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What's new in Weight Loss surgery?

By Dr Ian Baxter
WEIGHT LOSS MANAGEMENT

People have explored and have tried many different options of weight loss. In short there are a growing number of products that have been marketed for weight loss, the Orbera Balloon, the Endosleeve and the EndoBarrier and some newer procedures that have been noted on the internet.  We will look at these one by one. 

Orbera Gastric Balloon

 

  1. The Orbera Gastric Balloon or non-surgical gastric balloon. This is a system that has been available for a number of years.  The idea of the product is that it is placed using an endoscope under twilight sedation and a balloon is placed into the stomach and then gradually inflated up to some 600mL.  This creates a sense of fullness I the stomach, you cannot have a large meal because the balloon inside the stomach prevents you from eating large meals. 

The device has been trialled.  Some of the drawbacks are that it can be quite unsafe given twilight sedation and placing a balloon into the stomach in an obese patient with a difficult airway.  Secondly the balloon cannot be left there indefinitely and most of the studies are between 3 and 6 months and there are no reported studies over a year.  Once the balloon is removed the idea is that patient has changed their eating behaviour but more often than not once the balloon is removed that space that was occupied in the stomach has now disappeared and patients start eating again and weight gain occurs. 

It is not covered by Medicare or health funds and there is a very good reason for this as there is no research that shows that there is a lasting benefit with the procedure.  The Orbera Balloon is available for patients.  The cost varies but it is around $5000 Australian and it has not really gained in popularity because of the above problems. 

 

The EndoBarrier

  1. The EndoBarrier. The EndoBarrier is a device that is a plastic sleeve that is placed at the pylorus or the bottom part of the stomach and then run along the first part of the bowel to prevent absorption of material in the first metre of the small bowel.  The idea is that is where a lot of hormonal and nerve changes happen and you are bypassing this region of the small bowel, you have an element of malabsorption and significant hormonal and nerve changes to promote weight loss.  The device is inserted via an endoscope under sedation and no incisions are required.  The device is meant to be implanted into the bottom of the stomach and then the sleeve pushed through into the small bowel.  It cannot be left for a prolonged period of time, conventionally 6 months and weight loss has been achieved.  However, significant complications have occurred because of the implantation device moving and it can obstruct the bowel and it can perforate through the bowel. It is not a permanent solution and has to be removed and complications have happened whilst trying to remove the device. 

Again, despite it being advertised and being on channel 7 at one stage as a potential for weight loss surgery it is not long term. It is not covered under Medicare or with private health insurance and it has to be paid for. 

  1. The Endosleeve. As endoscopic or technology using the endoscope, or tube that is looking into your stomach, to perform an endoscopy has enabled devices to be passed along the device to enable suturing.  There have been some attempts to perform a sleeve on the inside of the stomach, the potential advantages are that you are not using any incisions to perform narrowing of the stomach and a number of sutures are placed across the stomach to create a small stomach and to make the endoluminal or the look from inside the stomach appear like a sleeve.  However, significant complications have occurred with suturing the spleen, organs and causing a leak of the stomach contents (peritonitis requiring re-operation).  Also placing stiches and narrowing the stomach does not involve removal of the stomach and one of the reasons why the sleeve is so effective is that removal of the stomach results in decreased ghrelin and therefore decreased hunger and this is not achieved using an Endosleeve. 

The other factor is that if the sutures are not applied correctly you can get an hourglass deformity of the stomach which will not make an effective sleeve so patients don’t lose weight and secondly you cannot re-operate on those patients and perform a sleeve after it has been performed because of the deformed stomach and retained metal devices using the Endosleeve. 

Weight loss achieved is approximately 20% so it is not as effective as a sleeve.  This procedure is being done in small number in Brisbane, Sydney and Melbourne and is very experimental currently.  The advantage of the technique is that it does not use any abdominal incisions but significant complications have occurred as can occur with a sleeve and there is a concern about a “salvage” procedure if the Endosleeve fails to work as a primary operation. 

The general principles of performing a sleeve, which is removal of 3/4 of the stomach and having a nicely fashioned sleeve so that it looks and is uniformly narrowed along the entire stomach around a bougie is not performed.  Sutures can open up and the stomach can re-expand again. 

In summary, as with all of medicine new techniques and procedures are looked and looked for. These procedures are available in Australia and are being done in small numbers but my main concern is that long term efficacy is not there.  There are significant risks even though these procedures are being marketed as not being surgical and minimally invasive.  If complications do occur they are certainly significant and can be life threatening.  As a unit we are not considering moving into doing these procedures because of the above reasons.  Like all medicine, advances do happen and in the future I am sure we will have some valuable adjunct procedures that are able to be offered besides a band, a sleeve and a bypass.