**3. Endoscopic bariatric therapy**

Primary endoscopic obesity therapy has now been given the proper name "bariatric endoscopy" or "endoscopic bariatric therapy". This illustrates the relevance of endoscopy for the treatment of obese patients. EBT currently includes six different mechanisms:


In **Table 1** we present an overview of all endoscopic therapeutic concepts with available correlated EWL is presented.

For the completeness of the review, the swallow balloons Elipse™ and OBALLON™ are mentioned at this point. However, they do not require endoscopic control or filling and are therefore not considered further in this review.

EAES and IFSO guidelines recommend consultation on surgical or endoscopic bariatric therapy based on initial weight, previous eating habits, expected weight loss, patient-related risk stratification (pre-existing conditions, compliance) and local availability of surgical and/or endoscopic bariatric surgery experts EAES 2020 [1, 10]. The choice of bariatric intervention should be based on the consensus of a supervising, interdisciplinary board of experts, whose members are from the fields of surgery, nutritional medicine, endocrinology and psychology, and the fully informed patient.

*Bariatric Surgery—from the Non-surgical Approach to the Post-Surgery Individual Care… DOI: http://dx.doi.org/10.5772/intechopen.95259*


#### **Table 1.**

*Mechanisms of endoscopic bariatric treatment, products and procedures are listed with mean EWL% after 12 months if available.*

In **Figure 1** following mechanisms and products are illustrated in a sketch:


#### **3.1 Space occupying**

The common gastric balloons are well accepted. Besides the expected nausea and belching, possible gastric ulcerations and perforations should be discussed with the patients.

All endoscopic, bariatric mechanisms that have a timely limit should be combined with an intensive nutritional, medical and psychological therapy. Obesity is a chronic disease, so there is always the risk of a "yo-yo" effect after removal of the space occupying device in such procedures. This development must be discussed with the patient.

The time-limited procedures are particularly suitable with a step-by-step concept prior to bariatric surgery.

#### **Figure 1.**

*Relevant techniques and devices of EBT are sketchily presented. A) Orbera Intragastric balloon. B) Reshape duo Intragastric balloon. C) Transpyloric shuttle-device. D) POSE*™ *operating platform with fundal accomodation. E) Endoscopic gastric sleeve with the OverStitch*™*-device. F) Endomina-suturing-system. G) Aspire assist-device. H) Endobarrier duodeno-jejunal bypass liner. I) SatiSphere-device.*

#### *3.1.1 Spatz3*

The Spatz3 (Spatz FGIA, Great Neck, NY, USA) intragastric balloon is the only space occupying system for using a time of 12 months. The balloon is placed endoscopically and filled with 400-750 ml saline and methylene blue.

Results: Usuy and Brooks reported 2018 about 165 patients with implanted Spatz3 balloons in two centers. Mean EWL after one year was 67.4% [3].

Complications: Complications were nausea (89–92%), vomiting (21–71%), and abdominal pain (22–24%). Five patients developed gastric ulcers, one gastric perforation occurred at week 17 after implantation.

#### **3.2 ReShape duo intragastric balloon**

The ReShape IGB (Reshape, San Clemente, CA, USA) device contains of two silicone balloons attached to each other by a flexible tube. It is inserted and retrieved endoscopically. Device is placed for 6 months. The ReShape Duo is filled *Bariatric Surgery—from the Non-surgical Approach to the Post-Surgery Individual Care… DOI: http://dx.doi.org/10.5772/intechopen.95259*

with 900 mL of saline solution (450 mL to each balloon). Each balloon has independent channels to prevent deflation of the other balloon if one leaks.

Results: In a seven-center study of Agnihotri and colleagues 202 patients were enrolled. EWL after 6 months was 29.9% [4]. In the REDUCE pivotal trial, including 326 patients, EWL was 25.1% in the Reshape arm compared to 11.3% in the sham arm [22].

Complications: Most common SAEs were nausea, vomiting, and abdominal pain that generally resolved after 1 week. The gastric ulceration rate was 0.9%.

#### **3.3 Orbera**

The Orbera (Apollo Endosurgery, Austin, TX, USA) is a single, spherical balloon composed of silicone previously known as the BioEnterics Intragastric Balloon (BIB; Allergan, Irvine, California, USA). The balloon filling volume ranges between 400 and 700 mL of saline.

Results: Courcoulas and colleagues [23] reported in a multicenter, randomized, comparative study about 137 patients with implanted Orbera balloon. Mean EWL after 9 months was 26.5%.

Complications: Early removal of the IGB occurred in 18.75% of patients. The most common adverse events were pain and nausea [23]. Reported SAEs with this balloon were rare, and consisted of migration in 1.4% of patients and gastric perforation in 0.1% [24].

#### **3.4 TransPyloric shuttle**

The TransPyloric Shuttle (BAROnova Inc. Goleta, CA) consists of a spherical silicone bulb attached to a smaller silicone bulb by a flexible tether. Intermitted occlusion of the gastric antrum is reached by the larger bulb when the smaller bulb entering the duodenum with peristalsis.

Results: A randomized clinical trial showed a mean EWL of 30.9% at 12months follow-up [6].

Complications: Premature balloon removal occurred in 22.7% (46/203) of the cases. SAEs were rare (2.8%) and included: esophageal rupture, device impaction, upper abdominal pain, gastric ulcer, vomiting, pneumothorax. Premature balloon removal occurred in 22.7% (46/203) of the cases.

#### **3.5 Heliosphere bag**

The Heliosphere BAG is filled with 950 mL of air rather than fluid. Balloons were implanted for six months.

Results: Lecumberri and colleagues reported about 82 patients with a EWL of 31.87% six months after insertion [8].

Complications: The Heliosphere BAG deflated and passed spontaneously in 2 cases (3%). De Castro et al. [25] described 2013 a comparative, prospective study of 91 patients: Orbera balloon (73 patients) with Heliosphere BAG (18 patients, mean BMI 45.2 kg/m<sup>2</sup> ). In this study balloon extraction was difficult in 8 cases, and a rigid esophagoscope as required in 4 cases; laparoscopic surgery was required to remove BAG in 1 case. BAG was significantly more likely to result in retrieval complications.

#### **4. Endoscopic gastroplasty, endoscopic sleeve**

Endoscopic gastroplasty or sleeve procedures are enjoying increasing popularity. The principle of all the procedures listed is a reduction of the stomach volume by

endoluminally placed sutures or clips. The procedures are performed transorally, so that no permanent scars result. By means of a suture/clip machine placed on the endoscope, the stomach is contracted from the intraluminal side and fixed accordingly, thus reducing its lumen. The change in the shape and function of the stomach primarily leads to delayed gastric emptying and thus increased saturation. Weight loss and reduction of the diabetic metabolic state are the result. These procedures have been evaluated for patients with obesity class 1 to 3 and are associated with excellent long-term results.
