positive esophageal/GEJ findings,ECE failed to identify the following:hiatal hernia in two patients,mild esophagitis in two patients,and mild Schatzki ring in two patients.ECE was able to identify the entire esophagus in 100%,gastric cardia in0%,gastric body in 100%,gastric antrum in 70%,pylorus in 60%,and duodenum in 0%.CONCLUSION:There were no significant differences in the likelihood of identifying a positive finding using ECE compared with EGD in preoperative evaluation of bariatric patients.展开更多
文摘Obesity is a global health epidemic with considerable economic burden.Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk.Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease(GERD)has been a topic of debate.GERD,including erosive esophagitis,is highly prevalent in the obese population.The role of pre-operative endoscopy in bariatric surgery has been controversial.Two schools of thought exist on the matter,one that believes routine upper endoscopy before bariatric surgery is not warranted in the absence of symptoms and another that believes that symptoms are poor predictors of underlying esophageal pathology.This debate is particularly important considering the evidence for the association of laparoscopic sleeve gastrectomy(LSG)with de novo and/or worsening GERD compared to the less popular Roux-en-Y gastric bypass procedure.In this paper,we try to address 3 burning questions regarding the inter-relationship of obesity,GERD,and LSG:(1)What is the prevalence of GERD and erosive esophagitis in obese patients considered for bariatric surgery?(2)Is it necessary to perform an upper endoscopy in obese patients considered for bariatric surgery?And(3)What are the long-term effects of sleeve gastrectomy on GERD and should LSG be done in patients with pre-existing GERD?
文摘Obesity is a chronic,progressive,and relapsing disease of excess adiposity that contributes to more than two hundred medical conditions and is projected to affect more than half the adult population of the United States by the year 2030.Given the limited penetrance of traditional bariatric surgery,as well as the cost and adherence barriers to anti-obesity medications,there is growing interest in the rapidly evolving field of endoscopic bariatric therapies(EBTs).EBTs are minimally invasive,same-day,per-oral endoscopic procedures and include endoscopic sleeve gastroplasty,intragastric balloons,and endoscopic bariatric revisional procedures.This field represents an exciting and innovative subspe-cialty within gastroenterology.However,building a successful endoscopic bariatric practice requires intentional,coordinated,and sustained efforts to overcome the numerous obstacles to entry.Common barriers include acquisition of the technical and cognitive skillset,practice limitations including the availability of nutrition counseling,facility capabilities,direct-to-consumer marketing,and financial pressures such as facility and anesthesia fees.As the highest-volume center for metabolic and bariatric endoscopy in the United States,we provide insights into successfully establishing an endoscopic bariatric program.
文摘The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy(EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass(RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status postRYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.
文摘The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this complex disorder. The development of new laparoscopic and minimally invasive treatments for medically-complicated obesity has made it essential that gastrointestinal physicians obtain a thorough understanding of past developments and possible future directions in bariatrics. New laparoscopic advancements provide patients and practitioners with a variety of options that have an improved safety profile and better efficacy without open, invasive surgery. The mechanisms of weight loss after bariatric surgery are complex and may in part be related to altered release of regulatory peptide hormones from the gut. Endoscopic techniques designed to mimic the effects of bariatric surgery and endolumenal inter-ventions performed entirely through the gastrointestinal tract offer potential advantages. Several of these new techniques have demonstrated promising, preliminary results. We outline herein historical and current trends in the development of bariatric surgery and its transition to safer and more minimally invasive procedures designed to induce weight loss.
文摘Background:Bariatric surgery represents an important treatment option for severely obese patients with nonalcoholic fatty liver disease(NAFLD).However,there remains inadequate data regarding the effects of different bariatric procedures on various NAFLD parameters,especially for histological outcomes.Thus,this meta-analysis aimed to compare the effects of restrictive bariatric procedures and foregut bypass on the metabolic,biochemical,and histological parameters for patients with NAFLD.Methods:Medline and Embase were searched for articles relating to bariatric procedures and NAFLD.Pairwise meta-analysis was conducted to compare efficacy of bariatric procedures pre-vs.post-procedure with subgroup analysis to further compare restrictive against foregut bypass procedures.Results:Thirty-one articles involving 3,355 patients who underwent restrictive bariatric procedures(n=1,460)and foregut bypass(n=1,895)were included.Both foregut bypass(P<0.01)and restrictive procedures(P=0.03)significantly increased odds of fibrosis resolution.Compared to restrictive procedures,foregut bypass resulted in a borderline non-significant decrease in fibrosis score(P=0.06)and significantly lower steatosis score(P<0.001).For metabolic parameters,foregut bypass significantly lowered body mass index(P=0.003)and low-density lipoprotein(P=0.008)compared to restrictive procedures.No significant differences were observed between both procedures for aspartate aminotransferase(P=0.17)and alkaline phosphatase(P=0.61).However,foregut bypass resulted in significantly lower gamma-glutamyl transferase than restrictive procedures(P=0.01)while restrictive procedures resulted in significantly lower alanine transaminase than foregut bypass(P=0.02).Conclusions:The significant histological and metabolic advantages and comparable improvements in biochemical outcomes support the choice of foregut bypass over restrictive bariatric procedures in NAFLD management.
文摘The prevalence of obesity continues to rise,and along with it comes a multitude of health-related consequences.The healthcare community has consistently struggled with providing treatment options to obese patients,in part due to the reluctance of patients in pursuing the more effective(yet invasive)surgical approaches such as sleeve gastrectomy and Rou-en-Y gastric bypass.On the other hand,the less invasive approach such as lifestyle/behavioral interventions and pharmacotherapy(Orlistat,Phenteramine,Phentermine/Topiramate,Locaserin,Naltrexon/Buproprion,and Liraglutide)have very limited efficacy,especially in the morbidly obese patients.Despite our best efforts,the epidemic of obesity continues to rise and pose enormous costs on our healthcare system and society.Bariatric endoscopy is an evolving field generated to combat this epidemic through minimally invasive techniques.These procedures can be performed in an ambulatory setting,are potentially reversible,repeatable,and pose less complications than their invasive surgical counterparts.These modalities are designed to alter gut metabolism by means of space occupation,malabsorption,or restriction.In this review we will discuss different bariatric endoscopic options(such as intragastric balloons,endoscopic sleeve gastroplasty,endoscopic aspiration therapies and gastrointestinal bypass sleeves),their advantages and disadvantages,and suggest a new paradigm where providers may start incorporating this modality in their treatment approach for obese patients.
基金Supported by The Deanship of Scientific Research at King Saud University funding of this research through the Research Group Project,No.RGP-VPP-279
文摘 Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents(SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwenta computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.
文摘A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the longterm impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a longterm approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees' prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicate
基金Supported by Korea Health Technology R and D Project through the Korea Health Industry Development Institute,and Ministry of Health and Welfare,South Korea,No.HI14C3477
文摘Endoscopic bariatric therapy may be a useful alternative to pharmacological treatment for obesity, and it provides greater efficacy with lower risks than do conventional surgical procedures. Among the various endoscopic treatments for obesity, the intragastric balloon is associated with significant efficacy in body weight reduction and relief of comorbid disease symptoms. Anatomically, this treatment is based on gastric space-occupying effects that increase the feeling of satiety and may also affect gut neuroendocrine signaling. The simplicity of the intragastric balloon procedure may account for its widespread role in obesity treatment and its applicability to various degrees of obesity. However, advances in device properties and procedural techniques are still needed in order to improve its safety and cost-effectiveness. Furthermore, verification of the physiological outcomes of intragastric balloon treatment and the clinical predictive factors for treatment responses should be considered. In this article, we discuss the types, efficacy, safety, and future directions of intragastric balloon treatment.
文摘Endoscopic sleeve gastroplasty(ESG)is a minimally invasive procedure used in the treatment of obesity,with a complication rate of less than 2%of cases.There have been only two reported cases worldwide of gallbladder injuries as a major complication of ESG.CASE SUMMARY We present the case of a 34-year-old patient who developed a complication after ESG.The patient experienced epigastric and right hypochondrium pain 12 h after the procedure,and a positive Murphy’s sign was identified on physical examination.Laboratory results showed a leukocyte count of 17×10^(3)/μL,and computed tomography indicated the presence of free fluid in the pelvic cavity and perihepatic recesses as well as a possible suture in the wall of the Hartmann’s pouch toward the anterior surface of the stomach.A diagnostic laparoscopy was performed,revealing plication of the Hartmann’s pouch wall to the anterior stomach wall.Laparoscopic cholecystectomy and lavage were carried out.The patient had a stable recovery and was discharged 72 h after surgery,tolerating oral intake.CONCLUSION Gallbladder plication should be suspected if signs and symptoms consistent with acute cholecystitis occur after ESG.
文摘Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early(< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late(> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.
文摘The most effective and durable treatment for obesity is bariatric surgery.However,less than 2% of eligible patients who fulfill the criteria for bariatric surgery undergo the procedure. As a result,there is a drive to develop less invasive therapies to combat obesity. Endoscopic bariatric therapies(EBT) for weight loss are important since they are more effective than pharmacological treatments and lifestyle changes and present lower adverse event rates compared to bariatric surgery. Endoscopic sleeve gastroplasty(ESG) is a minimally invasive EBT that involves remodeling of the greater curvature. ESG demonstrated favorable outcomes in several centers,with up to 20.9% total body weight loss and 60.4% excess weight loss(EWL) on 2-year follow-up,with a low rate of severe adverse events(SAE). As such,it could be considered safe and effective in light of ASGE/ASMBS thresholds of > 25% EWL and ≤ 5% SAE,although there are no comparative trials to support this. Additionally,ESG showed improvement in diabetes mellitus type 2,hypertension,and other obesity-related comorbidities. As this procedure continues to develop there are several areas that can be addressed to improve outcomes,including device improvements,technique standardization,patient selection,personalized medicine,combination therapies,and training standardization. In this editorial we discuss the origins of the ESG,current data,and future developments.
文摘Obesity is the abnormal accumulation of fat or adipose tissue in the body.It has become a serious health problem in the world in the last 50 years and is considered a pandemic.Body mass index is a widely used classification.Thus,obese individuals can be easily classified and standardized.Obesity is the second cause of preventable deaths after smoking.Obesity significantly increases mortality and morbidity.We thought of preparing a publication about routine procedures for the preoperative evaluation of obesity.The question that we asked as bariatric and metabolic surgeons but which was not exactly answered in the literature was“Is esophagogastroduodenoscopy(EGD)necessary before bariatric surgery?”We found different answers in our literature review.The European Association of Endoscopic Surgery guidelines recommend EGD for all bariatric procedures.They strongly recommend it for Roux-en-Y gastric bypass(RYGB).As a result of a recent study by the members of the British Obesity&Metabolic Surgery Society,preoperative EGD is routinely recommended for patients und-ergoing sleeve gastrectomy,even if they are asymptomatic,but not recommended for RYGB.It is recommended for symptomatic patients scheduled for RYGB.According to the International Sleeve Gastrectomy Expert Panel Consensus Statement,preoperative EGD is definitely recommended for patients scheduled for sleeve gastrectomy,but its routine use for RYGB is controversial.However,a different view is that the American Society for Gastrointestinal Endoscopy recom-mends endoscopy only for symptomatic patients scheduled for bariatric surgery.In the literature,the primary goal of EGD recommended for sleeve gastrectomy has been interpreted as determining esophagitis caused by gastroesophageal reflux.In the light of the literature,it is stated that this procedure is not necessary in America,while it is routinely recommended in the European continent.Considering medicolegal cases that may occur in the future,we are in favor of performing EGD before bariatric surgery.In conc
文摘alcohol as the leading cause of cirrhosis in the Western world.There remains to be a licensed pharmacological treatment for NAFLD.Weight loss is advised for all patients with NAFLD.Many patients however,struggle to lose the recommended weight with lifestyle modification alone.Many drugs have either failed to show significant improvement of steatosis or are poorly tolerated.Bariatric surgery has been shown to reduce liver steatosis and regress liver fibrosis.The pathophysiology is not fully understood,however recent evidence has pointed towards changes in the gut microbiome following surgery.Novel endoscopic treatment options provide a minimally invasive alternative for weight loss.Randomised controlled trials are now required for further clarification.
文摘There is no consensus when it comes to the necessity of an oeso-gastroduodenal fibroscopy(OGDF) before and after bariatric surgery. Many reports expressed the preoccupations about a gastroesophagal reflux disease(an acute risk of Barrett's esophagus) and its consequences after a sleeve gastrectomy(SG) and the risk of leaving a premalignant lesion in an excluded stomach after a Roux-en-Y gastric bypass. The International Federation for the Surgery of Obesity and Metabolic Disorders recommends a surveillance endoscopy, routinely after a SG. After review of the literature, we set out the arguments in favor of performing a systematic preoperative and post-operative OGDF.
文摘Obesity is a chronic,relapsing,multifactorial pandemic defined as the excessive or abnormal accu・mulation of body fat due to genetic,biological,microbial,and environmental factors that promote a positive energy balance mainly associated with increased intake and reduced consumption.1-3 Obesity is the consequence of enormous multisystem disorders,in eluding cardiovascular disease,4 type 2 diabetes,5 tumors,&sleep apnea,7-10 etc.,significantly increases mortality rate,11-13 and accounts for substantial elevation in health expenditures.14 Compared with Western countries.
文摘The fast increase in the number of patients undergoing bariatric surgery has led to the emergence of bariatric endoscopy as a therapeutic interface for minimally invasive treatment of complications. These techniques have the potential to be safer, reversible and cost-effective, with decreased morbidity, because of their less invasive nature.
文摘AIM:To determine if esophageal capsule endoscopy(ECE)is an adequate diagnostic alternative to esophagogastroduodenoscopy(EGD)in pre-bariatric surgery patients.METHODS:We conducted a prospective pilot study to assess the diagnostic accuracy of ECE(PillCam ESO2,Given Imaging)vs conventional EGD in pre-bariatric surgery patients.Patients who were scheduled for bariatric surgery and referred for pre-operative EGD were prospectively enrolled.All patients underwent ECE followed by standard EGD.Two experienced gastroenterologists blinded to the patient’s history and the findings of the EGD reviewed the ECE and documented their findings.The gold standard was the findings on EGD.RESULTS:Ten patients with an average body mass index of 50 kg/m2were enrolled and completed the study.ECE identified 11 of 14(79%)positive esophageal/gastroesophageal junction(GEJ)findings and 14of 17(82%)combined esophageal and gastric findings identified on EGD.Fisher’s exact test was used to compare the findings and no significant difference was found between ECE and EGD(P=0.64 for esophageal/GEJ and P=0.66 for combined esophageal and gastric findings respectively).Of the positive esophageal/GEJ findings,ECE failed to identify the following:hiatal hernia in two patients,mild esophagitis in two patients,and mild Schatzki ring in two patients.ECE was able to identify the entire esophagus in 100%,gastric cardia in0%,gastric body in 100%,gastric antrum in 70%,pylorus in 60%,and duodenum in 0%.CONCLUSION:There were no significant differences in the likelihood of identifying a positive finding using ECE compared with EGD in preoperative evaluation of bariatric patients.
