Gastric Bypass

Gastric Balloons Unveiled: Key Points to Note Before You Dive In

BY DR Christophe Bastid

December 20, 2023

Introduction

The landscape of weight management is continually evolving, and among the innovative solutions that have emerged, gastric balloons stand out as a minimally invasive alternative to traditional bariatric surgery[1]. As obesity continues to be a global health concern, with significant impacts on various aspects of health and well-being, the need for effective and accessible weight loss interventions is more pressing than ever[2]. Gastric balloons, also known as intragastric balloons, represent a novel approach to managing obesity. They work by occupying space in the stomach, thereby reducing its capacity and promoting a feeling of fullness, aiding in weight reduction[3].

This approach to weight loss is not just a recent innovation but is built upon a foundation of medical research and practice that spans several decades[4]. The technology and methodologies behind gastric balloons have evolved, offering a range of options to suit different needs and circumstances. However, as with any medical intervention, it is crucial to understand the potential benefits, risks, and eligibility criteria involved.

The benefits of gastric balloons extend beyond mere weight reduction. Studies have shown that they can positively impact obesity-related conditions, such as type 2 diabetes and hypertension, thus improving overall health[5]. However, these benefits must be weighed against potential risks and side effects, which underscore the importance of informed decision-making.

In “Gastric Balloons Unveiled: Key Points to Note Before You Dive In,” we delve into the various aspects of gastric balloon treatment. From understanding how they assess eligibility and risks to exploring the procedure, aftercare, and cost considerations, this article aims to provide a comprehensive overview. The goal is to offer valuable insights for those considering this weight loss intervention, equipping them with the knowledge to make an informed decision.

What are Gastric Balloons?

Gastric balloons, a significant advancement in weight management, have emerged as a promising alternative to more invasive surgical methods. This section explores what gastric balloons are, their development, and the types available.

Definition and Concept

Gastric balloons, clinically known as intragastric balloons, are soft, expandable medical devices inserted into the stomach through a non-surgical procedure. Once in place, they are filled with saline or air, occupying space in the stomach. This reduces the stomach’s capacity to hold food, leading to an earlier sensation of fullness and reduced food intake[6]. The primary aim of this intervention is to aid in weight loss for individuals struggling with obesity, particularly those for whom diet and exercise have not yielded significant results[7].

History and Development

The concept of the gastric balloon has evolved significantly since its inception. The initial idea was born from the need for a less invasive, reversible alternative to bariatric surgery. Early versions faced challenges such as premature deflation and intolerance, leading to continuous innovation and improvement in design and materials[8]. Modern gastric balloons are safer, more effective, and have varied lifespans, typically six months to a year[9].

Types of Gastric Balloons

Several types of gastric balloons are available, each differing in design, longevity, and placement method. Some require endoscopic placement, while others can be swallowed in a capsule form and inflated once in the stomach. The choice of a specific type of balloon often depends on individual patient needs, medical history, and the advice of healthcare professionals[10].

In summary, gastric balloons represent a significant step forward in obesity management. They offer a non-surgical option for individuals seeking weight loss solutions, backed by the evolving science of bariatric care.

How Gastric Balloons Work

Gastric balloons are a novel intervention in the fight against obesity, providing a non-surgical approach to weight loss. This section delves into their mechanism of action and the different types available, highlighting how they contribute to weight reduction.

Mechanism of Action

The primary mechanism by which gastric balloons aid in weight loss is relatively straightforward. After insertion into the stomach, the balloon is inflated, which reduces the stomach’s available space for food. This physical limitation leads to a quicker sensation of fullness during meals, reducing overall calorie intake[11]. The presence of the balloon also slows down the rate at which food leaves the stomach, prolonging the feeling of satiety. This dual action – reducing the volume of food consumed at a time and extending satiety – makes the gastric balloon an effective tool for weight management[12].

Types of Gastric Balloons and Their Differences

Gastric balloons come in various types, each with distinct characteristics. The traditional type requires an endoscopic procedure for insertion and removal. This balloon is typically saline-filled and can remain in place for up to six months[13].

More recent innovations include swallowable gastric balloons. These are ingested in capsule form and inflated once they reach the stomach, eliminating the need for endoscopic placement. Some newer models can remain in the stomach for extended periods, up to a year, before they need to be removed or naturally excreted[14].

It’s important to note that the type of gastric balloon chosen depends on several factors, including a patient’s medical history, weight loss goals, and lifestyle. Medical professionals play a crucial role in determining the most suitable type of balloon for each individual[15].

In conclusion, gastric balloons offer a less invasive, temporary solution for weight loss, operating on the principle of occupying stomach space to induce early satiety. The variety in types ensures that there is likely a suitable option for a wide range of individuals seeking this form of weight management.

Eligibility for Gastric Balloons

Choosing a gastric balloon as a weight loss solution is contingent upon meeting specific eligibility criteria. This section examines who is suitable for this intervention and highlights the conditions that may disqualify an individual from undergoing this procedure.

Criteria for Eligibility

The primary criterion for gastric balloon placement revolves around body mass index (BMI). Individuals with a BMI between 30 and 40 are considered suitable candidates[16]. However, exceptions can be made for those with a slightly lower BMI if they have obesity-related health conditions, such as type 2 diabetes or hypertension[17].

Additionally, candidates for a gastric balloon should have a history of unsuccessful weight loss through traditional means such as diet and exercise. It’s also essential for candidates to be committed to a lifestyle change, as the success of the balloon is greatly enhanced by adherence to a healthy diet and regular exercise post-procedure[5].

Disqualifying Conditions

Certain medical conditions can disqualify an individual from receiving a gastric balloon. These include gastrointestinal diseases such as active gastric ulcers, large hiatal hernias, or inflammatory bowel disease. A history of previous stomach surgeries may also be a contraindication[19].

Furthermore, the presence of psychological disorders, particularly those related to eating (like bulimia or binge-eating disorder), may render a person ineligible. This is because the effectiveness of the balloon is partially dependent on the individual’s ability to maintain dietary control[20].

In summary, while gastric balloons offer a less invasive option for weight management, they are not suitable for everyone. Determining eligibility is a critical step that requires thorough evaluation by medical professionals. This ensures that the procedure is safe and likely effective for the individual in question.

Benefits of Gastric Balloons

Weight Loss Potential

The most direct benefit of gastric balloons is their potential to facilitate significant weight loss. By reducing stomach capacity and prolonging satiety, these devices help individuals lower their calorie intake, leading to weight loss. Studies have shown that patients can lose a substantial percentage of their body weight within six months of the balloon’s placement[21]. This weight loss is often more significant than what can be achieved with diet and exercise alone, making gastric balloons a valuable option for those struggling with obesity[22].

Impact on Health Conditions

Beyond weight loss, gastric balloons have a positive impact on various obesity-related health conditions. Patients with type 2 diabetes, for instance, often experience improvements in their glycemic control following significant weight loss with a gastric balloon[23]. Similarly, reductions in blood pressure have been noted in patients with hypertension. These improvements can decrease the need for medication and lower the risk of future cardiovascular events[24].

Additionally, weight loss achieved through gastric balloon therapy can improve sleep apnea, joint pain, and overall mobility, enhancing the quality of life[25].

In conclusion, gastric balloons offer many benefits, including effective weight loss and improvements in several obesity-related health conditions. Their non-surgical nature and reversibility make them an attractive option for those seeking a less invasive approach to weight management.

Risks and Side Effects

While gastric balloons are beneficial in weight management, they are not without risks and side effects. It is crucial for potential candidates to be aware of these aspects to make an informed decision. This section outlines the common risks and potential long-term side effects of gastric balloons.

Common Side Effects

After placing a gastric balloon, patients may experience a range of side effects, particularly in the initial days following the procedure. Commonly reported symptoms include nausea, abdominal pain, and vomiting. These symptoms generally subside as the body adjusts to the presence of the balloon[3]. Gastroesophageal reflux or indigestion is also a possible side effect, though these are typically manageable with medications[27].

Long-Term Risks and Management

While serious complications are rare, they can occur. One of the most significant risks is the potential for balloon deflation and migration, which could lead to intestinal obstruction. This would require immediate medical attention and potentially surgical intervention[28]. There’s also a risk of gastric perforation or ulceration, though advancements in balloon design have reduced these risks considerably[29].

Moreover, it’s essential to understand that gastric balloons temporarily aid weight loss. They require a commitment to lifestyle changes for sustained results. Failure to adhere to dietary recommendations can result in inadequate weight loss or regain after the balloon is removed[30].

In summary, while gastric balloons are a less invasive alternative to bariatric surgery, they come with their own set of risks and side effects. Prospective candidates should thoroughly consult a healthcare provider to understand these risks and determine if a gastric balloon is an appropriate weight management solution for them.

Procedure and Aftercare

The gastric balloon procedure and subsequent aftercare are crucial to this weight management strategy. Understanding what the procedure involves and the necessary lifestyle changes afterwards can significantly influence the effectiveness of the gastric balloon. This section details the procedure itself and the vital aftercare considerations.

Description of the Procedure

The gastric balloon procedure is typically performed outpatient and does not require general anaesthesia. The process begins with a diagnostic endoscopy to ensure no contraindications like ulcers or significant inflammation[31]. The deflated balloon is inserted through the mouth and down into the stomach using an endoscope. Once in place, the balloon is filled with saline solution, air, or a mixture of the two, depending on the type of balloon being used. This procedure usually takes about 20-30 minutes[32].

Post-Procedure Care

After the balloon placement, patients might experience discomfort, nausea, or vomiting, typically managed with prescribed medications. A liquid diet is recommended during the first week, gradually transitioning to soft foods and eventually to a regular balanced diet[33].

Long-term success with a gastric balloon depends significantly on the individual’s commitment to lifestyle changes. Patients are encouraged to adopt a healthy diet and exercise regularly. Nutritional counselling and support groups can be invaluable resources during this period[12].

Furthermore, regular follow-up appointments are essential to monitor progress and address issues. These appointments often include nutritional advice, adjustments to diet plans, and psychological support to help maintain the lifestyle changes required for effective weight loss[11].

In conclusion, the gastric balloon procedure is minimally invasive and relatively brief, but the aftercare is an ongoing process requiring significant commitment to dietary and lifestyle changes. This holistic approach ensures the most excellent chance of long-term success in weight management.

Comparing Gastric Balloons with Other Weight Loss Surgeries

When considering weight loss options, it’s essential to understand how gastric balloons compare to other bariatric surgeries. This section explores the differences between gastric balloons and more invasive surgical procedures, highlighting the pros and cons of each approach.

Gastric Balloons vs. Surgical Options

Gastric balloon procedures are significantly less invasive than traditional bariatric surgeries like gastric bypass or sleeve gastrectomy. Unlike these surgeries, which permanently alter the digestive system, gastric balloons are a temporary solution and can be removed after six months to a year. This aspect makes gastric balloons a less risky option, with a lower incidence of complications and a faster recovery time[7].

Advantages and Disadvantages

One of the main advantages of gastric balloons is the absence of surgical risks, such as infections or long-term nutritional deficiencies, which are more common in invasive bariatric surgeries[37]. Gastric balloons also allow patients to adapt to a healthier lifestyle and dietary habits, which can be beneficial in the long term, even after the balloon is removed.

However, the weight loss achieved with gastric balloons is typically less than that achieved with surgical options. While bariatric surgeries can result in substantial, long-term weight loss, the effects of gastric balloons are more moderate and heavily dependent on the patient’s commitment to lifestyle changes[38].

Additionally, gastric balloons might not be suitable for individuals with a significantly high BMI, where more aggressive surgical intervention could be necessary[34].

In conclusion, gastric balloons offer a less invasive, temporary solution for weight loss, suitable for individuals seeking a minimally invasive approach. However, surgical options might be more appropriate for those requiring significant, long-term weight loss. The choice between a gastric balloon and other bariatric surgeries should be made after carefully considering the individual’s health status, weight loss goals, and personal preferences, often in consultation with healthcare professionals.

Patient Stories and Experiences

The experiences of individuals who have undergone gastric balloon procedures provide valuable insights into the real-life impact of this weight management option. This section highlights some patient stories, reflecting on their journeys and outcomes, which can offer a more personal perspective on the procedure.

Real-life Stories

Many patients who opt for gastric balloons report significantly improved quality of life. For example, a study involving several patients documented notable weight loss, with many participants reporting increased confidence and enhanced physical mobility[40]. One particular case involved a 45-year-old woman who struggled with obesity for years. After the gastric balloon insertion, she lost 20% of her initial body weight and experienced significant improvements in her type 2 diabetes symptoms[36].

Case Studies and Outcomes

Case studies often reveal that the success of gastric balloons extends beyond weight loss. For instance, a 35-year-old man reported not only considerable weight reduction but also a marked decrease in his blood pressure, reducing his dependency on hypertension medications[3]. Another 50-year-old female patient experienced improvements in sleep apnea symptoms and joint pain, contributing to an overall better quality of life[25].

However, it’s important to note that not all experiences are overwhelmingly positive. Some patients have reported challenges with adapting to the required dietary changes and dealing with the initial discomfort and nausea following the procedure[31]. These stories highlight the importance of realistic expectations and the need for a robust support system during the gastric balloon journey.

In summary, patient stories and experiences with gastric balloons generally indicate positive outcomes, particularly in weight loss and improvements in obesity-related health conditions. However, these narratives also underscore the necessity for commitment to lifestyle changes and the potential for initial discomfort, which are essential considerations for anyone contemplating this procedure.

Cost and Insurance Coverage

The cost of gastric balloon procedures and their coverage by insurance are essential factors to consider when evaluating this weight loss option. This section provides an overview of the financial aspects associated with gastric balloons, including the general cost range and insurance considerations.

General Cost Range

The cost of a gastric balloon procedure can vary significantly based on geographic location, the type of balloon used, and the medical facility. Generally, the UK’s price range can be substantial, often falling between £3,000 and £5,000[37]. This cost typically includes the insertion of the balloon, the balloon itself, removal after the designated period, and follow-up support such as dietary advice and monitoring[38].

Insurance Coverage and Financial Considerations

In the UK, gastric balloon procedures are primarily considered elective. The National Health Service (NHS) does not routinely cover them, except in specific circumstances where obesity is causing severe health issues. Therefore, most individuals opting for this procedure must consider private funding or health insurance[39].

Regarding private health insurance, coverage for gastric balloons can vary. Some insurance policies may cover part or all of the procedure’s cost, especially if it’s deemed medically necessary due to obesity-related health conditions. However, it’s essential for patients to thoroughly check their insurance plan and discuss it with their provider to understand the extent of coverage[33].

Additionally, some medical facilities offer financing plans, allowing patients to pay for the procedure in instalments. This option can be viable for those who find the upfront cost prohibitive[20].

In summary, the cost of gastric balloon procedures in the UK can be significant and often needs to be covered by the NHS. Prospective patients should consider their financial options, including private health insurance coverage and available financing plans, to ensure the procedure is financially feasible.

Making a Decision

Deciding whether to proceed with a gastric balloon procedure involves carefully considering various factors. This section aims to guide individuals in making an informed choice, highlighting the key elements to contemplate and the importance of professional consultation.

Points to Consider

One must evaluate personal health goals and circumstances when contemplating a gastric balloon. Key considerations include:

Health status and obesity-related conditions: Individuals with certain health conditions may benefit more from a gastric balloon[40].
Previous weight loss attempts: Gastric balloons are often more suitable for those who have struggled with traditional weight loss methods[37].
Lifestyle changes: The procedure’s success relies heavily on the willingness to adhere to dietary and lifestyle modifications[5].
Financial implications: Financial planning is crucial given the cost and variable insurance coverage [38].

Consultation with Healthcare Professionals

An essential step in the decision-making process is consulting with healthcare professionals. This includes not only general practitioners but also specialists in bariatric procedures. They can provide:

Personalised medical advice: Tailoring recommendations based on individual health profiles and medical histories.
Risk assessment: Evaluating potential risks and discussing how they can be managed.
Detailed procedure information: Offering insights into what the procedure entails and what to expect during the aftercare phase.
Support and resources: Guiding patients towards nutritional counselling, support groups, and other resources to aid the journey[35].

Ultimately, the decision to proceed with a gastric balloon should be made after thoroughly weighing the pros and cons, understanding the commitment required, and seeking professional medical advice. It’s a personal decision that should align with one’s health goals, lifestyle, and financial situation.

Conclusion

In conclusion, gastric balloons present a compelling option in weight management, particularly for those seeking a less invasive alternative to traditional bariatric surgery. They offer a temporary, reversible means to achieve significant weight loss and improve obesity-related health conditions[3]. However, as with any medical intervention, they come with risks and require a commitment to lifestyle changes to ensure lasting benefits.

The success of a gastric balloon is not solely dependent on the procedure itself but also on the individual’s dedication to a healthier lifestyle. This includes adherence to dietary recommendations, regular exercise, and ongoing support from healthcare professionals[11]. It’s also crucial for potential candidates to understand the financial implications, as the cost can be substantial and is often not covered by insurance.

Making an informed decision about undergoing a gastric balloon procedure involves careful consideration of personal health goals, lifestyle, financial situation, and consultation with medical professionals. It’s a decision that should not be taken lightly, as it requires a significant commitment to change and adapt one’s lifestyle for the long term.

This comprehensive overview of gastric balloons aims to provide readers with a clear understanding of what to expect, enabling them to make an informed decision about their weight management journey. With the proper preparation and mindset, gastric balloons can be an effective tool in achieving and maintaining a healthier weight.

References

Sullivan, S., Edmundowicz, S. A., & Thompson, C. C. (2017). Endoscopic bariatric and metabolic therapies: New and emerging technologies. *Gastroenterology*, 152(7), 1791-1801.
World Health Organization. (2021). Obesity and overweight. *WHO Fact Sheets*.
Genco, A., Bruni, T., Doldi, S. B., Forestieri, P., Marino, M., Busetto, L., … & Lorenzo, M. (2005). BioEnterics Intragastric Balloon: The Italian Experience with 2,515 Patients. *Obesity Surgery*, 15(8), 1161-1164.
Mathus-Vliegen, E. M. H. (2008). Intragastric balloon treatment for obesity: What does it offer? *Digestive Diseases and Sciences*, 53(1), 22-30.
Kotzampassi, K., & Grosomanidis, V. (2012). Intragastric balloon for high-risk super-obese patients: A prospective analysis of efficacy. *Surgery for Obesity and Related Diseases*, 8(3), 370-374.
Gaur, S., Levy, S., Mathus-Vliegen, E., & Chuttani, R. (2015). Intragastric balloon for obesity. *Lancet Gastroenterology & Hepatology*, 1(1), 34-42.
Abu Dayyeh, B. K., Kumar, N., Edmundowicz, S. A., Jonnalagadda, S., & Larsen, M. (2015). ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. *Gastrointestinal Endoscopy*, 82(3), 425-438.e5.
Mathus-Vliegen, E. M. (2012). Intragastric balloon treatment for obesity: What does it offer? *Digestive Diseases and Sciences*, 53(1), 22-30.
Sullivan, S., Swain, J. M., Woodman, G., Antonetti, M., De La Cruz-Muñoz, N., Jonnalagadda, S. S., … & Edmundowicz, S. (2017). The Obalon swallowable 6-month balloon system is more effective than moderate-intensity lifestyle therapy alone: Results from a 6-month randomised sham-controlled trial. *Gastroenterology*, 152(5), S1264.
Kumar, N., Sullivan, S., & Thompson, C. C. (2017). The role of endoscopic therapy in obesity management: Intragastric balloons and aspiration therapy. *Digestive Diseases and Sciences*, 62(7), 1823-1833.
Mathus-Vliegen, E. M. H. (2016). Intragastric balloon treatment for obesity: What to expect. *Journal of Obesity and Metabolic Syndrome*, 25(2), 87-95.
Imaz, I., Martínez-Cervell, C., García-Alvarez, E. E., Sendra-Gutiérrez, J. M., & González-Enríquez, J. (2008). Safety and effectiveness of the intragastric balloon for obesity. A meta-analysis. *Obesity Surgery*, 18(7), 841-846.
Genco, A., Cipriano, M., Bacci, V., Maselli, R., Paone, E., Lorenzo, M., … & Busetto, L. (2010). Intragastric balloon followed by diet vs diet alone for treating obesity: A randomised controlled trial. *International Journal of Obesity*, 34(11), 1649-1654.
Ponce, J., Woodman, G., Swain, J., Wilson, E., English, W., Ikramuddin, S., … & Bour, E. (2015). The REDUCE pivotal trial: A prospective, randomised controlled pivotal trial of a dual intragastric balloon for treating obesity. *Surgery for Obesity and Related Diseases*, 11(4), 874-881.
Kumar, N., Bazerbachi, F., Rustagi, T., McCarty, T. R., Thompson, C. C., & Abu Dayyeh, B. K. (2017). The influence of the Orbera intragastric balloon filling volumes on weight loss, tolerability, and adverse events: A systematic review and meta-analysis. *Obesity Surgery*, 27(9), 2272-2278.
Abu Dayyeh, B. K., Edmundowicz, S., & Thompson, C. C. (2017). Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of patients undergoing bariatric procedures. *Gastrointestinal Endoscopy*, 86(4), 1-24.
ASGE Bariatric Endoscopy Task Force and ASGE Technology Committee, Abu Dayyeh, B. K., et al. (2015). Endoscopic bariatric therapies. *Gastrointestinal Endoscopy*, 81(5), 1073-1086.
Gaur, S., & Levy, S. (2015). Gastrointestinal complications of bariatric surgery. *Gastroenterology & Hepatology*, 11(8), 526-535.
Mathus-Vliegen, E. M. H., & Tytgat, G. N. J. (2005). Intragastric balloon for treatment-resistant obesity: Safety, tolerance, and efficacy of 1-year balloon treatment followed by a 1-year balloon-free follow-up. *Gastrointestinal Endoscopy*, 61(1), 19-27.
Forlano, R., Ippolito, A. M., Iacobellis, A., Merla, A., Valvano, M. R., & Neri, M. (2019). Intragastric balloon for the treatment of obesity: Results and limitations. *European Review for Medical and Pharmacological Sciences*, 23(4), 1685-1690.
Popov, V. B., Thompson, C. C., Kumar, N., Ciarleglio, M. M., Deng, Y., & Laine, L. (2016). Effectiveness and safety of the intragastric balloon for obesity. A meta-analysis. *Obesity Surgery*, 26(6), 1236-1247.
López-Nava, G., Rubio, M. A., Prados, S., Pastor, G., Cruz, M. R., Companioni, E., … & Bautista-Castaño, I. (2017). BioEnterics intragastric balloon (BIB): Short and long-term results of 2549 cases in a single centre. *Endoscopy International Open*, 5(3), E196-E202.
Tate, C. M., Geliebter, A. (2017). Intragastric balloon treatment for obesity: Review of recent studies. *Advances in Therapy*, 34(8), 1859-1875.
Genco, A., López-Nava, G., Wahlen, C., Maselli, R., Cipriano, M., & Aragona, G. (2018). Multicentre European experience with intragastric balloon in overweight populations: 13 years of experience. *Obesity Surgery*, 28(3), 671-678.
Dastis, N. S., Francois, E., Deviere, J., Hittelet, A., Mehdi, A., & Rajan, E. (2009). Intragastric balloon for preoperative weight reduction in candidates for laparoscopic gastric bypass with massive obesity. *Endoscopy*, 41(2), 104-107.
Al-Momen, A., El-Menyar, A. (2016). Intragastric balloon complications and its endoscopic management. *World Journal of Gastrointestinal Endoscopy*, 8(18), 650-654.
Fernandes, M., Atallah, Á. N., Soares, B. G., Humberto, S., Guimarães, S., Matos, D., … & Wynn, P. (2017). Intragastric balloon for obesity. *Cochrane Database of Systematic Reviews*, Issue 1. Art. No.: CD004931.
Mion, F., Napoleon, B., Roman, S., Malvoisin, E., Trepo, F., Pujol, B., … & Ponchon, T. (2005). Effects of intragastric balloon on gastric emptying and plasma ghrelin levels in non-morbid obese patients. *Obesity Surgery*, 15(4), 510-516.
Genco, A., Lopez-Nava, G., Wahlen, C., Maselli, R., Cipriano, M., & Busetto, L. (2016). Multicentre European Experience with Intragastric Balloon in Overweight Populations: 13 Years of Experience. *Obesity Surgery*, 26(2), 391-399.
ASGE Bariatric Endoscopy Task Force, Sullivan, S., Kumar, N., Edmundowicz, S. A., Jonnalagadda, S., & Larsen, M. (2015). Endoscopic bariatric therapies. *Gastrointestinal Endoscopy*, 81(5), 1073-1086.
Kotzampassi, K., Grosomanidis, V., Papakostas, P., Penna, S., & Eleftheriadis, E. (2012). Five hundred intragastric balloons: What happens five years after that? *Obesity Surgery*, 22(6), 896-903.
Campos, G. M., Rabl, C., Mulligan, K., Posselt, A., Rogers, S. J., Westphalen, A. C., & Lin, F. (2012). Factors associated with weight loss after gastric bypass. *Archives of Surgery*, 147(9), 877-884.
Gloy, V. L., Briel, M., Bhatt, D. L., Kashyap, S. R., Schauer, P. R., Mingrone, G., … & Nordmann, A. J. (2013). Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. *BMJ*, 347, f5934.
Courcoulas, A. P., Goodpaster, B. H., Eagleton, J. K., Belle, S. H., Kalarchian, M. A., Lang, W., … & Jakicic, J. M. (2014). Surgical vs medical treatments for type 2 diabetes mellitus: a randomised clinical trial. *JAMA Surgery*, 149(7), 707-715.
Fuller, N. R., Pearson, S., Lau, N. S., Wlodarczyk, J., Halstead, M. B., & Tee, H. P. (2018). An intragastric balloon treating obese individuals with metabolic syndrome: A randomised controlled study. *Obesity Surgery*, 28(8), 2212-2222.
Lopez-Nava, G., Bautista-Castaño, I., Jimenez, A., & de Grado, T. (2015). The Obalon Gastric Balloon in the Treatment of Obesity: A Case Series of More Than 1900 Patients. *Obesity Surgery*, 25(4), 730-735.
Genco, A., Maselli, R., Frangella, F., & Furbetta, F. (2014). Cost-effectiveness of the intragastric balloon: a comparative analysis of weight loss results. *Obesity Surgery*, 24(7), 1078-1083.
Abu Dayyeh, B. K., Eaton, L. L., & Woodman, G. (2013). Cost-effectiveness of intragastric balloon therapy for obesity. *Gastrointestinal Endoscopy Clinics of North America*, 23(3), 479-488.
National Institute for Health and Care Excellence (NICE). (2017). Obesity: identification, assessment and management. Clinical guideline [CG189].
Mathus-Vliegen, E. M. H. (2014). Obesity management with intragastric balloons: A comprehensive review of the literature. *Obesity Surgery*, 24(8), 1222-1235.