Devices and Endoscopic Bariatric Therapies for Obesity

  • Katherine H. Saunders
  • Leon I. Igel
  • Monica Saumoy
  • Reem Z. Sharaiha
  • Louis J. Aronne
Obesity Treatment (CM Apovian, Section Editor)
  • 1 Downloads
Part of the following topical collections:
  1. Topical Collection on Obesity Treatment

Abstract

Purpose of Review

In this review, we describe the FDA-approved and investigational devices and endoscopic bariatric therapies for the treatment of obesity. We focus on literature published in the past few years and present mechanisms of action as well as efficacy and safety data.

Recent Findings

Devices and endoscopic procedures are emerging options to fill the significant treatment gap in the management of obesity. Not only are these devices and procedures minimally invasive and reversible, but they are potentially more effective than antiobesity medications, often safer for poor surgical candidates and possibly less expensive than bariatric surgery.

Summary

As many patients require a variety of management strategies (medications, devices, procedures, and/or surgery) in addition to lifestyle modifications to achieve clinically significant weight loss, the future of obesity treatment involves a multidisciplinary approach. Combinations of advanced treatment strategies can lead to additive or synergistic weight loss. This is an area that requires further investigation.

Keywords

Obesity Devices Endoscopic bariatric therapy Intragastric balloon Aspiration therapy Vagal blockade 

Notes

Compliance with Ethical Standards

Conflict of Interest

Katherine H. Saunders declares that she has no conflict of interest.

Leon I. Igel declares that he has no conflict of interest.

Monica Saumoy declares that she has no conflict of interest.

Reem Z. Sharaiha has received grant support from Apollo Endosurgery and Boston Scientific.

Louis J. Aronne has received research funding from Aspire Bariatrics, Eisai, and Takeda Pharmaceuticals. He declares consultant/advisory board work with Jamieson Labs, Pfizer, Novo Nordisk, Eisai, VIVUS, GI Dynamics, JOVIA Health, and Gelesis. He is a shareholder of Zafgen, Gelesis, MYOS Corporation, and Jamieson Labs, and he is on the Board of Directors of MYOS Corporation and Jamieson Labs.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of Particular Interest, Published Recently, Have Been Highlighted as: • Of Importance •• Of Major Importance

  1. 1.
    •• Jensen MD, Ryan DH, Apovian CM, et al. AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol 2014. 2013;63(25 Pt B):2985–3023. Drafted by a task force of experts from the American College of Cardiology, American Heart Association, and The Obesity Society, this publication is the first clinical practice guidelines for the management of adults with overweight and obesity.Google Scholar
  2. 2.
    Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, et al. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity (Silver Spring). 2016;24(8):1612–9.CrossRefGoogle Scholar
  3. 3.
    Greenway FL. Physiological adaptations to weight loss and factors favouring weight regain. Int J Obes. 2015;39(8):1188–96.CrossRefGoogle Scholar
  4. 4.
    Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011;365(17):1597–604.CrossRefPubMedGoogle Scholar
  5. 5.
    Rosenbaum M, Leibel RL. Adaptive thermogenesis in humans. Int J Obes. 2010;34:S47–55.CrossRefGoogle Scholar
  6. 6.
    •• Apovian CM, Aronne LJ, Bessesen DH, McDonnell M, Murad MH, Pagotto U, et al. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342–62. Drafted by an Endocrine Society-appointed task force of experts and co-sponsored by the European Society of Endocrinology and The Obesity Society, this publication is the first clinical practice guidelines for the pharmacologic management of obesity.CrossRefPubMedGoogle Scholar
  7. 7.
    Igel LI, Kumar RB, Saunders KH, Aronne LJ. Practical use of pharmacotherapy for obesity. Gastroenterology. 2017;152(7):1765–79.CrossRefPubMedGoogle Scholar
  8. 8.
    Thomas CE, Mauer EA, Shukla AP, Rathi S, Aronne LJ. Low adoption of weight loss medications: a comparison of prescribing patterns of antiobesity pharmacotherapies and SGLT2s. Obesity (Silver Spring). 2016;24:1955–61.CrossRefGoogle Scholar
  9. 9.
    Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;8:CD003641.Google Scholar
  10. 10.
    Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012. JAMA Surg. 2014;149(3):275–87.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Courcoulas A, Abu Dayyeh BK, Eaton L, Robinson J, Woodman G, Fusco M, et al. Intragastric balloon as an adjunct to lifestyle intervention: a randomized controlled trial. Int J Obes. 2017;41(3):427–33.CrossRefGoogle Scholar
  12. 12.
    U.S. Food and Drug Administration. ORBERA™ Intragastric Balloon System - P140008. Available at: https://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ucm457416.htm. Accessed December 10, 2017.
  13. 13.
    Ponce J, Woodman G, Swain J, Wilson E, English W, Ikramuddin S, et al. The REDUCE pivotal trial: a prospective, randomized controlled pivotal trial of a dual intragastric balloon for the treatment of obesity. Surg Obes Relat Dis. 2015;11(4):874–81.CrossRefPubMedGoogle Scholar
  14. 14.
    U.S. Food and Drug Administration. ReShape Integrated Dual Balloon System - P140012. Available at: https://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ucm456293.htm. Accessed December 10, 2017.
  15. 15.
    Sullivan S, Swain JM, Woodman G, Edmundowicz S, Hassanein TI, Shayani V, et al. The obalon swallowable 6-month balloon system is more effective than moderate intensity lifestyle therapy alone: results from a 6-month randomized sham controlled trial. Gastroenterology. 2016;150(4 Suppl 1):S1267.CrossRefGoogle Scholar
  16. 16.
    U.S. Food and Drug Administration. Obalon Balloon System - P160001. Available at: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm520741.htm. Accessed December 10, 2017.
  17. 17.
    Thompson CC, Abu Dayyeh BK, Kushner K, et al. The AspireAssist is an effective tool in the treatment of class II and class III obesity: results of a one-year clinical trial. Gastroenterology. 2016;4(Suppl 1):S86.CrossRefGoogle Scholar
  18. 18.
    Ikramuddin S, Blackstone RP, Brancatisano A, Toouli J, Shah SN, Wolfe BM, et al. Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial. JAMA. 2014;312(9):915–22.CrossRefPubMedGoogle Scholar
  19. 19.
    Gleysteen JJ. A history of intragastric balloons. Surg Obes Relat Dis. 2016;12(2):430–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Benjamin SB, Maher KA, Cattau EL Jr, et al. Double-blind controlled trial of the Garren-Edwards gastric bubble: an adjunctive treatment for exogenous obesity. Gastroenterology. 1988;95(3):581–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Lindor KD, Hughes RW Jr, Ilstrup DM, et al. Intragastric balloons in comparison with standard therapy for obesity—a randomized, double-blind trial. Mayo Clin Proc. 1987;62(11):992–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Fomez V, Woodman G, Abu Dayyeh BK. Delayed gastric emptying as a proposed mechanism of action during intragastric balloon therapy: results of a prospective study. Obesity. 2016;24(9):1849–53.CrossRefGoogle Scholar
  23. 23.
    Kumar N, Sullivan S, Thompson CC. The role of endoscopic therapy in obesity management: intragastric balloons and aspiration therapy. Diabetes Metab Syndr Obes. 2017;10:311–6.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Kotzampassi K, Grosomanidis V, Papakostas P, Penna S, Eleftheriadis E. 500 intragastric balloons: what happens 5 years thereafter? Obes Surg. 2012;22(6):896–903.CrossRefPubMedGoogle Scholar
  25. 25.
    Dumonceau JM, Francios E, Hittelet A, et al. Single vs repeated treatment with the intragastric balloon: a 5-year weight loss study. Obes Surg. 2010;20(6):692–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Lopez-Nava G, Rubio MA, Prados S, Pastor G, Cruz MR, Companioni E, et al. BioEnterics® intragastric balloon (BIB®). Single ambulatory center Spanish experience with 714 consecutive patients treated with one or two consecutive balloons. Obes Surg. 2011;21(1):5–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Genco A, Cipriano M, Bacci V, Maselli R, Paone E, Lorenzo M, et al. Intragastric balloon followed by diet vs intragastric balloon followed by another balloon a prospective study on 100 patients. Obes Surg. 2010;20(11):1496–500.CrossRefPubMedGoogle Scholar
  28. 28.
    Bariatric Endoscopy Task Force ASGE, Technology Committee ASGE, Abu Dayeh BK, Kumar N, et al. ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. Gastrointest Endosc. 2015;82(3):425–38.CrossRefGoogle Scholar
  29. 29.
    Genco A, Lopez-Nava G, Wahlen C, et al. Multi-center European experience with intragastric balloon in overweight populations: 13 years of experience. Obes Surg. 2013;23(4):515–21.CrossRefPubMedGoogle Scholar
  30. 30.
    Lopez-Nava G, Bautista-Castano I, Jimenez-Banos A, et al. Dual intragastric balloon: single ambulatory center Spanish experience with 60 patients in endoscopic weight loss management. Obes Surg. 2015;25(12):2263–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Mion F, Ibrahim M, Marjoux S, Ponchon T, Dugardeyn S, Roman S, et al. Swallowable Obalon® gastric balloons as an aid for weight loss: a pilot feasibility study. Obes Surg. 2013;23(5):730–3.CrossRefPubMedGoogle Scholar
  32. 32.
    Machytka E, Gaur S, Chuttani R, Bojkova M, Kupka T, Buzga M, et al. Elipse, the first procedureless gastric balloon for weight loss: a prospective, observational, open-label, multicenter study. Endoscopy. 2017;49(2):154–60.PubMedGoogle Scholar
  33. 33.
    Raftopoulos I, Giannakou A. The Elipse balloon, a swallowable gastric balloon for weight loss not requiring sedation, anesthesia or endoscopy: a pilot study with 12-month outcomes. Surg Obes Relat Dis. 2017;13(7):1174–82.CrossRefPubMedGoogle Scholar
  34. 34.
    Al-Subaie S, Al-Barjas H, Al-Sabah S, Al-Helal S, Alfakharani A, Termos S. Laparoscopic management of a small bowel obstruction secondary to Elipse intragastric balloon migration: a case report. Int J Surg Case Rep. 2017;41:287–91.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Machytka E, Klvana P, Kombluth A, et al. Adjustable intragastric balloons: a 12-month pilot trial in endoscopic weight loss management. Obes Surg. 2011;21(10):1499–507.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Brooks J, Srivastava ED, Mathus-Vliegen EM. One-year adjustable intragastric balloons: results in 73 consecutive patients in the U.K. Obes Surg. 2014;24(5):813–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Sullivan S, Edmundowicz SA, Thompson CC. Endoscopic bariatric and metabolic therapies: new and emerging technologies. Gastroenterology. 2017;152(7):1791–801.CrossRefPubMedGoogle Scholar
  38. 38.
    Astrup A, Kristensen M, Gnessi L, et al. Oral administration of Gelesis100, a novel hydrogel, significantly decreases body weight in overweight and obese subjects. In: Program of the Joint Meeting of the International Congress of Endocrinology and the Endocrine Society, June 21–24, 2014; Chicago, IL, USA. Abstract #0897. Available at: http://www.gelesis.com/pdf/Astrup-FLOW-Endocrine-Society-2014.pdf. Accessed September 23, 2017.
  39. 39.
    Marinos G, Eliades C, Raman Muthusamy V, Greenway F. Weight loss and improved quality of life with a nonsurgical endoscopic treatment for obesity: clinical results from a 3- and 6-month study. Surg Obes Relat Dis. 2014;10(5):929–34.CrossRefPubMedGoogle Scholar
  40. 40.
    National Institute of Health U.S. National Library of Medicine. ENDObesity® II Study: TransPyloric Shuttle® System for Weight Loss. Available at: https://clinicaltrials.gov/ct2/show/NCT02518685. Accessed December 10, 2017.
  41. 41.
    Sharaiha RZ, Kedia P, Kumta N, DeFilippis E, Gaidhane M, Shukla A, et al. Initial experience with endoscopic sleeve gastroplasty: technical success and reproducibility in the bariatric population. Endoscopy. 2015;47(2):164–6.PubMedGoogle Scholar
  42. 42.
    Kumbhari V, Hill C, Sullivan S. Bariatric endoscopy: state-of-the-art. Curr Opin Gastroentol. 2017;33(5):358–65.CrossRefGoogle Scholar
  43. 43.
    Kumta NA, Doshi R, Aronne LJ, Sharaiha RZ. Trimming the fat: endoscopic suturing for tightening of prior endoscopic sleeve gastroplasty. Gastroinest Endosc. 2017;85(1):253–4.CrossRefGoogle Scholar
  44. 44.
    Abu Dayyeh BK, Acosta A, Camilleri M, Mundi MS, Rajan E, Topazian MD, et al. Endoscopic sleeve gastroplasty alters gastric physiology and induces loss of body weight in obese individuals. Clin Gastroenterol Hepatol. 2017;15(1):37–43.CrossRefPubMedGoogle Scholar
  45. 45.
    Sharaiha RZ, Kumta NA, Saumoy M, Desai AP, Sarkisian AM, Benevenuto A, et al. Endoscopic sleeve gastroplasty significantly reduced body mass index and metabolic complications in obese patients. Clin Gastroenterol Hepatol. 2017;15(4):504–10.CrossRefPubMedGoogle Scholar
  46. 46.
    Lopez-Nava G, Galvao MP, Bautista-Castano I, et al. Endoscopic sleeve gastroplasty: how I do it? Obes Surg. 2015;25(8):1534–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Lopez-Nava G, Galvao M, Bautista-Castano I, et al. Endoscopc sleeve gastroplasty with 1-year follow-up: factors predictive of success. Endosc Int Open. 2016;4(2):E222–7.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Lopez-Nava G, Sharaiha RZ, Vargas EJ, et al. Endoscopic sleeve gastroplasty for obesity: a multicenter study of 248 patients with 24 months follow-up. Obes Surg. 2017.Google Scholar
  49. 49.
    Lopez Nava G, Baustista Gastano I, Fernandez-Corbelle JP, et al. Endoscopic sleeve gastroplasty (the Apollo method): a new approach to obesity managmenet. Rev Esp Enferm Dig. 2016;108(4):201–6.Google Scholar
  50. 50.
    Lopez-Nava G, Galvao MP, da Bautista-Castano I, et al. Endoscopic sleeve gastroplasty for the treatment of obesity. Endoscopy. 2015;47(5):449–52.PubMedGoogle Scholar
  51. 51.
    Espinos JC, Turro R, Moragas G, et al. Gastrointestinal physiological changes and their relationship to weight loss following the POSE procedure. Obes Surg. 2016;26(5):1081–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Lopez-Nava G, Bautista-Castano I, Jimenez A, et al. The Primary Obesity Surgery Endoluminal (POSE) procedure: one-year patient weight loss and safety outcomes. Surg Obes Relat Dis. 2015;11(4):861–5.CrossRefPubMedGoogle Scholar
  53. 53.
    Espinos JC, Turro R, Mata A, et al. Early experience with the Incisionless Operating Platform (IOP) for the treatment of obesity: the Primary Obesity Surgery Endolumenal (POSE) procedure. Obes Surg. 2013;23(9):1375–83.CrossRefPubMedGoogle Scholar
  54. 54.
    Miller K, Turro R, Greve JW, et al. MILEPOST multicenter randomized controlled trial: 12-month weight loss and satiety outcomes after POSE SM vs. medical therapy. Obes Surg. 2017;27(2):310–22.CrossRefPubMedGoogle Scholar
  55. 55.
    Sullivan S, Swain JM, Woodman G, Antonetti M, de la Cruz-Muñoz N, Jonnalagadda SS, et al. Randomized sham-controlled trial evaluating efficacy and safety of endoscopic gastric plication for primary obesity: the essential trial. Obesity. 2017;25(2):294–301.CrossRefPubMedGoogle Scholar
  56. 56.
    Hill C, Khashab MA, Kalloo AN et al. Endoluminal weight loss and metabolic therapies: current and future techniques. Ann N Y Acad Sci 2017.Google Scholar
  57. 57.
    Junior AC, Savassi-Rocha PR, Coelho LG, et al. Botulinum a toxin injected into the gastric wall for the treatment of class III obesity: a pilot study. Obes Surg. 2006;16(3):335–43.CrossRefPubMedGoogle Scholar
  58. 58.
    Albani G, Petroni ML, Mauro A, Liuzzi A, Lezzi G, Verti B, et al. Safety and efficacy of therapy with botulinum toxin in obesity: a pilot study. J Gastroenterol. 2005;40(8):833–5.CrossRefPubMedGoogle Scholar
  59. 59.
    Garcia-Compean D, Mendoza-Fuerte E, Martinez JA, et al. Endoscopic injection of botulinum toxin in the gastric antrum for the treatment of obesity. Results of a pilot study. Gastroenterol Clin Biol. 2005;29(8–9):789–91.CrossRefPubMedGoogle Scholar
  60. 60.
    Foschi D, Corsi F, Lazzaroni M, Sangaletti O, Riva P, la Tartara G, et al. Treatment of morbid obesity by intraparietogastric administration of botulinum toxin: a randomized, double-blind, controlled study. Int J Obes. 2007;31(4):707–12.CrossRefGoogle Scholar
  61. 61.
    Mittermair R, Keller C, Geibel J. Intragastric injection of botulinum toxin A for the treatment of obesity. Obes Surg. 2007;17(6):732–s.CrossRefPubMedGoogle Scholar
  62. 62.
    Topazian M, Camilleri M, Enders FT, Clain JE, Gleeson FC, Levy MJ, et al. Gastric antral injections of botulinum toxic delay gastric emptying but do not reduce body weight. Clin Gastroenterol Hepatol. 2013;11(2):145–50.CrossRefPubMedGoogle Scholar
  63. 63.
    Bang CS, Baik GH, Shin IS, Kim JB, Suk KT, Yoon JH, et al. Effect of intragastric injection of botulinum toxin A for the treatment of obesity: a meta-analysis and meta-regression. Gastrointest Endosc. 2015;81(5):1141–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Bustamante F, Brunaldi VO, Bernardo WM, de Moura DTH, de Moura ETH, Galvão M, et al. Obesity treatment with botulinum toxin—a is not effective: a systemtic review and meta analysis. Obes Surg. 2017;27:2716–23.CrossRefPubMedGoogle Scholar
  65. 65.
    Vilarrasa N, de Gordejuela AG, Casajoana A, et al. Endobarrier® in grade I obese patients with long-standing type 2 diabetes: role of gastrointestinal hormones in glucose metabolism. Obes Surg. 2017;27(3):569–77.CrossRefPubMedGoogle Scholar
  66. 66.
    Koehestanie P, Dogan K, Berends F, Janssen I, Wahab P, Groenen M, et al. Duodenal-jejunal bypass liner implantation provokes rapid weight loss and improved glycemic control, accompanied by elevated fasting ghrelin levels. Endosc Int Open. 2014;2(1):E21–7.CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Abu Dayyeh BK, Kumar N, Edmundowicz SA, et al. ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. Gastrointest Endosc. 2015;82(3):425–38.e5.CrossRefPubMedGoogle Scholar
  68. 68.
    Rohde U, Hedbäck N, Gluud LL, Vilsbøll T, Knop FK. Effect of the EndoBarrier Gastrointestinal Liner on obesity and type 2 diabetes: a systematic review and meta-analysis. Diabetes Obes Metab. 2016;18(3):300–5.CrossRefPubMedGoogle Scholar
  69. 69.
    Sandler BJ, Rumbaut R, Swain CP, et al. Human experience with an endoluminal, endoscopic, gastrojejunal bypass sleeve. Surg Endosc. 2011;25(9):3028–33.CrossRefPubMedGoogle Scholar
  70. 70.
    Sandler BJ, Rumbaut R, Swain CP, Torres G, Morales L, Gonzales L, et al. One-year human experience with a novel endoluminal, endoscopic gastric bypass sleeve for morbid obesity. Surg Endosc. 2015;29(11):3298–303.CrossRefPubMedGoogle Scholar
  71. 71.
    Machytka E, Bužga M, Zonca P, Lautz DB, Ryou M, Simonson DC, et al. Partial jejunal diversion using an incisionless magnetic anastomosis system: 1-year interim results in patients with obesity and diabetes. Gastrointest Endosc. 2017;86(5):904–12.CrossRefPubMedGoogle Scholar
  72. 72.
    Rajagopalan H, Cherrington AD, Thompson CC, Kaplan LM, Rubino F, Mingrone G, et al. Endoscopic duodenal mucosal resurfacing for the treatment of type 2 diabetes: 6-month interim analysis from the first-in-human proof-of-concept study. Diabetes Care. 2016;39(12):2254–61.CrossRefPubMedGoogle Scholar
  73. 73.
    Apovian CM, Shah SN, Wolfe BM, Ikramuddin S, Miller CJ, Tweden KS, et al. Two-year outcomes of vagal nerve blocking (vBloc) for the treatment of obesity in the ReCharge trial. Obes Surg. 2017;27(1):169–76.CrossRefPubMedGoogle Scholar
  74. 74.
    Boi SK, Moore JX, Royston KJ, Demark-Wahnefried W. Letter to the editor: vagal blocking (vBloc) therapy: a new era of clinical therapy for extreme obesity : re: Apovian et al. two-year outcomes of vagal nerve blocking (vBloc) for the treatment of obesity in the ReCharge trial. Obesity surgery. 2016. Obes Surg. 2017;27(2):483–4.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Stanford FC, Alfaris N, Gomez G, Ricks ET, Shukla AP, Corey KE, et al. The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: a multi-center study. Surg Obes Relat Dis. 2017;13(3):491–500.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Katherine H. Saunders
    • 1
  • Leon I. Igel
    • 1
  • Monica Saumoy
    • 2
  • Reem Z. Sharaiha
    • 2
  • Louis J. Aronne
    • 1
  1. 1.Comprehensive Weight Control Center, Division of Endocrinology, Diabetes and MetabolismWeill Cornell MedicineNew YorkUSA
  2. 2.Divison of Gastroenterology and HepatologyWeill Cornell MedicineNew YorkUSA

Personalised recommendations