Intragastric balloons for obesity: sometimes “a water bomb waiting to explode”

We read with interest the excellent review paper by Tsesmeli & Coumaros on endoscopic devices for weight reduction, and we like their objective evidence-based analysis of the current status of intragastric balloon implantation [ 1 ]. There is no question that some of these methods can benefit patients with morbid obesity [ 1 ] [ 2 ] [ 3 ]. However, it seems to us that the current data do not appear to support routine clinical use of these devices. It is noteworthy that most studies have included only small numbers of patients, as is well shown in Table 1 of the paper by Tsesmeli & Coumaros [ 1 ]. We recently treated a 55-year-old man with morbid obesity who was admitted to our service because of dyspnea. The patient’s clinical history was remarkable for a cumulative weight gain of 60 kg that had begun 48 months previously after he stopped smoking, resulting in a weight of 150 kg. Due to the previous nicotine abuse, he showed signs of mild chronic obstructive pulmonary disease (COPD). At a weight of 150 kg he had undergone placement of a gastric balloon at another medical center 18 months previously. Soon thereafter he had developed abdominal pain and severe gastroesophageal reflux symptoms, including heartburn, regurgitation, retrosternal pain, and cough. As a result of these symptoms he ate less, which led to a 30 kg weight loss over a 7-month period. The patient mentioned that he felt afraid of eating for fear of developing these severe symptoms. During this time frame, the signs and symptoms of his COPD worsened dramatically. Thus, he was placed on oral corticosteroids which in turn resulted in a weight gain of 42 kg. On clinical examination he appeared in mild distress. His height and weight were 175 cm and 162 kg, respectively, resulting in a body mass index (BMI) of 52.9. An echocardiogram revealed a massively enlarged right ventricle with a maximal diameter of 8.1 cm (normal 4.2 cm) and a normal left ventricle function. The pulmonary artery pressure was 75 mmHg. Thus a cor pulmonale with right heart failure could be diagnosed. We speculate that the intragastric balloon might have resulted in worsening of the COPD. Possible mechanisms include gastroesophageal reflux, as he described typical symptoms after balloon implantation. According to the Montreal classification, both asthma and COPD can develop or worsen due to gastroesophageal reflux disease (GERD) [ 4 ]. However, even though the balloon might not have been associated with COPD or cor pulmonale, we want to express caution about the routine clinical use of the intragastric balloon. Most studies mention that co-morbidities improve after balloon placement [ 2 ] [ 3 ]. However, this case shows the contrary, with worsening massive “rebound” weight gain due to the corticosteroids prescribed for worsening COPD. After successful treatment of the cardiac problems, we suggested removal of the gastric balloon. However, due to his bad experience during previous endoscopy, the patient is refusing further interventions. We hope that the balloon lasts long enough for us to convince him on follow-up to have it removed, before “explosion” of this “water bomb.” Competing interests: None

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