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occurrence each of esophageal rupture (associated with unsuccessful TPS deployment), upper abdominal
pain, vomiting and device impaction, device intolerance and device impaction, gastric ulcer and device
[58]
impaction, and device impaction . Although this device achieved FDA approval, it was never
commercially marketed.

SatiSphere
The SatiSphere (Endosphere, Columbus, OH) is 20-25 cm long and is composed of mesh spheres that are
mounted on a preformed memory wire with curled ends that adapt to the shape of the duodenum. It self-
anchors in the distal stomach and proximal duodenum, where it slows food transit through the duodenum.
This delayed transit may impact GI satiety hormone regulation and glucose metabolism [59,60] . EWL was
18.4% among patients who completed the treatment compared to 4.4% in the control group (P = 0.02).
However, 10 out of 21 patients in the treatment group experienced spontaneous device migration, with
management varying based on the device’s location. Three devices were excreted naturally without causing
intestinal damage, one was removed via upper GI endoscopy, four through colonoscopy, and two required
[60]
laparoscopic surgery . This led to the premature termination of the trial.

ABSORPTION-LIMITING DEVICES
Duodenojejunal bypass liner
EndoBarrier (GI Dynamics, Lexington, MA), also referred to as the duodenojejunal bypass liner (DJBL), is a
single-use endoscopic device consisting of a 60-cm impermeable fluoropolymer liner that is anchored in the
duodenal bulb to prevent the mixing of chyme with bile and pancreatic secretions [Figure 3A] [37,61,62] . It is
placed and removed endoscopically with fluoroscopic assistance, and removal is recommended within 12
months due to increased risks without added benefits for prolonged use. DJBL mimics the metabolic effects
of RYGB by excluding the duodenum and proximal jejunum, which enhances insulin sensitivity and glucose
regulation. It works by reducing the anti-incretin effect, increasing glucagon-like peptide-1 (GLP-1) and
peptide YY (PYY) levels, and decreasing glucose-dependent insulinotropic polypeptide (GIP), leading to
improved glycemic control and enhanced satiety. Unlike RYGB, which reduces ghrelin levels, the DJBL
tends to increase fasting ghrelin. Both interventions expose the distal small intestine to undigested food,
which triggers hormonal changes that support weight loss and metabolic improvements [61,62] . DJBL has been
shown to have a lower mean TBWL (15.04% vs. 27.93%, P < 0.05) and mean EWL (44.48% vs. 67.26%) than
RYGB but similar improvement in glycemic control after 12 months . Severe adverse event rate has been
[61]
reported to be 19.7%. The most concerning adverse events are liver abscesses, GI bleeding (often due to
ulcerations and perforations with prolonged use), device migration, and obstruction . FDA approval is still
[63]
pending.

Gastroduodenojejunal bypass sleeve
The gastroduodenojejunal bypass sleeve (GJBS; ValenTx, Inc., Maple Grove, MN) is a 120-cm
fluoropolymer with a polyester cuff at its proximal end, which is attached to the gastroesophageal junction
[37]
with transmural anchors. The sleeve extends into the proximal jejunum [Figure 3B] . Its placement
requires a combined endoscopic and laparoscopic procedure with fluoroscopic assistance, but its retrieval,
[64]
which is done after 12 months, is accomplished endoscopically . It is designed to replicate the effects of
RYGB by restricting food intake, bypassing the stomach and a portion of the small intestine, and delivering
undigested food directly to the jejunum . In a small prospective study of 12 patients, 2 of the 12 patients
[22]
who underwent device implantation did not tolerate the device and required early explantation within the
first 4 weeks. The remaining 10 patients who completed the study had a mean EWL of 35.9% with
improvement in comorbidities (diabetes mellitus and blood glucose control, hypertension, hyperlipidemia)
during the 12-month study period. However, 4 patients were found to have partial cuff detachment. The
mean EWL in those with intact cuffs was 54% at 12 months and 30% at 14 months post-explantation. No