This ASG video tip is sponsored by Braintree, maker of the newly approved Souflave and Soutab. Hi, I'm Praneeth Perera with the ASG tip for bariatric gastric balloon removal. These are my relevant disclosures. So today we're going to be talking via case presentation, the technique for bariatric gastric balloon removal and also factors to consider prior to and during removal of these balloons. We now see in more and more gastric balloons for weight loss. It's very enticing for patients as it provides a non-surgical method for weight loss. With these specific balloons, which is sometimes a single, double, even triple balloon, the idea is it's essentially a space occupying lesion. Patients have early satiety. It stays in place for about six to 12 months and the hope is it ends up also modifying patient's behavior afterwards once it's removed. So during the process, patients eat less, lose weight, and after about six months in the US, 12 months outside of the US usually, once it's removed, the hope is that they've now have learned behavior for a reduced PO intake and they will continue this behavior once the balloon is removed. So our case today is a 54 year old female who underwent placement of a single gastric bariatric balloon two weeks prior to her presentation to the hospital. After the balloon was placed, she had issues with significant nausea and vomiting as well as early satiety. Significant enough that she went to Urgent Care's emergency rooms and was noted to have significant electrolyte disturbances. At these facilities, they did not feel comfortable with balloon removal, so she basically was hydrated and then told to follow up with her provider. Unfortunately, she couldn't go back to where she received the balloon, so she presented to a hospital with acute kidney injury as well as significant electrolyte disturbances. So endoscopically, when you came into the stomach, you see here there is a complete obstruction of the stomach. She's presenting like a gastric outlet obstruction and this can sometimes happen in patients who have these balloons placed. So things to consider. Usually, if you have to remove it for this reason, patients can only tolerate liquids, if anything. If you are removing this once the patient is completed six to twelve months, usually we recommend they be on clear liquids for several days prior to removal. We usually perform this under anesthesia, especially given issue in terms of aspiration if they do present with gastric outlet obstruction symptoms. This can be done under either MAG or general anesthesia. You'll also need a therapeutic gastroscope and we're going to talk about two different methods for removal depending on what equipment you have available at your facility. So they actually do manufacture gastric balloon removal kits and these consist of a puncture needle and a Fisher grabber device to retrieve it. So if you have these available, this is one thing you would need to use along with a empty 10cc syringe as well as some methodology of lubrication. Some people suggest using lubrication injected with the scope versus mineral oil versus just simple water to remove the balloon. If you don't have a gastric balloon removal kit, you can also use either a 19 gauge or 22 gauge FNB needle. Obviously the bigger gauge needle, the easier it is to drain fluid. You need a snare as well as some lubrication assistive medium. So the gastric balloon removal kit, this is what it looks like on the left. You'll see this is the actual aspiration needle set. It's a blunt end that goes in and then once the nurse actually opens the needle up, you can see encased in here within here is a needle that is used to puncture the actual balloon itself. And on the right side you're going to see the retrieval device which consists basically of these two fish hooks to grab firm hold of the balloon to remove it. So with the gastric balloon removal kit, you advance the gastroscope to the actual balloon. In this case we use the therapeutic gastroscope. You insert the needle aspiration catheter through the scope and above the needle. You then have the nurse expose the needle and you want to puncture the balloon itself. It's going to need a firm puncture. These are usually thick silicone balloons because these have to last in the stomach for 6 to 12 months. Once the needle is in place, you're going to remove the stylet. And once you remove the stylet, typically we attach a 10cc syringe to the other end of the catheter. You remove the plunger and we attach the suction system within the syringe itself. This is the easiest way to get good suction to try and drain these balloons. Once the balloon is deflated, you're going to remove the needle and on the picture on the left you can see this is what the balloon looks deflated. Typically these things hold around 500cc, so we basically wait until it's completely deflated. When you want to remove these balloons, you're going to get areas of resistance. Things to be careful for is the GE junction, the upper esophageal sphincter, and if they're intubated, you may get some resistance of the balloon with the actual ETT tube. So there are some people who recommend going in and actually lubricating the GE junction with mineral oil, injecting lubrication. For this case, we just use water as a safer alternative. You're going to grab the deflated balloon with the extraction forceps and remove the balloon, keeping it tight within the scope. With the EOS fine needle biopsy setup, it's essentially the same thing except now you're using either a 19 gauge or a 22 gauge F&B needle which goes through the scope. You sharpen the needle. Once it's advanced through, you puncture the balloon, remove the stylet, and again attach the suction syringe or attach a suction cathode to the suction syringe. Again, it's approximately about 500cc of fluid that will be removed. Once it's completely deflated, you remove the needle, again lubricate the GE junction, and you can grasp the balloon using a large cold snap. Things to consider after the procedure itself. Usually after removal, we go back to look for any evidence of tears or traumas from removal. Again, the areas of resistance you're going to see are with the GE junction as well as the upper soft shell sphincter and the ETT tube if the patient is intubated. Once this is removed, the patient can resume their regular diet immediately. So in conclusion, sometimes these patients when they present for early removal, they'll have issues with nausea, vomiting, and present with gastric outlet obstruction. We recommend anesthesia for these cases. It can be done via MAC versus general anesthesia. Typically, if you're going to remove these electively or even on the urgent side, you want to make sure the patient's been on clear liquids for a couple of days and you can either use a gastric balloon removal kit or an F&B needle to actually puncture the balloon and aspirate the fluid out.

bariatric gastric balloons

removal technique

factors to consider

weight loss

behavior modification