Bariatric Times - September 2008 - (Page 15)

Bariatric Times • September 2008 Emerging Technologies 15 A number of new technologies are in development that promise to radically change THE FACE OF BARIATRIC SURGERY IN THE NEXT DECADE leak. If it leaked and decreased in size, it was at risk for migration into the intestine, which could result in obstruction and intestinal perforation. Not surprisingly, the GarronEdwards gastric bubble was pulled from the market and gastric balloon placement abandoned as a treatment option for obesity.3 However, recently, gastric balloons have resurfaced with the introduction of the Allergan Intragastric Balloon (formerly known as the BIB®). This balloon features a new design developed to reduce the risks seen with the gastric bubble. The Allergan Intragastric Balloon is spherical in shape with no edges and is doublelayered to reduce the risk of leak. Studies have shown the Allergan Intragastric Balloon to achieve a weight loss of 25 to 35 percent of excess weight with few complications.4,5 While intragastric balloon placement does not appear to represent a primary treatment for morbidly obese patients, it may have a role as a first stage in a staged approach for high risk or super-superobese patients or as a treatment for less severe obesity. Although the gastric balloon is still not FDA-approved in the US, there are now several different balloons available worldwide. bariatric surgical procedures in the world. However, at present, band adjustments require needle punctures, which have several limitations. First, they can be painful and may lead to bleeding or infection. Second, the instillation of saline is a method that is prone to inaccuracy. Last, band adjustment sometimes requires fluoroscopic assistance, which is expensive and exposes the patient to radiation. In the future, adjustable gastric bands may contain a small “watch” motor than can be accurately adjusted by radiofrequency instead of the current expandable bladder that requires saline instillation. This would eliminate the risks associated with needle punctures. early reports of cholecystectomies performed via the vagina. Are gastric bands and sleeve gastrectomies far behind? In addition, there are now a number of instruments that have been designed to suture or plicate from inside the stomach endoscopically.6,7 These devices are introduced down the mouth into the stomach either through or alongside an endoscope. These include StomaphyXTM produced by Endogastric Solutions (Figures 4 and 5), TransportTM (Figures 8 and 9) manufactured by USGI Medical, Inc, and Ethicon Endo-Surgey’s Endoscopic Suturing System (Figure 10) manufactured by Ethicon Endosurgery. These devices can be used to volumereduce dilated gastric pouches, narrow dilated gastrojejunostomies, and even close gastrogastric fistula. Endoscopic gastric partitioning is also being investigated either via endoscopic suturing devices such as the Bard EndocinchTM, the TOGATM device by Satiety (Figures 2 and 3), or the Endoscopic Suturing System. Should these techniques prove successful, it would not be out of the realm of possibility to design a technique for an endoscopic or endoscopic-assisted Roux-en-Y gastric bypass. While all of these endoluminal and natural orifice procedures appear attractive, to date there have been very little data published, comprising only small patient numbers and limited follow-up. Better data from a greater number of patients with longer follow-up would be necessary to prove that these procedures are truly safe and, more significantly, efficacious. ENDOSCOPIC GASTROINTESTINAL SLEEVES Another endoscopic application is the insertion of an impermeable sleeve into the gastrointestinal tract. In both animal and preliminary human studies, the sleeve has been shown to be effective for weight loss and for improving diabetes.8,9 The EndoBarrierTM (Figure 1) created by GI Dynamics has been demonstrated to be safe and effective with six-month follow-up. The device is a soft, 60cm sleeve that is deployed with an endoscope. The device is anchored into the proximal duodenum and is extended down into the jejunum. It can also be easily endoscopically explanted. In 12 morbidly obese patients, four of which had type II diabetes, there was a 23.6-percent loss of excess weight and all patients could be taken off of their oral hypoglycemic medications.9 The EndoBarrierTM may offer an exciting and safe alternative to traditional bariatric surgery, especially for type II diabetics. However, it is not currently known how long the sleeve can safely be left in the gastrointestinal tract, and the mechanism of action is not yet determined (i.e., nutrient NATURAL ORIFICE SURGERY Natural orifice and endoluminal surgery refers to operating via natural openings such as the mouth, anus, or vagina instead of incisions on the abdominal wall. Conceivably, the concept of operating without the need to make incisions would be very attractive for patients in that there would be less or no postoperative pain, and obviously there would be no scars. There are several potential applications for natural orifice surgery. It can be used as the access platform for conventional procedures such as the adjustable gastric band, vertical sleeve gastrectomy, and even Roux-en-Y gastric bypass. There have been MECHANICAL GASTRIC BANDS Laparoscopic adjustable gastric banding is one of the most popular FIGURE 1. EndoBarrier has demonstrated safe and effective with six-month follow-up. TM FIGURE 2. TOGATM device stapling on a double layer of stomach to create a gastric sleeve. (Courtesy of Satiety) FIGURE 3. Deployment of the TOGATM restrictor at the bottom of the gastric sleeve. (Courtesy of Satiety)

Table of Contents Feed for the Digital Edition of Bariatric Times - September 2008

Bariatric Times - September 2008 Emerging Technologies Case Report Sleeve Gastrectomy after a Jejunoileal Bypass Reversal Editorial Message Contents Editorial Board Walk from Obesity The Latest on Nutrition and Hair Loss in the Bariatric Patient Consultant’s Corner Journal Watch Calendar of Events Advertiser Index

Bariatric Times - September 2008

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