In obesity with type 2 diabetes, duodenal-jejunal bypass liners improved weight loss and HbA1c during treatment

This randomized controlled trial (RCT) of 77 obese adults with type 2 diabetes found that adding an endoscopic duodenal–jejunal bypass liner (DJBL) to a dietary intervention improved weight loss and HbA1c after 6 months of treatment, but the benefit was not maintained 6 months after the DJBL was removed. The rate of adverse events (AEs) was 76% in the DJBL group, compared to 59% in the patients who received only the dietary intervention.

The study was published in the December 2014 Annals of Surgery. The following commentary by Lawrence J. Cheskin, MD, and Gerard E. Mullin, MD, was published in the ACP Journal Club section of the Feb. 17, 2015, Annals of Internal Medicine.

Clinicians caring for severely obese patients (with or without diabetes) have several management options, which vary in invasiveness, AEs, cost, and effectiveness. Unfortunately, long-term control of obesity remains poor.

To avoid some of the risks associated with surgery, as well as irreversible anatomical disruption, endoscopic procedures are being evaluated for approval by the US Food and Drug Administration. Endoscopic placement of a DJBL to impair macronutrient absorption and perhaps affect satiety is a newer technology that has not consistently shown strong efficacy for weight loss and has high rates of AEs. Koehestanie and colleagues report the results of a small RCT, which was supported by the manufacturer. Although the DJBL group had both statistically and clinically better weight loss and improved HbA1c levels than the diet-only group, the effect did not persist after the liner was removed at 6 months.

The effect of keeping the liner in place longer or replacing it periodically is unknown but is a potential safety concern given the relatively high rates of AEs reported in the study. Side effects affecting appetite may also be a reason for the observed weight reductions. Nonetheless, weight loss is important and should be assessed over a longer follow-up period to determine the true value of DJBLs as an adjunctive tool in obesity management.

Bariatric surgery can produce rapid improvements in diabetes and inflammatory markers within days after surgery. Favorable changes in gut-derived hormones and microbiota may account for these improvements and favor sustained weight control. On the other hand, placement of an artificial liner may foster formation of a pathogenic biofilm and disrupt gut-barrier function. A better understanding of the mechanisms for the long-term success of surgery will help to facilitate future design of endoscopically placed devices for improved weight regulation and diabetes control.