Depression, anxiety tied to intragastric balloon intolerance, early removal

Intragastric balloons (IGBs) are a less-invasive alternative to metabolic bariatric surgery (MBS) in the treatment of obesity and its complications, but many Asians suffer intolerance and have a higher rate of early balloon removal relative to Caucasians, reports a Singapore study. Moreover, both depression and anxiety are associated with early IGB removal. 

“Identifying patients at risk of intolerance and early removal enables the healthcare team to implement necessary countermeasures, reducing this risk and increasing the success of IGB therapy,” the investigators said. 

Furthermore, “in patients with a history of depression or anxiety, it is important to ensure adequate counselling and preparation prior to balloon insertion,” they added. 

Fifty-four consecutive patients who underwent IGB insertion from July 2017 to July 2022 in a single tertiary institution in Singapore were included in this retrospective cohort study. Of the patients, 47 (87.0 percent) completed therapy, while seven (13.0 percent) had early removal of the balloon due to intolerance. The investigators then compared the characteristics of both groups. 

In multivariate analysis, both depression (p=0.012) and anxiety (p=0.001) were significantly associated with early balloon removal after adjusting for age, sex, ethnicity, height, nulliparity, balloon type, and volume. [Ann Acad Med Singap 2024;53:551-561] 

In univariate analysis, only anxiety was a significant predictor of early IGB removal (odds ratio, 9.111, 95 percent confidence interval, 1.624–51.124). Depression, on the other hand, showed no significant association with early balloon removal. 

“Identifying predictors of balloon intolerance and early removal can enhance patient selection and improve periprocedural care,” the investigators said. 

“It allows clinicians to make informed decisions about patient suitability and tailor their approach to achieve best possible results for each patient,” they noted. 

Satiety  

IGBs work by acting as an artificial bezoar that occupies space in the stomach and induces early satiety, lesser food intake, and as a result weight loss. These balloons, unlike MBS, are reversible and do not alter the gastrointestinal anatomy. [Psychol Health Med 2018;23:840-845] 

A previous meta-analysis of five randomized controlled trials with a total of 903 patients showed a mean percentage of 17.98-percent (p<0.00001) excess weight loss difference between the IGB and control groups, with results significantly in favour of IGB over sham and lifestyle intervention. [Obes Surg 2020;30:2743-2753] 

Other studies have also explored the sustainability of weight loss after balloon removal. A randomized sham-controlled study with crossover at 3 months demonstrated continued weight loss for 3 months following balloon removal. [Int J Obes 2006;30:129-133] 

Apart from weight loss, other benefits derived from IGB insertion include a significant decrease in hepatic steatosis, insulin resistance, and improvement in obesity-related comorbidities. [Gastrointest Endosc 2010;71:927-933] 

Balloon type 

With regard to the type of IGB, an earlier study reported higher symptom severity with the Elipse balloon immediately after insertion. However, Elipse was then tolerated by patients after 72 hours. [Int J Surg 2017;48:16-22; Surg Obes Relat Dis 2018;14:311-317] 

Another type is the adjustable Spatz3, which alleviated early intolerance in 80 percent of patients in a previous study. In the current study, one patient with Spatz3 had the balloon downsized from 700 to 500 mL due to persistent nausea and vomiting. [Obes Surg 2018;28:1271-1276] 

“Overall, our results nonetheless found that there was no statistically significant association between the type of balloon (p=0.741) or balloon volume (p=0.892) on intolerance and early removal,” the investigators said.  

“Other factors—including age, sex, ethnicity, preoperative weight, BMI, height, nulliparity, diabetes, and the use of proton pump inhibitors—were not significant predictors of intolerance and early removal,” they added.