What is the recommended approach for weight loss with gastric expanders?

Weight Loss with Gastric Expanders: Recommended Approach

For individuals with obesity seeking weight loss who have failed conventional weight-loss strategies, intragastric balloon (IGB) therapy combined with lifestyle modification is recommended over lifestyle modification alone to improve weight loss outcomes and obesity-related comorbidities. 1

Effectiveness of Intragastric Balloons

Intragastric balloons have demonstrated significant benefits for weight loss compared to standard of care:

• Randomized controlled trials show IGBs result in greater weight loss than lifestyle modifications alone:

  • 15.46 lbs average weight loss at 6 months
  • 13.12 lbs average weight loss at 9 months
  • 9.76 lbs average weight loss at 12 months 1

• Beyond weight loss, IGBs provide additional health benefits:

  • Improved liver function (ALT decreased by 9 U/L, AST by 3 U/L)
  • Greater remission of diabetes, hypertension, and dyslipidemia
  • Reduced waist circumference by 4.1 cm compared to non-invasive approaches 1

Patient Selection Criteria

IGBs should be considered for:

• Patients with BMI between 30-40 kg/m² (based on US trials) 1
• Individuals who have failed conventional weight-loss strategies
• Patients who are not candidates for or do not desire bariatric surgery 1

Implementation Protocol

1. Pre-procedure preparation:

   • Comprehensive assessment of weight history and previous attempts at weight loss
   • Evaluation for contraindications

2. Device selection:

   • Fluid-filled balloons may provide more weight loss but have lower tolerability and less favorable safety profiles than gas-filled balloons
   • Use shared decision-making to determine device choice based on patient preferences 1

3. Mandatory adjunctive therapies:

   • Moderate to high-intensity lifestyle modification interventions (strong recommendation) 1
   • Prophylactic PPI therapy to prevent gastric ulceration (strong recommendation) 1
   • Perioperative antiemetic regimens and scheduled antiemetics for 2 weeks post-placement 1
   • Daily supplementation with 1-2 adult dose multivitamins 1

4. Post-removal maintenance:

   • Implement subsequent weight-loss or maintenance interventions including:
     • Dietary interventions
     • Pharmacotherapy
     • Repeat IGB placement
     • Consideration of bariatric surgery in appropriate candidates 1

Comparative Effectiveness

When considering the spectrum of weight loss interventions:

• Lifestyle modification alone: Modest results with high regain rates
• Pharmacotherapy: Modest benefits for patients with BMI >27 kg/m² with comorbidities 1
• Intragastric balloons: Intermediate option with moderate weight loss (9-15 lbs over 6-12 months) 1
• Bariatric surgery: Most effective for long-term weight loss (loss of two-thirds of excess weight) but more invasive 1

Common Pitfalls and Caveats

• Weight regain: Weight loss benefits from IGBs tend to decrease over time, with maximum benefit at 6 months 1
• Side effects: Nausea, vomiting, and abdominal pain are common, especially in the first weeks after placement 1
• Compliance: Success depends on adherence to concurrent lifestyle modifications 1
• Device selection: Fluid-filled balloons may provide more weight loss but have lower tolerability than gas-filled balloons 1
• Unrealistic expectations: Patients should understand that IGBs provide less dramatic weight loss than bariatric surgery 2

Post-IGB Considerations

For patients with inadequate response to IGB therapy, sequential options include:

• Sequential IGB placement (can achieve greater BMI reduction but with increased risk of complications) 1
• Consideration of endoscopic sleeve gastroplasty or other endoscopic bariatric therapies 3
• Bariatric surgery for those with BMI ≥40 kg/m² or BMI ≥35 kg/m² with severe obesity-related complications 1

The approach to weight loss with gastric expanders should follow a progressive algorithm, starting with the least invasive option (IGB with lifestyle modification) and escalating to more invasive procedures if needed based on patient response, preferences, and risk factors.