Le e s o he Edi o
1130-0108/2015/107/3/183-184
Re is a española de en eRmedades diges i as
CopyRigh © 2015 aRán ediCiones, s. l. Re esp en eRm dig (Mad id
Vol. 107, N.º 3, pp. 183-184, 2015
Cholecys i is and duodenal is ula as
EndoBa ie ®-associa ed complica ions.
Minimally in asi e ea men
Key wo ds: EndoBa ie ®. Complica ion. Cholecys i is. Fis ula.
T ea men .
Dea Edi o ,
We epo he case o a pa ien wi h obesi y and ype-2 dia-
be es melli us who, one mon h a e endoscopic duodenojejunal
bypass (EndoBa ie ® echnique) had, as a complica ion he e-
o , acu e cholecys i is and duodenal is ula seconda y o bulba
ansmu al pene a ion and gall-bladde impac ion by one o he
ancho s, which could be sol ed using minimally in asi e lapa o-
scopic su ge y wi h endoscopic EndoBa ie ® wi hd awal.
Case epo
A 55-yea -old male p esen ed wi h g ade-II obesi y (body
weigh 94.5 kg, 208 lbs, BMI 36 kg/m2), hype ension, hype -
choles e olemia, and ype-2 diabe es melli us on 2 o al an idia-
be ic d ugs (OADs) and 80 UI o insulin. Following a mul idis-
ciplina y assessmen , endoscopic placemen o an EndoBa ie ®
de ice was ag eed, and he p ocedu e was une en ul. The
pa ien had a ollow-up isi a 4 weeks and was in good heal h,
ha ing los 7.5 kg (16.5 lbs) in weigh and educed OADs and
insulin equi emen s by hal .
A week la e he p esen ed wi h e e and abdominal pain. The
ollowing was pe o med:
– Physical examina ion: Abdominal gua ding in he igh
uppe quad an .
– Lab es s: Leukocy osis (21,000/ul).
– Abdominal CT: Acu e ali hiasic emphysema ous cholecys-
i is wi h ai bubbles in cys ic duc and ai le el in gall-blad-
de , and a p ope ly placed EndoBa ie ® de ice.
A lapa oscopic cholecys ec omy was pe o med, and acu e
ali hiasic gang enous cholecys i is seconda y o bulba ansmu-
al pene a ion and gall-bladde impac ion by an EndoBa ie ®
ancho (Fig. 1) was ound. Pa hology con i med he p esence
o acu e gang enous cholecys i is wi h bile cul u e posi i e o
Clos idium pe ingens.
To pid pos -su gical cou se wi h abdominal gua ding p omp ed a
ollow- h ough e alua ion, which showed a small duodenal is ula.
A gas oscopy was pe o med (Fig. 2), which con i med a
small bulba is ula o i ice, and i was decided o endoscopi-
cally wi hd aw he EndoBa ie ® de ice, he p ocedu e being
une en ul.
Subsequen ly he pa ien had a sa is ac o y eco e y wi h
conse a i e medical he apy, and was discha ged a e 10 days.
Fig. 1. Su gical image: A de ice ancho may be seen eme ging om he
duodenal bulb in o he pe i oneal ca i y.
184 LETTERS TO THE EDITOR Re esp en eRm Dig (maDRiD)
Re esp en eRm Dig 2015; 107 (3): 183-184
Discussion
The endoscopic duodeno-jejunal bypass p o ided by he
EndoBa ie ® de ice (GI Dynamics, Inc, Wa e own, Mass.)
en ails he placemen o a lexible, lined, in aluminal luo o-
polyme slee e (p os hesis) which is endocopically ancho ed
wi hin he duodenal bulb by i e c own-shaped ings (each wi h
wo 4-mm ni inol ancho s), and ex ends abou 60 cm along he
duodenum o he p oximal jejunum, hus p o iding an “inne
ba ie ” (“Endo-Ba ie ”) which sepa a es inges ed ood om
in es inal illi, p esumably o e ing a simila e ec o su gical
gas ic bypass (1,2).
Knowledge o a neu oho monal ac o ope a ing a he duo-
denal wall, he de ice’s malabso p i e e ec and some mechan-
ical componen o delayed gas ic oiding posi ion he p oce-
du e as an al e na i e, complemen a y echnique alid o he
managemen o adul pa ien s wi h obesi y and diabe es melli us
in addi ion o ca dio ascula isk ac o s and ela ed me abolic
synd ome (2-9).
The EndoBa ie ® echnique is exclusi ely endoscop-
ic. Implan a ion (5) and emo al (7) issues we e ound wi h
i s -gene a ion EndoBa ie ® de ices (4-7,9). Wi h he echni-
cal imp o emen s in oduced in second-gene a ion EndoBa ie ®
de ices, p ima ily in ol ing he ancho ing mechanism and loca-
ion, o e all majo complica ions ha e dec eased below 5 %, and
he echnique is now sa e and eliable. In ou expe ience wi h 24
p ocedu es and ollow-up up o 6 mon hs o e all ole abili y has
been excellen , and no o he majo complica ions had p e iously
a isen. Acu e gang enous cholecys i is seconda y o gall-bladde
impac ion by an EndoBa ie ® ancho is a majo complica ion
ha had no been epo ed o his day, likely due o a somewha
o a ed placemen o he ancho ing c own-shaped ings. Du ing
lapa oscopic cholecys ec omy, likely seconda y o in aope a i e
pe i oneal washing and handling, ancho s budged and ga e ise
o he small is ula de ec ed by adiology and endoscopy, which
could be sol ed by endoscopic de ice emo al and conse a i e
medical he apy.
To conclude, we conside ha , in expe hands, EndoBa ie ®
ep esen s a sa e, e ec i e endoscopic echnique, al hough majo
complica ions such as acu e gang enous cholecys i is and duode-
nal is ula, p e iously un epo ed, may a ise and equi e de ice
emo al as well as a mo e in asi e he apeu ic app oach.
Fo his eason we belie e ha his he apy should only be
o e ed in e e ence hospi als wi h a mul idisplina y eam, an
endoscopic Obesi y T ea men Uni speci ically ained in his
echnique, and join coope a ion wi h a specialis eme gency
su ge y depa men o he ea ly managemen o po en ial majo
complica ions.
Edua do Espine -Coll1, Jo di Pujol-Gebelli2,
Amado Ga cía-Ruiz-de-Go dejuela2, Anna Casajoana-Badia2,
Ja ie Neb eda-Du án1, An onio Juan-C eix-Comamala1,
José An onio Gómez-Vale o1 and Ca men Vila-Lolo1
1UTEO – Unidad de T a amien o Endoscópico de la Obesidad.
Gas odex. Hospi al Uni e si a io Qui ón-Dexeus. Ba celona,
Spain. 2Uni a de Ci u gia Me abòlica i de la Obesi a .
Hospi al Uni e si a i de Bell i ge. L’Hospi ale ,
Ba celona. Spain
Re e ences
1. Espine -Coll E, Neb eda-Du án J, Gómez-Vale o JA, Muñoz-Na as
M, Pujol-Gebelli J, Vila-Lolo C, e al. Cu en endoscopic echniques
in he ea men o obesi y. Re Esp En e m Dig 2012;104(2):72-87.
2. Fishman E, Melanson D, Lampo R, La ine A. A no el endoscopic
deli e y sys em o placemen o a duodenal-jejunal implan o he
ea men o obesi y and ype 2 diabe es. Con P oc IEEE Eng Med
Biol Soc 2008;2501-3.
3. Ve dam FJ, Liedo p PR, Geubbels N, Schou en R, Janssen IM, Koek
GH, e al. EndoBa ie o coun e ac ing obesi y and me abolic syn-
d ome. Med Tijdsch Geneeskd 2012;156(13):A3844.
4. Ge sin KS, Ro hs ein RI, Rosen hal RJ, S e anidis D, Deal SE, Wuwa-
da TS, e al. Open-label, sham-con olled ial o an endoscopic duode-
nojejunal bypass line o p eope a i e weigh loss in ba ia ic su ge y
candida es. Gas oin es Endosc 2010;71(6):976-82.
5. Schou en R, Rijs CS, Bou y ND, Hamee eman W, Koek GH, Janssen
IM, e al. A mul icen e , andomized e icacy s udy o he EndoBa -
ie Gas oin es inal Line o p esu gical weigh loss p io o ba ia ic
su ge y. Ann Su g 2010;251(2):236-43.
6. Ta no M, Rod íguez L, Escalona A, Ramos A, Ne o M, Alamo M,
e al. Open label, p ospec i e, andomized con olled ial o an endo-
scopic duodenal-jejunal bypass slee e e sus low calo ie die o p e-
ope a i e weigh loss in ba ia ic su ge y. Su g Endosc 2009;23:650-6.
7. Rod íguez-G une L, Gal ao Ne o MP, Alamo M, Ca doso Ramos
A, B an e Baez P, Ta no M. Fi s human expe ience wi h endoscopi-
cally deli e ed and e ie ed duodenal-jejunal bypass slee e. Su g
Obes Rela Dis 2008;4:55-9.
8. Pa el SR, Hakim D, Mason J, Hakim N. The duodenal-jejunal by-pass
slee e (Endoba ie Gas oin es inal Line ) o weigh loss and ea -
men o ype 2 diabe es. Su g Obes Rela Dis 2013;9(3):482-4.
9. Mou a EG, Ma ins BC, Lopes GS, O so IR, de Oli ei a SL, Gal-
ao Ne o MP, e al. Me abolic imp o emen s in obese ype 2 diabe es
subjec s o 1 yea wi h an endoscopically deployed duodenal-jejunal
bypass line . Diabe es Technol The 2012;14(2):183-9.
Fig. 2. Endoscopic image: A pe iulce a i e is ula o i ice is seen in
he bulba EndoBa ie ® ancho age a ea, which p omp s endoscopic
emo al.
