Reply to Ulbricht et al.

We appreciate the interest and kind comments of Dr. Ulbricht and colleagues on our review on intragastric balloons for weight reduction. Their letter reports a case of severe pulmonary disease as a possible extraesophageal complication of gastroesophageal reflux disease (GERD) associated with intragastric balloon implantation.

Obesity itself is a risk factor for GERD. The double-blind, randomized sham-controlled study by Genco et al. on the use of the Bioenterics Intragastric Balloon (BIB) for weight reduction in morbidly obese patients reported that 17 patients (53.12 %) were complaining of classic reflux symptoms, which were well controlled by doubling the omeprazole dosage (40 mg/day) [1]. In the sham-controlled randomized study by Mathus-Vliegen & Tytgat on use of the BIB in treatment-resistant obese patients, three patients (7 %) could not tolerate the BIB because of severe erosive reflux disease. Severe esophagitis was found in another patient with a small hiatal hernia and substantial weight loss (32.6 kg) during BIB treatment. Two more patients developed esophagitis, which was attributed to the intake of nonsteroidal anti-inflammatory drugs. Although esophageal erosions were observed in 10 patients at first BIB removal, they had disappeared at the follow-up endoscopy [2]. No extraesophageal manifestations of GERD were mentioned after BIB implantation. A large number of anthropometric parameters of obesity have also been associated with respiratory disorders [3]. Sleep apnea has been mainly assessed in obese patients who had intragastric balloon placement, and large uncontrolled studies showed quite favorable results [4] [5]. Moreover, exacerbation of pulmonary dysfunction in extreme obesity with the use of intragastric balloons has not been reported [6]. However, well-designed studies of the impact of intragastric balloon use on co-morbidities of the bariatric population are still lacking.

As the authors raise issues about routine clinical use of intragastric balloons, one must keep in mind that these devices should be used in selected patients with specific precautions. A careful preintervention evaluation by a multidisciplinary bariatric medical team may be useful. The filling volume of the intragastric balloon should be in accordance with the manufacturer’s instructions. The intragastric balloon is considered to be safe for a period of no longer than 6 months; after that, it should be removed or replaced. Although gastroesophageal symptoms are usual during the first few days after placement, tolerance should be evaluated at regular intervals. The goal of intragastric balloon placement is to restrict oral intake without symptoms. If these are refractory to medical therapies, early removal is the treatment of choice. For patient safety, the above information should be given clearly to all candidates for intragastric balloon treatment. In addition, gastroenterologists should inform them about the disappointing possibilities of lack of success in weight loss or of weight regain after intragastric balloon treatment.

Competing interests: None

References

• 1 Genco A, Cipriano M, Bacci V. et al . BioEnterics Intragastric Balloon (BIB): a short-term, double-blind, randomised, controlled, crossover study on weight reduction in morbidly obese patients.  Int J Obes (Lond). 2006;  30 129-133
• 2 Mathus-Vliegen E M, Tytgat G N. Intragastric balloon for treatment-resistant obesity: safety, tolerance, and efficacy of 1-year balloon treatment followed by a 1-year balloon-free follow-up.  Gastointest Endosc. 2005;  61 19-26
• 3 Wei Y-F, Wu H-D, Chang C-Y. et al . The impact of various anthropometric measurements of obesity on pulmonary function in candidates for surgery.  Obes Surg. 2009;  [Epub ahead of print] DOI 10.1007/s11695 – 009 – 9961 – 0
• 4 Genco A, Bruni T, SB D oldi. et al . BioEnterics Intragastric Balloon: the Italian experience with 2515 patients.  Obes Surg. 2005;  15 1161-1164
• 5 Sallet J A, Marchesini J B, Paiva D S. et al . Brazilian multicenter study of the intragastric balloon.  Obes Surg. 2004;  14 991-998
• 6 Göttig S, Daskalakis M, Weiner S. et al . Analysis of safety and efficacy of intragastric balloon in extremely obese patients.  Obes Surg. 2009;  19 677-683