A 48-year-old male with a history of high blood pressure and morbid obesity and a BMI of 53 Kg/m2 was evaluated for surgical treatment of morbid obesity and its comorbidities. No hiatal hernia or mucosal lesions were found in the upper endoscopy. The clo test was negative
The abdominal ultrasound revealed an enlarged and steatotic liver. The ASA Score was II.
Performing a RYGBP in a patient with this BMI and an enlarged liver might lead to an increased rate of unexpected injuries or postoperative complications.
Performing a sleeve gastrectomy is feasible but in a superobese patient it may require conversion to a BPD-DS due to insufficient weight loss.
Using an intragastric balloon plus close follow-up may lead to a BMI decrease and a reduction of the size of the liver, thus making the patient suitable for a Roux en Y Gastric Bypass
The procedure is performed under sedation with the patient in left lateral decubitus and the anesthesiologist supervising the vital signs. An oral protector is placed to keep the mouth open, allowing access to the endoscope and protecting the patient’s teeth. First we perform a brief endoscopic evaluation basically to suction all the gastric contents.
The balloon is fully collapsed and attached to a tube that serves as a guide to push it down from the mouth to the esophagus and stomach. This maneuver is supervised by means of the endoscope. With the balloon in place the guide is removed.
Then a connection is made to fill the balloon with methylene blue diluted in a saline solution. If the balloon bursts, the methylene blue will show in the patient’s urine. The three channel connection facilitates this step.
By means of the endoscope we ensure that the balloon becomes distended away from the pylorus and the esophagus. This maneuver is repeated several times until a total of 500cc is reached. To finish the procedure, the tube is pulled out detaching it from the balloon, which is left inside the stomach.
This is a simple procedure that took 18 minutes. The patient was discharged the following day with good oral tolerance to diet. Prophylactic antiemetics were given for a week.