Invasieve aanpak van OBESITAS

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1 Boudewijn De Waele, Heelkunde, UZ Brussel

Invasieve aanpak

van OBESITAS

Zaterdag 1 December 2007

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Invasieve aanpak van OBESITAS

1. Gastroscopische behandeling - maagballon

- transoral intragastric surgery 2. Minimaal Laparoscopische behandeling

- gastric pacemaker 3. Heelkunde

- restrictie - malabsorptie

- kombinatie restrictie + malabsorptie

Invasieve aanpak van OBESITAS

1. Gastroscopische behandeling (Maagballon) - Garren-Edwards Gastric Bubble - Taylor Intragastric Balloon - BioEnterics Intragastric Balloon - Heliosphere BAG

Garren-Edwards gastric bubble

• FDA Approval :1985

• Elastomeric plastic

• Self-sealing inflation

valve

• Position controlled

fluoroscopically

• Inflated with 200 ml of air

• Disconnection of filling

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3 Garren-Edwards gastric bubble

Garren-Edwards bubble

• “hundreds of individuals across the country are seeking implantation as soon as possible” (Clark Ch.1986)

• “since 1985 tens of thousands of intragastric balloons for the treatment of obesity (20.000 in 1986) have been inserted”(Kral JG, Gastroenterology 1988)

• But…”The enthusiasm of users of the GE bubble has virtually disappeared (Marshall, Am Journal Gastroenterol, 1990 )

Garren-Edwards air bubble

Enthusiasm disappeared as a result of: -lack of efficacy -Significant complications: - premature deflation - intestinal obstruction - gastric ulceration - and death… -SHORTCOMINGS : - small volume - irregular shape

Taylor Intragastric Balloon

• substantially larger

(500-550 ml)

• Silicone

• Smooth (no edges)

• Pear-shaped

• Liquid-filled

Improved results, but still disappointing !

International Workshop (Tarpon Springs, Florida) for establishing the characteristics of a “good” intragastric balloon, resulting in the

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BioEnterics Intragastric Balloon (BIB)

• perfectly spherical

• silicone

• smooth surface

• liquid-filled

• radioopaque marker

• adjustable in volume

(400-800ml)

• no leak

BIB Maagballon

klaar voor plaatsing

BioEnterics Maagballon

- gevuld met 500-700

ml.water

- vrij rondzwevend in

de maag

- blijft 6 maand tot één

jaar

- moet dan terug

verwijderd worden

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5 Heliosphere Intragastric Balloon

»

Nieuwe kenmerken:

- met lucht gevuld

- gewicht : 30 gram

- betere konstruktie

van de wand van de

ballon

- minder poreus

- minder

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RESULTS

CONCLUSION: The best indications for BIB were:

-Morbidly obese patients (BMI>40) and super-obese patients (BMI>50) in preparation for bariatric operations

-obese patients with BMI 35-40 with co-morbidities in preparation for bariatric surgery -obese patients with BMI 30-35 with a chronic disease otherwise unresolved -patients with BMI<30 only in a multidisciplinary approach

(Doldi et al., Obesity Surgery,2002)

RESULTS

Conclusion: BIB intragastric balloon as a means of weight reduction in the obese patient led to a 50.8% loss of excess weight after 6 months. Although severe morbidity can occur, the BIB provides a means for short-term weight reduction in conjunction with dietary measures.

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7 Invasieve aanpak van OBESITAS

1. Gastroscopische behandeling - maagballon

- transoral intragastric surgery 2. Minimaal Laparoscopische behandeling

- gastric pacemaker 3. Heelkunde

- restrictie - malabsorptie

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Invasieve aanpak van OBESITAS

1. Gastroscopische behandeling

2. Minimaal Laparoscopische behandeling (Gastric Pacemaker)

3. Heelkunde - restrictieve - malabsorptieve

• Implantable Gastric Stimulation (IGS)

Surgical procedure

- general anesthesia

- laparoscopic insertion of

bipolar leads in muscular

wall of the stomach

- peroperative gastroscopy

- implantation pulse generator

in abdominal wall

- electrical activation at one

month following implantation

Implantable Gastric Stimulation (IGS)

Mechanisms of Action

Effect on - myoelectrical activity

- hormonal control

1°) Myoelectrical activity - Intrinsic pacemaker in stomach

>gastric rythmic waves >impor-tant role in the regulation of gastric motility

- IGS : repetitive electrical pulses to the stomach >disturbs the natural pacemaker! EFFECTS: in the fasting state : gastric distension>activation stretch

recep-tors, causing satiety

in the fed state : suppression of gastric peristaltism>delay in gastric emptying

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9 Implantable Gastric Stimulation (IGS)

Mechanisms of Action

Effect on - myoelectrical activity

- hormonal control 2°)Hormonal control

- Satiety hormones

Different gastrointestinal hormones are involved in

°regulation of food intake (CNS) °gastrointestinal motility Most GI hormones (leptin, CCK, somatostatin,etc.): increasing con-centration > increasing satiety. Ghrelin : increasing concentration

> increasing appetite - IGS : suppression of the production of ghrelin >reduction of appetite

Implantable Gastric Stimulation (IGS)

Advantages

- simplicity,safety,rapid procedure - no alterations to GI tract - avoiding morbidity and mortality of

common bariatric operations - lack of nutritional side-effects

Complications

Implantable Gastric Stimulation (IGS)

Effect on weight loss:

Results

Conclusion:

“While the exact mechanisms of gastric stimulation remain incompletely understood , it appears that the implantation of an IGS is associated with weight loss, a decrease in blood pressure in hypertensive patients, and a reduction or elimination of symptoms in those who had GERD.

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Implantable Gastric Stimulation (IGS)

Results

Effect on blood pressure:

“The blood pressure findings are impressive…We usually start the hypertensive patient immediately on anti-hypertensive medication. After gastric stimulation, blood pressure values drop far more than anticipated, to the extent that we often modify or discontinue medication. We suspect that gastric stimulation influences the autonomic nervous system”

(V.Cigaina, Obesity Surgery, 2004)

Invasieve aanpak van OBESITAS

1. Gastroscopische behandeling 2. Minimaal Laparoscopische behandeling 3. Heelkunde

- restrictieve - malabsorptieve

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11 Invasieve aanpak van OBESITAS

-restrictieve - malabsorptieve

Vertical Banded Gastroplasty (MASON) versus

Adjustable Gastric Banding (KUZMAK)

“To permit correction of changes in stoma diameter occurring with the passage of time, the band was modified in 1986 by adding an adjustable portion ( SASGB or Stoma adjustable silicone gastric banding ) ” Dr Kuzmak LI, Irvington, NJ, USA;

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“En octobre 1992, nous avons placé, pour la première fois à notre connaissance, un anneau de Kusmak par coelioscopie. Des modifications techniques se sont avérées nécessaires” (Cadière et al.).

“In 1992 we started an animal laboratory program at the dept.of Experimental Surgery, University of Liege, Belgium. We performed our first human LAGB on September 1,1993” (Belachew et al.).

“With growing experience, LASGB could be considered a “one-day surgery” procedure in the near future” (1997).

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“The present study demonstrates that LAGB for obesity may be performed on an ambulatory basis without complications”(2004)

Vertical Banded Gastroplasty versus

Adjustable Gastric Banding

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13 Laparoscopic Adjustable Gastric Banding

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17 Adjustment of the Gastric Band

Nieuw…

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Invasieve aanpak van OBESITAS

- restrictieve -malabsorptieve

Biliopancreatic Diversion (Scopinaro)

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19 Invasieve aanpak van OBESITAS

-kombinatie restrictie + malabsorptie

Roux-en-Y Gastric Bypass

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