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Castro et al. Mini-invasive Surg 2020;4:47 I http://dx.doi.org/10.20517/2574-1225.2020.14 Page 3 of 13
[7]
saline or air that can hold up to 400 to 800 mL . In the United States, it is sold as the Orbera Intragastric
[9]
Balloon System (Apollo Endosurgery, Austin, TX), which was approved for use in 2015 . Other available
balloons include ReShape (ReShape Medical Inc., San Clemente, CA) that consists of a dual balloon system.
The Obalon (Obalon Therapeutics, San Diego, CA) is distinguished from the others because it is placed in the
[9]
stomach by swallowing a deflated balloon in the form of a capsule, thus having a smaller capacity (250 mL) .

A study evaluated the use of the Orbera intragastric balloon alone and before definite bariatric surgery
over a period of 16 years. The authors reported positive short-term outcomes for the use of IGB alone,
with EWL of 17.2% at 1 year; however, after 2 years weight loss was not maintained. The patients who
had placement of the IGB and then underwent bariatric surgery had long-term sustained weight loss. The
[10]
[11]
authors concluded that IGB should be used as a bridge therapy to definitive therapy . Moore et al.
evaluated the outcomes at 6 months in 1,343 patients who had one or up to three Obalon IGB placed. The
majority of adverse events were mild and did not require intervention; nonetheless, two severe adverse
events were reported which included balloon slippage to the pylorus and gastric perforation. Although
weight loss was achieved in the population studied, long-term data are still needed to prove its efficiency.
The most common adverse events reported with the use of IGB are abdominal pain, nausea, vomiting, and
balloon deflation [10-12] . The use of IGB should be considered as either bridge therapy to definitive bariatric
surgery or in patients who need only moderate weight loss in combination with behavior modification.

Aspiration therapy
Aspiration therapy removes up to 30% of gastric contents after a meal through a percutaneous endoscopic
gastrostomy tube thus reducing the amount of chyme that reaches the small bowel for absorption [13,14] . It
should be considered in cases of severe obesity as a bridge therapy to more effective weight loss procedures.
The AspireAssist System (AspireAssist; Aspire Bariatrics, King of Prussia, PA) has two components, the
A-Tube and the skin-port that is attached to the tube and in the US is approved for patients with BMI of
35 to 55 kg/m who have previously failed to lose weight with non-surgical alternatives. Four studies have
2
[13]
been conducted to evaluate the effects of aspiration therapy on weight loss . A US pilot study comprised
of 18 obese patients, compared weight loss outcomes in patients with aspiration therapy (n = 11) and
patients with lifestyle therapy (n = 7) at 1 year. The aspiration therapy group lost 18.6% ± 2.3% of their body
[15]
weight versus 5.9% ± 5.0% in the lifestyle therapy group . A multi-center, randomized, controlled trial, the
PATHWAY trial, evaluated 1-year outcomes in 207 patients who had the aspiration system (AspireAssist
System) placed compared to patients who had lifestyle counseling alone. The authors reported 37.2%
EWL in the AspireAssist System group and 13.0% EWL in the lifestyle counseling group. Additionally, the
Impact of Weight on Quality of Life score had a higher increase in the treated group across all five score
measures. The majority of adverse events occurred within 7 days of the procedure and included peristomal
granulation tissue, abdominal pain, nausea/vomiting, and other less infrequent events. Five serious adverse
events were reported in 4 patients and consisted of peritonitis, severe abdominal pain, pre-pyloric ulcer,
and A-tube replacement because of skin-port malfunction . A multicenter study conducted in Europe
[16]
included 201 participants and followed them at 1, 2, 3, and 4 years after the procedure. The authors
reported reduction in weight, glycated hemoglobin, triglycerides, and blood pressure. There were serious
complications that included buried bumpers in 7 participants which resolved by replacement/removal of
the A-Tube, and one case of peritonitis that resolved with antibiotic treatment . Although preliminary
[17]
results seem promising, this device can’t be applied alone for obesity management which makes it a less
attractive alternative.

Endoluminal bypass liners
There are two endoluminal bypass liners that are still being trialed and yet to be FDA-approved, the gastro-
duodenal bypass liner and the duodeno-jejunal bypass sleeve. Both systems create a mechanical barrier
between food and the proximal small bowel, which mimic the excluded biliopancreatic limb of a Roux-