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Obesity Surgery (2018) 28:1419–1421

https://doi.org/10.1007/s11695-018-3148-5

LETTER TO THE EDITOR

Elipse Balloon: the Pitfalls of Excessive Simplicity


Luigi Angrisani 1 & Antonella Santonicola 2 & Antonio Vitiello 3 & Maria Paola Belfiore 4 & Giuseppe Belfiore 5 &
Paola Iovino 2

Published online: 26 February 2018


# Springer Science+Business Media, LLC, part of Springer Nature 2018

To the Editor, weight = 92 kg; BMI = 30.06 kg/m2). Abdominal ultra-


We read with great interest the manuscript by Genco et al. sound was unremarkable, but x-ray examination showed
[1] describing their initial experience with 38 patients who gastric dilation, air-fluid levels in the small bowel, and a
successfully completed the therapy with Elipse intragastric radiopaque imagine that raised the suspicion of Elipse
balloon (IGB) (Allurion Technologies, Wellesley, MA, balloon valve in the left side of the abdomen (Fig. 1a,
USA). After the scheduled 16 weeks of therapy, 37 balloons b). A nasogastric tube was positioned, and intravenous
were spontaneously evacuated, and one balloon was endo- fluids and antibiotic therapy were administered.
scopically removed, without any complication. The authors Computed tomography (CT) confirmed small bowel ob-
concluded that Elipse balloon is a safe device that can be struction due to the presence of a partially desufflated
swallowed and excreted without serious adverse events, balloon in the jejunal tract. The day after, another CT
avoiding an upper gastrointestinal (UGI) endoscopy. demonstrated the progression of the balloon, closer to
Despite these interesting and encouraging results, we the anterior abdominal wall allowing a guided aspiration
report different experience with this device. A 55-year- of 85 cm3 from the device. A small amount of liquid was
old man with a BMI of 33.3 kg/m2 (weight 102 kg) and left in the lumen of device in order to allow further radio-
hepatic steatosis underwent insertion of Elipse balloon logical studies (Fig. 2a, b). Due to persistence of symp-
under our care in October 2016. After 6 weeks, the patient toms and deterioration of clinical conditions, a laparo-
was readmitted to the hospital complaining with severe scopic exploration was performed but the Elipse device
abdominal pain, nausea, vomiting, and no bowel move- was not found during the small bowel inspection from
ment since 24 h. Weight loss was about 10 kg (body Treitz ligament to ileocecal valve. A Foley catheter was
positioned in the rectum and contrast medium was admin-
istered revealing the presence of balloon in the descend-
ing colon. So the desufflated balloon was removed by
* Paola Iovino colonoscopy. There were no perioperative complications
piovino@unisa.it and the patient was discharged on the second post-
1
operative day. Unfortunately few months later, the patient
General and Endoscopic Surgery Unit, S. Giovanni Bosco Hospital,
Department of Public Health, BFederico II^ University of Naples,
regained weight.
Naples, Italy Recently, a similar episode of small bowel obstruction
2
Gastrointestinal Unit, Department of Medicine and Surgery,
due to Elipse balloon migration has been reported in a
University of Salerno, Via S Allende, 84081 Baronissi, Salerno, Italy woman with previous multiple cesarean sections. A surgi-
3
Department of Medicine and Surgery, Federico II University,
cal intervention was required. The authors hypothesized
Naples, Italy that the incomplete balloon filling or the premature cath-
4
Department of Experimental Medicine, University of Campania
eter disconnection during balloon placement could have
BLuigi Vanvitelli^, Naples, Italy promoted the balloon migration [2]. Previously, Machytk
5
Department of Radiology, BS. Anna-S. Sebastiano^ Hospital,
et al. reported the mechanism underlying balloon
Caserta, Italy desufflation. According to their explanation, the
1420 OBES SURG (2018) 28:1419–1421

Fig. 2 Computed tomography (CT) of the abdomen. a Presence of the


partially desufflated balloon in a jejunal loop. b CT-guided aspiration of
fluid from the balloon

Fig. 1 Abdominal X-ray. a Air-fluid levels of the small bowel. b


effectiveness of these devices, and a multidisciplinary ap-
Radiopaque imagine suspected for balloon valve (indicated by the arrow)
proach is mandatory for patient’s selection and prompt
detection of complications that should be managed in an
absorbable material inside the balloon gradually degrades appropriate setting only by an expert bariatric team.
until the release valve opens and allows the balloon to
empty spontaneously [3]. Endoluminal techniques cur-
Compliance with Ethical Standards
rently represent a minority of bariatric procedures. In the Conflict of Interest The authors declare that they have no conflict of
IFSO worldwide survey 2014 [4], we reported 14,725 interest.
endoluminal procedures, accounting for 2.4% of all
bariatric-metabolic interventions. More robust results are Ethical Approval Statement For this type of study, formal consent is not
available for Orbera intragastric balloon. For this type of required.
balloon, the reported migration rate is 1.4% and the prev-
Informed Consent Statement Informed consent was obtained from the
alence of small bowel obstruction is 0.3% [5]. patient.
Unfortunately, the literature data of Elipse IGB treatment
are still scanty and, although all IGB procedures, especial-
ly without endoscopy, are easy to perform and appealing
for management of different obesity classes, caution is References
recommended. Our patient, specifically, had no contrain-
dications to balloon placement (i.e., previous abdominal 1. Genco A, Ernesti I, Ienca R, et al. Safety and efficacy of a new
surgery); however, the migration occurred but it was swallowable intragastric balloon not needing endoscopy: early
Italian experience. Obes Surg. 2017;28:405–9. https://doi.org/10.
quickly recognized and properly treated. Future advances
1007/s11695-017-2877-1.
in device properties and procedural techniques are wel- 2. Al-Subaie S, Al-Barjas H, Al-Sabah S, et al. Laparoscopic manage-
co m e i n o r d er to im pr o ve t h e sa f et y an d co s t - ment of a small bowel obstruction secondary to Elipse intragastric
OBES SURG (2018) 28:1419–1421 1421

balloon migration: a case report. Int J Surg Case Rep. 2017;41:287– 4. Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery and
91. https://doi.org/10.1016/j.ijscr.2017.10.050.4. endoluminal procedures: IFSO worldwide survey 2014. Obes Surg.
3. Machytka E, Chuttani R, Bojkova M, et al. Elipse™, a procedureless 2017;27(9):2279–89. https://doi.org/10.1007/s11695-017-2666-x.
gastric balloon for weight loss: a proof-of-concept pilot study. Obes 5. Kim SH, Chun HJ, Choi HS, et al. Current status of intragastric
Surg. 2016;26(3):512–6. https://doi.org/10.1007/s11695-015-1783- balloon for obesity treatment. World J Gastroenterol. 2016
7. Jun 28;22(24):5495–504. https://doi.org/10.3748/wjg.v22.i24.5495.

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