Effects on physiologic measures of appetite from intragastric balloon and endoscopic sleeve gastroplasty: results of a prospective study

Background: Endoscopic bariatric therapies can help address widening management gaps in obesity. Their ability to facilitate weight loss is largely tied to influences on appetite through perturbations of gastric emptying and accommodation. As these tools gain traction in obesity therapy, their physiologic underpinnings require exploration, which may enhance efficacy, tolerance, and patient-tailored care.Methods: We prospectively assessed consecutive subjects with fluid-filled intragastric balloons (IGBs) (n = 18) placed between October 2016 and June 2017 or underwent endoscopic sleeve gastroplasty (ESG) (n = 23) from March 2018 to June 2018. Patients underwent physiologic appraisal at 3 months with13C-spirulina-based gastric emptying breath test to determine time to half emptying (T50), as well as maximum tolerated volume (MTV) of a standard nutrient drink test. Changes in T50 and MTV at 3 months were compared with percent total body weight loss (%TBWL) at 3 and 6 months using best-fit linear regression.Results: The change in T50 at 3 months correlated with %TBWL at 3 months for IGB (P = 0.01) and ESG (P = 0.01) but with greater impact on %TBWL in IGB compared to ESG (R2 = 0.42vs. 0.26). Change in T50 at 3 months was predictive of weight loss at 6 months for IGB (P = 0.01) but not ESG (P = 0.11). ESG was associated with greater decrease in MTV compared to IGB (340.25 ± 297.97 mLvs. 183.00 ± 217.13 mL,P = 0.08), indicting an enhanced effect on satiation through decreased gastric accommodation. Changes in MTV at 3 months did not correlate with %TBWL for either IGB (P = 0.26) or ESG (P = 0.49) but trended toward significance for predicting %TBWL at 6 months for ESG (P = 0.06) but not IGB (P = 0.19).Conclusion: IGB and ESG both induce weight loss but likely through distinct gastric motor function phenotypes, and gastric emptying may predict future weight loss in patients with IGB.

Endoscopic pancreatic duct stenting for pain palliation in selected pancreatic cancer patients:a systematic review and meta-analysis

Background Abdominal pain is a debilitating symptom affecting-80%of pancreatic cancer(PC)patients.Pancreatic duct(PD)decompression has been reported to alleviate this pain,although this practice has not been widely adopted.We aimed to evaluate the role,efficacy,and safety of endoscopic PD decompression for palliation of PC post-prandial obstructive-type pain.Methods A systematic review until 7 October 2020 was performed.Two independent reviewers selected studies,extracted data,and assessed the methodological quality.Results We identified 12 publications with a total of 192 patients with PC presenting with abdominal pain,in whom PD decompression was attempted,and was successful in 167 patients(mean age 62.5 years,58.7%males).The use of plastic stents was reported in 159 patients(95.2%).All included studies reported partial or complete improvement in pain levels after PD stenting,with an improvement rate of 93%(95%confidence interval,79%-100%).The mean duration of pain improvement was 94616 days.Endoscopic retrograde cholangiopancreatography(ERCP)-related adverse events(AEs)were postsphincterotomy bleeding(1.8%),post-ERCP pancreatitis(0.6%),and hemosuccus pancreaticus(0.6%).AEs were not reported in two patients who underwent endoscopic ultrasound-guided PD decompression.In the 167 patients with technical success,the stent-migration and stent-occlusion rates were 3.6%and 3.0%,respectively.No AE-related mortality was reported.The methodological quality assessment showed the majority of the studies having low or unclear quality.Conclusion In this exploratory analysis,endoscopic PD drainage may be an effective and safe option in selected patients for the management of obstructive-type PC pain.However,a randomized–controlled trial is needed to delineate the role of this invasive practice.

Endo-anesthesia:a primer

Gastrointestinal(GI)endoscopy has witnessed a Cambrian explosion of techniques,indications,and expanding target populations.GI endoscopy encompasses traditional domains that include preventive measures,palliation,as alternative therapies in patients with prohibitive risks of more invasive procedures,and indicated primary treatments.But,it has expanded to include therapeutic and diagnostic interventional endosonography,luminal endoscopic resection,third space endotherapy,endohepatology,and endobariatrics.The lines between surgery and endoscopy are blurred on many occasions within this paradigm.Moreover,patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management.The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients.This further necessitates specialized programs to ensure appropriate evaluation,risk stratification,and optimization for safe sedation and general anesthesia if needed.This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices.In this primer,we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.

Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery

Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease(GERD)or worsening of pre-existing GERD.The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation.However,there is currently no standardized approach for the assessment of GERD in these patients.In this review,we delineate the relationship between GERD and the most common bariatric surgeries:sleeve gastrectomy(SG)and Roux-en-Y gastric bypass(RYGB),with a focus on pathophysiology,objective assessment,and underlying anatomical and motility disturbances.We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB,determine the underlying cause,and guide the management and treatment.

Acute pancreatitis associated with intravenous administration of propofol:evaluation of causality in a systematic review of the literature

Acute pancreatitis(AP)associated with intravenous administration of propofol has been described with unknown causal relation.We therefore assessed this causality in a systematic review.Multiple databases were searched on 16 August 2017;studies were appraised and selected by two reviewers based on a priori criteria.Propofol causality was evaluated with the Naranjo scale and Badalov classification.We identified 18 studies from 11 countries with a total of 21 patients,and the majority had adequate methodological quality.The median age was 35 years(range,4–77)and 10(48%)were males.Overall,propofol was administrated in 8 patients as sedative along with induction/maintenance of anesthesia in 13 patients;median dose was 200 mg,with intermediate latency(1–30 days)in 14(67%).Serum triglycerides were>1000 mg/dL in four patients.Severe AP was observed in four patients(19%).AP recurrence occurred in one out of two patients who underwent rechallenge.Mortality related to AP was 3/21(14%).Propofol was the probable cause of AP according to the Naranjo scale in 19 patients(89%).Propofol-induced AP has a probable causal relation and evidence supports Badalov class Ib.Hypertriglyceridemia is not the only mechanism by which propofol illicit AP.Propofol-induced AP was severe in 19%of patients with a mortality rate related to AP of 14%.Future research is needed to delineate whether this risk is higher if combined with other procedures that portend inherent risk of pancreatitis such as endoscopic retrograde cholangiopancreatography.

Celiac artery mesenteric fat measurement with endosonography(CAMEUS)reliably correlates with obesity and related comorbidities

Background:Visceral fat represents a metabolically active entity linked to adverse metabolic sequelae of obesity.We aimed to determine if celiac artery mesenteric fat thickness can be reliably measured during endoscopic ultrasound(EUS),and if these measurements correlate with metabolic disease burden.Methods:This was a retrospective analysis of patients who underwent celiac artery mesenteric fat measurement with endosonography(CAMEUS)measurement at a tertiary referral center,and a validation prospective trial of patients with obesity and nonalcoholic steatohepatitis who received paired EUS exams with CAMEUS measurement before and after six months of treatment with an intragastric balloon.Results:CAMEUS was measured in 154 patients[56.5%females,mean age 56.5±18.0years,body mass index(BMI)29.8±8.0 kg/m^(2)]and was estimated at 14.7±6.5mm.CAMEUS better correlated with the presence of non-alcoholic fatty liver disease(NAFLD)(R^(2)=0.248,P<0.001)than BMI(R^(2)=0.153,P<0.001),and significantly correlated with metabolic parameters and diseases.After six months of intragastric balloon placement,the prospective cohort experienced 11.7%total body weight loss,1.3 points improvement in hemoglobin A1c(P=0.001),and a 29.4%average decrease in CAMEUS(−6.4±5.2mm,P<0.001).CAMEUS correlated with improvements in weight(R^(2)=0.368),aspartate aminotransferase to platelet ratio index(R^(2)=0.138),and NAFLD activity score(R^(2)=0.156)(all P<0.05).Conclusions:CAMEUS is a novel measure that is significantly correlated with critical metabolic indices and can be easily captured during routine EUS to risk-stratify susceptible patients.This station could allow for EUS access to sampling and therapeutics of this metabolic region.