Introduction: Bariatric surgery is a safe and effective treatment for obesity, although in super-obese patients (BMI ≥50 kg/m2) it can become challenging for anatomical and anesthesiologic issues. Several bridging therapies have been proposed to increase preoperative weight loss and decrease perioperative morbidity and mortality. The aim of this study was to compare the efficacy and safety of different two-stage approaches in super-obese patients: laparoscopic sleeve gastrectomy (LSG) following preoperative liraglutide therapy versus LSG with preoperative intragastric balloon (IGB) during a 1-year follow-up. Methods: Clinical records of 86 patients affected by super-obesity who underwent two-stage approach between January 2019 and January 2022 were retrospectively reviewed using a prospectively maintained database. Patients were separated into two groups: those managed with preoperative IGB and those with liraglutide 3.0 mg prior to LSG. Weight (kg), BMI (kg/m2), %EWL, and %EBWL were reported and compared between the two groups at the end of bridging therapy, at 6th month and 12th month postoperatively. Postoperative complications were recorded. Results: Forty-four patients underwent IGB insertion prior to LSG, while 42 were treated with liraglutide. There were no statistical differences in baseline weight and BMI. At the end of preoperative treatment, the group treated with IGB reported a significant reduction in BMI (47.24 kg/m2 vs. 53.6 kg/m2; p < 0.391) compared to liraglutide group. There were no differences recorded between the two groups concerning postoperative complications. At 6 months, the liraglutide group had lower %EWL (15.8 vs. 29.84; p < 0.05) and %EBWL (27.8 vs. 55.6; p < 0.05) when compared to IGB group. At 12 months, the IGB preserved with higher %EWL (39.9 vs. 25; p < 0.05) and %EBWL (71.2 vs. 42; p < 0.05). Conclusion: A two-stage therapeutic approach with IGB prior to LSG in super-obese patients could be considered an attractive alternative to liraglutide as bridging therapy before bariatric surgery.

The worldwide prevalence rates of obesity have approximately doubled since 1980 to an extent that over one-third of the world’s population is now classified as overweight or obese [1]. Obesity is closely linked to multiple disease conditions: type 2 diabetes, hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea, non-alcoholic fatty liver disease, and several types of cancer, all of which have negative impact on the quality of life [2, 3]. To date, bariatric surgery is considered the most effective strategy in achieving long-term weight loss, with remission of related comorbidities and decrease of mortality [4]. While bariatric surgery is a safe treatment, with low rate of perioperative morbidity and mortality, in super-obese patients (body mass index [BMI] ≥50 kg/m2) it can be challenging because of difficulties in exposure caused by visceral fat, excessive visceral obesity, fatty liver retraction, and strong torque applied to laparoscopic instruments, as well as anesthesiologic issue [5]. Moreover, these patients suffer from complex health issues, with increased morbidity and mortality [6].

Therefore, the increased risk associated with these patients led to the creation of several therapeutic strategies with two-stage approach including the use of an intragastric balloon (IGB) or medical treatment, as liraglutide, to achieve weight loss, before definitive surgery [7, 8]. IGB is an Food and Drug Administration (FDA)-approved treatment for obese patients, offering a potentially safe and less invasive method for reducing gastric capacity and inducing weight loss with a lower complication rate than bariatric surgery [9]. The use of IGB alone with lifestyle changes has demonstrated an excess weight loss of 10% and BMI drop of 3.8 at 60 months in super-obese patients [10].

Liraglutide is a long-acting analogue of glucagon-like peptide-1 (GLP-1) and binds to GLP-1 receptors found in the peripheral and central nervous system, pancreas, intestine, kidney, stomach, heart. It was initially approved by FDA for medical treatment of type 2 diabetes and then for chronic weight management [11]. High-dose liraglutide (3.0 mg) is frequently used to promote weight reduction before surgery. It acts by slowing down gastric emptying time and regulating appetite by inducing a feeling of satiety [12, 13]. The aim of this retrospective study was to compare the efficacy and safety of different two-stage approaches in super-obese patients: laparoscopic sleeve gastrectomy (LSG) with preoperative liraglutide therapy versus LSG with preoperative IGB during a 1-year follow-up.

A single-center, retrospective observational study was carried out using a prospectively maintained database of obese patients undergoing LSG in a tertiary referral center for bariatric treatment. The analysis examines patients managed between January 2019 and January 2022. Patients over 18 years of age, with a BMI ≥50 kg/m2 with or without obesity-related comorbidity, and those who completed a 1-year follow-up were included in the study. Exclusion criteria were the prior use of GLP-1 agonist or IGB therapy, personal or family history of medullary thyroid carcinoma, personal or family history of multiple endocrine neoplasia, past history of pancreatitis, hepatic dysfunction (AST/ALT >3 times normal value), renal dysfunction (eGFR <45 mL/min/1.73 m2), previous bariatric or gastric surgery, acute coronary syndrome in previous 6 months, intolerance or allergy to liraglutide, discontinuation of IGB or liraglutide therapy, pregnancy or breastfeeding, patients with a large hiatal hernia or >5 cm hernia or ≤5 cm with associated severe or intractable gastro-esophageal reflux symptoms, and those who had an allergic reaction to materials contained in IGB. All the patients provided informed consent for surgery after thorough explanation and counseling of the benefit-risk ratio.

Patients fulfilling the inclusion criteria were asked to express a preference after discussing potential benefits and complications of both treatments. In the first group, obese patients were treated with an End-Ball™ (Medimar S.r.l. Unipersonale, Via Ebro, 8–20141 Milano) IGB. The deflated elastic spherical balloon, made of polyurethane, preloaded on a catheter, was advanced trans-orally into the stomach. An endoscope was then advanced alongside it, to ensure accurate placement of the balloon in the fundus. Under direct visualization, the balloon was then inflated by injecting 650 mL of saline solution mixed with methylene blue through the external portion of the catheter. The End-Ball™ IGB was implanted for 24 weeks and then retrieved endoscopically by puncturing the balloon with a needle, emptying the fluid content, and removing it through the mouth. Placement of the End-Ball™ Balloon was done as an outpatient procedure without general anesthesia, whereas removal was performed in the operating room under general anesthesia. Three weeks after IGB removal, LSG was planned. Possible nausea, vomiting, and fluid intolerance were treated with medical therapy.

The second group of patients was treated with liraglutide therapy before undergoing definitive LSG. Medical treatment was administered using a multidose pen injector. The starting dose of liraglutide was 0.6 mg/day administered subcutaneously. This was increased weekly by 0.6 mg up to the maximal dose of 3 mg until 24 weeks. Only patients that reached the maximal dose were included into the study. Patients were trained to self-administer the injection.

Demographic data were collected including age, gender, weight (kg), BMI (kg/m2), and comorbidities. Patients were revaluated in outpatient setting after 24 weeks of IGB and/or liraglutide therapy, evaluating weight (kg), BMI (kg/m2), percent excess weight loss (%EWL), and percent excess body weight loss (%EBWL). Percent weight loss was calculated by dividing the absolute pounds lost by the patient’s initial weight. %EBWL was calculated by dividing the difference between initial BMI and final BMI by the difference between initial BMI and a “normal” target BMI. In this study, %EBWL was calculated using a reference normal BMI of 25 kg/m2 [14]. Postoperative complications of LSG were recorded in accordance with the published Clavien-Dindo classification [15]. At 6- and 12-month follow-up, all patients underwent outpatient setting evaluation and were assessed for weight, BMI, %EWL, and %EBWL. Permission for the conduct of this retrospective analysis was provided by the local hospital Ethics Committee. All investigations complied with the principles of the Declaration of Helsinki.

Statistical Analysis

Continuous parameters were reported as median and interquartile ranges. Categorical variables were recorded as numbers and percentages where appropriate. Comparisons of categorical variables were performed by the χ2 and Fisher’s exact test where appropriate. Comparisons between groups were made using the Mann-Whitney U test. A p value <0.05 was considered statistically significant. Statistical analysis was carried out using RStudio (R version 4.0.3 10/ 10/2020 Copyright© 2020, The R Foundation for Statistical Computing).

A total of 86 patients affected by super-obesity were treated with two-stage management. Forty-four (median age 41.5 years, IQR 37.5–49.2, 77% women) of them (51%) underwent IGB prior to LSG, while forty-two (median age 41 years, IQR 35.5–48, 93% women) were treated with liraglutide therapy prior to definitive surgery, Figure 1. There were no significant differences in terms of gender, age, comorbidities such as cardiovascular disease, diabetes mellitus, chronic respiratory disease, and osteoarthritis. All patients were affected by super-obesity (BMI ≥50 kg/m2) without significant difference in terms of weight (151 kg, IQR 140–163 vs. 145 kg, IQR 133.5–164.5; p = 0.302) and BMI (55.9 kg/m2, IQR 53.3–59.3 vs. 57.5 kg/m2, IQR 51.2–59.2; p = 0.391). The baseline characteristics of the groups are reported in Table 1.

Fig. 1.

Included patients’ flowchart. GLP-1, glucagon-like peptide-1; IGB, intragastric balloon; LSG, laparoscopy sleeve gastrectomy.

Fig. 1.

Included patients’ flowchart. GLP-1, glucagon-like peptide-1; IGB, intragastric balloon; LSG, laparoscopy sleeve gastrectomy.

Close modal
Table 1.

Patient preoperative characteristics

IGB + LSG (n = 44)Liraglutide + LSG (n = 42)p value
Gender (M/F) 10/34 3/39 0.06 
23% versus 77% 7% versus 93% 
Age (years) 41.50 (37.5–49.25) 41 (35.50–48) 0.58 
Weight (kg) 151 (140–163) 145 (133.5–164.5) 0.302 
BMI (kg/m255.9 (53.3–59.3) 57.5 (51.2–59.2) 0.391 
Comorbidity, n (%) 
 None 1 (2.3) 1 (2.3) 
 Cardiac 31 (70.5) 22 (52.4) 0.13 
 Respiratory 22 (50) 18 (42.8) 0.65 
 Diabetes 38 (86) 35 (83.3) 0.76 
 Osteoarthritis 12 (27) 9 (21.4) 0.61 
IGB + LSG (n = 44)Liraglutide + LSG (n = 42)p value
Gender (M/F) 10/34 3/39 0.06 
23% versus 77% 7% versus 93% 
Age (years) 41.50 (37.5–49.25) 41 (35.50–48) 0.58 
Weight (kg) 151 (140–163) 145 (133.5–164.5) 0.302 
BMI (kg/m255.9 (53.3–59.3) 57.5 (51.2–59.2) 0.391 
Comorbidity, n (%) 
 None 1 (2.3) 1 (2.3) 
 Cardiac 31 (70.5) 22 (52.4) 0.13 
 Respiratory 22 (50) 18 (42.8) 0.65 
 Diabetes 38 (86) 35 (83.3) 0.76 
 Osteoarthritis 12 (27) 9 (21.4) 0.61 

Continuous parameters were reported as median and interquartile ranges. Categorical variables were recorded as numbers and percentages.

IGB, intragastric balloon; LSG, laparoscopic sleeve gastrectomy.

At the end of preoperative treatment, the group treated with IGB reported a significant difference in weight (125 kg, IQR 119–130 vs. 136.5 kg, IQR 125.5–154.5; p < 0.05) and BMI (47.24 kg/m2, IQR 46.2–48.9 vs. 53.6 kg/m2, IQR 47.7–55.8; p < 0.391) compared to liraglutide group. The median %EWL (15.5, IQR 13–18.7 vs. 6.71, IQR 5.8–7.4; p < 0.05) and the median %EBWL (28.5, IQR 24.8–33.07 vs. 11.8, IQR 10.3–14.3; p < 0.05) were significantly higher in IGB group when compared to liraglutide group.

In all patients, sleeve gastrectomy was performed laparoscopically without the need for open conversion. There were no differences recorded between the two groups concerning postoperative complications according to Clavien-Dindo grade (Table 2). The two leaks recorded in group 1 and the one in group 2 were all successfully managed with laparoscopic peritoneal lavage and insertion of a silicon drain in the subdiaphragmatic space. There was no mortality in the immediate postoperative period.

Table 2.

Postoperative complications according to Clavien-Dindo grade

IGB + LSG (n = 44), n (%)Liraglutide + LSG (n = 42), n (%)p value
None 37 (84) 39 (92.5) 0.31 
Grade 1 3 (7) 1 (2.5) 0.61 
Grade 2 2 (4.5) 1 (2.5) 
Grade 3    
 3a 
 3b 2 (4.5) 1 (2.5) 
IGB + LSG (n = 44), n (%)Liraglutide + LSG (n = 42), n (%)p value
None 37 (84) 39 (92.5) 0.31 
Grade 1 3 (7) 1 (2.5) 0.61 
Grade 2 2 (4.5) 1 (2.5) 
Grade 3    
 3a 
 3b 2 (4.5) 1 (2.5) 

Variables were recorded as numbers and percentages.

IGB, intragastric balloon; LSG, laparoscopic sleeve gastrectomy.

The relationship between different two-stage management and BMI, %EWL, and %EBWL at 6 and 12 months is shown in Figure 2. At 6 months, the liraglutide group had a significantly higher weight (124 kg, IQR 109.5–141 vs. 101, IQR 99–107; p < 0.05) and BMI (47.5 kg/m2, IQR 41.1–53 vs. 38.9 kg/m2, IQR 39.10–40.5; p < 0.05) with lower %EWL (15.8, IQR 11.1–21.1 vs. 29.84, IQR 26.8–34.6; p < 0.05) and %EBWL (27.8, IQR 19.6–38.9 vs. 55.6, IQR 49.9–61.7; p < 0.05) when compared to IGB group. Furthermore, at 12 months the IGB group preserved the lower weight (89 kg, IQR 85–91 vs. 112, IQR 95.2–128.75; p < 0.05) and BMI (33.9 kg/m2, IQR 32.2–35 vs. 41.8 kg/m2, IQR 36.8–48.9; p < 0.05) with higher %EWL (39.9, IQR 37.6–42.9 vs. 25, IQR 16.8–31; p < 0.05) and %EBWL (71.2, IQR 68.8–76.5 vs. 42, IQR 24.5–64; p < 0.05) compared to liraglutide group (Table 3).

Fig. 2.

Relationship between intragastric balloon (IGB) (with blue) and liraglutide (Lira) (with red) management and body mass index (BMI), percent excess weight loss (%EWL), and percent excess body weight loss (%EBWL) at 6 and 12 months.

Fig. 2.

Relationship between intragastric balloon (IGB) (with blue) and liraglutide (Lira) (with red) management and body mass index (BMI), percent excess weight loss (%EWL), and percent excess body weight loss (%EBWL) at 6 and 12 months.

Close modal
Table 3.

Relationship between different two-stage management and BMI, %EWL, and %EBWL at 6 and 12 months

IGB + LSG (n = 44)Liraglutide + LSG (n = 42)p value
Weight, 6 months, kg 101 (99–107) 124 (109.5–141) <0.05 
BMI, 6 months, kg/m2 38.9 (39.10–40.5) 47.5 (41.1–53) <0.05 
%EWL, 6 months 29.84 (26.8–34.6) 15.8 (11.1–21.1) <0.05 
%EBWL, 6 months 55.6 (49.9–61.7) 27.8 (19.6–38.9) <0.005 
Weight, 12 months, kg 89 (85–91) 112 (95.2–128.75) <0.05 
BMI, 12 months, kg/m2 33.9 (32.2–35) 41.86 (36.8–48.9) <0.05 
%EWL, 12 months 39.9 (37.6–42.9) 25 (16.8–31) <0.05 
%EBWL, 12 months 71.2 (68.8–76.5) 42 (24.25–64) <0.05 
IGB + LSG (n = 44)Liraglutide + LSG (n = 42)p value
Weight, 6 months, kg 101 (99–107) 124 (109.5–141) <0.05 
BMI, 6 months, kg/m2 38.9 (39.10–40.5) 47.5 (41.1–53) <0.05 
%EWL, 6 months 29.84 (26.8–34.6) 15.8 (11.1–21.1) <0.05 
%EBWL, 6 months 55.6 (49.9–61.7) 27.8 (19.6–38.9) <0.005 
Weight, 12 months, kg 89 (85–91) 112 (95.2–128.75) <0.05 
BMI, 12 months, kg/m2 33.9 (32.2–35) 41.86 (36.8–48.9) <0.05 
%EWL, 12 months 39.9 (37.6–42.9) 25 (16.8–31) <0.05 
%EBWL, 12 months 71.2 (68.8–76.5) 42 (24.25–64) <0.05 

Continuous parameters were reported as median and interquartile ranges.

IGB, intragastric balloon; LSG, laparoscopic sleeve gastrectomy; BMI, body mass index; %EWL, percent excess weight loss; %EBWL, percent excess body weight loss.

Bariatric surgery in super-obese (BMI ≥50 kg/m2) patients is a challenging treatment due to increased size of organs, excessive intraperitoneal fat, and increased perioperative risk related to the high rate of associated medical conditions such as hypertension, type II diabetes mellitus, hepatic steatosis, cardiac and respiratory comorbidities [16]. Moreover, it has been widely shown that bariatric surgery is an effective and safe treatment but in super-obese patients the therapeutic success is often less favorable with high rate of morbidity and mortality due to the increased risk of severe complications, such as pulmonary embolism [17].

In literature, the degree of bariatric surgery risk reduction is strictly linked with the decrease in median preoperative weight [18, 19]; for this reason, different types of bridging therapies have been proposed but, to date, there are no standard international guidelines and/or recommendations regarding the preoperative management of super-obese patients [20]. Liraglutide is one of the currently approved pharmacotherapies for obesity based on gut hormones. This long-acting analogue of GLP-1 in combination with a healthy, low-calory diet showed a 6–8% weight loss in adult without diabetes and 6% weight loss in patients with type II diabetes [13]. In our study, the group treated with 6 months of liraglutide 3 mg therapy, prior to definitive bariatric surgery, had a median %EWL of 6.71 and %EBWL of 11.8 with a reduction of the BMI at median value of 53.6 kg/m2. These important results were obtained by including only patients who underwent liraglutide 3 mg therapy continuously for 6 months. Furthermore, liraglutide efficacy was reported as long-term maintenance of weight loss in the SCALE maintenance study, after 4–12 weeks of diet, and liraglutide 3 mg showed a further 6% weight loss at 56 weeks compared with 0.2% of placebo [21]. Our cohort of liraglutide patients after 6 months of bridging medical therapy underwent definitive bariatric surgery with short- and long-term weight reduction. After 6 months, of strict and rigorous outpatient follow-up, the group had a %EWL of 15.8 with a %EBWL of 27.8 and a reduction of BMI to median value of 47.5 kg/m2, and this reduction of body weight increased at 12 months at a median %EWL of 25, % EBWL of 42, and a definitive reduction of BMI at 41.86 kg/m2, underling the long-term maintenance of weight loss. Hakim et al. [7], in a recent observational prospective study, demonstrated an incidence of adhesion in 22.2% of patients undergoing LSG after preoperative liraglutide intake. The risk of adhesion was reported in patients with a history of cessation of liraglutide due to abdominal pain, which could be explained by bouts of acute pancreatitis. However, none of the cases with adhesions had any complications. In our cohort of patients, we did not find intraoperative adhesions, and there were no statistical differences in terms of postoperative complication according to Clavien-Dindo classification between two groups. We reported only one postoperative leak in liraglutide group compared to two leaks in IGB group (p = 1). It is still unclear if the adhesion risk in patients treated with liraglutide could increase intra/postoperative complications.

In literature, different authors investigated the role of IGB as bridging therapy in super-obese patients [10, 20, 22] without uniformity of results in terms of weight loss. Ashrafian et al. [10] suggested the use of definitive bariatric surgery after IGB removal to continue weight loss and maintain it over a long time. They reported a transient fast short-term weight reduction (%EWL 18%) at 18 months associated with weight regain at 5 years with %EWL of 9%. Meanwhile, IGB with subsequent LSG at 5 years showed an EWL of 52.8%. In line with this study, our results showed an EWL of 39.9% and EBWL of 71.2% with a statistically significant difference compared to the group treated with medical therapy prior to surgery. Conversely, Hering et al. [8] and Banks et al. [23] reported comparable weight loss in patients without IGB prior to LSG, at 12 months and 24 months, respectively. However, both these studies included a very small number of patients, precluding a definitive comment on this subject. This variability in reported outcomes could be associated with the baseline heterogeneity of super-obese patients in terms of baseline BMI, comorbidities, and different types of balloon received. The decrease of visceral fat tissue and of organ size could improve technical operability, reducing intra- and postoperative complications. However, previous authors [23, 24] showed higher complications and length of hospital stay in patients who received IGB prior to surgery. The application of IGB is a safe technique but often leads to a gastric fundal inflammation, hypertrophy, and fibrosis of the gastric wall that could increase the risk of leakage from the staple line after LSG [25, 26]. In contrast, Busetto et al. [27] and Zerrweck et al. [28] reported decreased intraoperative conversion to open surgery, intraoperative time, and length of stay in the cohort of patients treated with IGB prior to definitive surgery. To reduce severe side effects, Hering et al. [8], in line with our methods, suggested a time interval of 21 days between IGB removal and bariatric surgery, thus allowing resolution of gastric inflammation and hypertrophy. Moreover, during bridging therapy with IGB, they reported a spike of weight loss at 3 months followed by a plateau and even a slight weight regain at 5 months, suggesting a reduction of preconditioning period to reduce peri-operative complications such as perforation, nausea, vomiting, and dehydration. In our cohort of patients, there was no mortality in the immediate postoperative period, without the need for open conversion in any case and with no statistical differences recorded between the two groups concerning postoperative complications. However, we reported more postoperative leaks compared to the liraglutide groups.

To date, there are no other studies comparing the efficacy and safety of LSG with preoperative liraglutide therapy versus LSG with preoperative IGB during a 1-year follow-up in super-obese patients. The main limitations of this study are the single-center experience, limited follow-up, and its retrospective nature, which opens it to possible selection bias. Prospective, multi-center, and long-term follow-up research studies are needed.

A two-stage therapeutic approach with IGB prior to laparoscopy sleeve gastrectomy in super-obese patients could be considered an attractive alternative to liraglutide for preoperative optimization before bariatric surgery. This invasive preoperative therapy provides additional benefits for short- and long-term weight loss, without increasing perioperative complications.

The studies involving human participants were reviewed and approved by the Ethics Committee of “Azienda Ospedaliera Universitaria Policlinico di Bari.” The patients/participants provided their written informed consent to participate in this study. This study protocol was reviewed and approved by the Ethics Committee of “Azienda Ospedaliera Universitaria Policlinico di Bari,” approval number 835512/date: June 15, 2022.

The authors have no conflicts of interests or disclosures to report.

This research did not receive any specific funding from any agencies in the public, commercial, or not-for-profit areas.

Conceptualization: G.T. and G.M.; methodology: G.T., A.D., C.G., V.L., and G.M; data curation: G.T., A.D., C.G., V.L., M.T.R., and G.M.; writing – original draft preparation: G.T., A.P., A.D., and G.M.; writing – reviewing and editing: all authors. All authors contributed to the article and approved the submitted version.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

1.
Chooi
YC
,
Ding
C
,
Magkos
F
.
The epidemiology of obesity
.
Metabolism
.
2019 Mar
92
6
10
.
2.
Misra
A
,
Khurana
L
.
Obesity-related non-communicable diseases: south asians vs white caucasians
.
Int J Obes
.
2011 Feb
35
2
167
87
.
3.
Avgerinos
KI
,
Spyrou
N
,
Mantzoros
CS
,
Dalamaga
M
.
Obesity and cancer risk: emerging biological mechanisms and perspectives
.
Metabolism
.
2019 Mar
92
121
35
.
4.
Kuno
T
,
Tanimoto
E
,
Morita
S
,
Shimada
YJ
.
Effects of bariatric surgery on cardiovascular disease: a concise update of recent advances
.
Front Cardiovasc Med
.
2019
;
6
:
94
.
5.
Dupree
A
,
El Gammal
AT
,
Wolter
S
,
Urbanek
S
,
Sauer
N
,
Mann
O
.
Perioperative short-term outcome in super-super-obese patients undergoing bariatric surgery
.
Obes Surg
.
2018 Jul
28
7
1895
901
.
6.
Peterson
K
,
Anderson
J
,
Boundy
E
,
Ferguson
L
,
Erickson
K
.
Rapid evidence review of bariatric surgery in super obesity (BMI ≥ 50 kg/m2)
.
J Gen Intern Med
.
2017 Apr
32
Suppl 1
56
64
.
7.
Hakim
M
,
Fathi
M
,
Abdulraziq
M
,
Al Shehri
M
.
Incidence of adhesions in patients using liraglutide before laparoscopic sleeve gastrectomy
.
Surg Endosc
.
2022 Nov
36
11
8503
8
.
8.
Hering
I
,
Dorries
L
,
Flemming
S
,
Krietenstein
L
,
Koschker
AK
,
Fassnacht
M
.
Impact of preoperative weight loss achieved by gastric balloon on peri- and postoperative outcomes of bariatric surgery in super-obese patients: a retrospective matched-pair analysis
.
Langenbecks Arch Surg
.
2022 Aug
407
5
1873
9
.
9.
Tate
CM
,
Geliebter
A
.
Intragastric balloon treatment for obesity: review of recent studies
.
Adv Ther
.
2017 Aug
34
8
1859
75
.
10.
Ashrafian
H
,
Monnich
M
,
Braby
TS
,
Smellie
J
,
Bonanomi
G
,
Efthimiou
E
.
Intragastric balloon outcomes in super-obesity: a 16-year city center hospital series
.
Surg Obes Relat Dis
.
2018 Nov
14
11
1691
9
.
11.
Monami
M
,
Dicembrini
I
,
Marchionni
N
,
Rotella
CM
,
Mannucci
E
.
Effects of glucagon-like peptide-1 receptor agonists on body weight: a meta-analysis
.
Exp Diabetes Res
.
2012
;
2012
:
672658
.
12.
le Roux
C
,
Aroda
V
,
Hemmingsson
J
,
Cancino
AP
,
Christensen
R
,
Pi-Sunyer
X
.
Comparison of efficacy and safety of liraglutide 3.0 mg in individuals with BMI above and below 35 kg/m²: a post-hoc analysis
.
Obes Facts
.
2017
;
10
(
6
):
531
44
.
13.
Papamargaritis
D
,
le Roux
CW
,
Holst
JJ
,
Davies
MJ
.
New therapies for obesity
.
Cardiovasc Res
.
2022 Nov 30
14.
Hatoum
IJ
,
Kaplan
LM
.
Advantages of percent weight loss as a method of reporting weight loss after Roux-en-Y gastric bypass
.
Obesity
.
2013 Aug
21
8
1519
25
.
15.
Clavien
PA
,
Barkun
J
,
de Oliveira
ML
,
Vauthey
JN
,
Dindo
D
,
Schulick
RD
.
The Clavien-Dindo classification of surgical complications: five-year experience
.
Ann Surg
.
2009 Aug
250
2
187
96
.
16.
Nguyen
NT
,
Magno
CP
,
Lane
KT
,
Hinojosa
MW
,
Lane
JS
.
Association of hypertension, diabetes, dyslipidemia, and metabolic syndrome with obesity: findings from the National Health and Nutrition Examination Survey, 1999 to 2004
.
J Am Coll Surg
.
2008 Dec
207
6
928
34
.
17.
Sapala
JA
,
Wood
MH
,
Schuhknecht
MP
,
Sapala
MA
.
Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis
.
Obes Surg
.
2003 Dec
13
6
819
25
.
18.
Van Nieuwenhove
Y
,
Dambrauskas
Z
,
Campillo-Soto
A
,
van Dielen
F
,
Wiezer
R
,
Janssen
I
.
Preoperative very low-calorie diet and operative outcome after laparoscopic gastric bypass: a randomized multicenter study
.
Arch Surg
.
2011 Nov
146
11
1300
5
.
19.
Anderin
C
,
Gustafsson
UO
,
Heijbel
N
,
Thorell
A
.
Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity Registry (SOReg)
.
Ann Surg
.
2015 May
261
5
909
13
.
20.
Loo
JH
,
Lim
YH
,
Seah
HL
,
Chong
AZQ
,
Tay
KV
.
Intragastric balloon as bridging therapy prior to bariatric surgery for patients with severe obesity (BMI ≥ 50 kg/m2): a systematic review and meta-analysis
.
Obes Surg
.
2022 Feb
32
2
489
502
.
21.
Wadden
TA
,
Hollander
P
,
Klein
S
,
Niswender
K
,
Woo
V
,
Hale
PM
.
Weight maintenance and additional weight loss with liraglutide after low-calorie-diet-induced weight loss: the SCALE Maintenance randomized study
.
Int J Obes
.
2015 Jan
39
1
187
.
22.
Yorke
E
,
Switzer
NJ
,
Reso
A
,
Shi
X
,
de Gara
C
,
Birch
D
.
Intragastric balloon for management of severe obesity: a systematic review
.
Obes Surg
.
2016 Sep
26
9
2248
54
.
23.
Banks
J
,
Abouelazayem
M
,
Kaur
V
,
McGlone
E
,
Fiorani
C
,
Reddy
M
.
Routine intra-gastric balloon insertion in the management of “super-super-obese” patients: an obituary
.
Obes Surg
.
2021 May
31
5
2319
23
.
24.
Coffin
B
,
Maunoury
V
,
Pattou
F
,
Hebuterne
X
,
Schneider
S
,
Coupaye
M
.
Impact of intragastric balloon before laparoscopic gastric bypass on patients with super obesity: a randomized multicenter study
.
Obes Surg
.
2017 Apr
27
4
902
9
.
25.
Kim
SH
,
Chun
HJ
,
Choi
HS
,
Kim
ES
,
Keum
B
,
Jeen
YT
.
Current status of intragastric balloon for obesity treatment
.
World J Gastroenterol
.
2016 Jun 28
22
24
5495
504
.
26.
Perisse
LG
,
Ecbc-Rj
PC
,
Ribeiro
KF
.
Gastric wall changes after intragastric balloon placement: a preliminary experience
.
Rev Col Bras Cir
.
2016 Jul-Aug
43
4
286
8
.
27.
Busetto
L
,
Segato
G
,
De Luca
M
,
Bortolozzi
E
,
MacCari
T
,
Magon
A
.
Preoperative weight loss by intragastric balloon in super-obese patients treated with laparoscopic gastric banding: a case-control study
.
Obes Surg
.
2004 May
14
5
671
6
.
28.
Zerrweck
C
,
Maunoury
V
,
Caiazzo
R
,
Branche
J
,
Dezfoulian
G
,
Bulois
P
.
Preoperative weight loss with intragastric balloon decreases the risk of significant adverse outcomes of laparoscopic gastric bypass in super-super obese patients
.
Obes Surg
.
2012 May
22
5
777
82
.