Medical and endoscopic weight management in Sydney

Why a gastroenterologist

Several of the conditions seen in this clinic are driven by weight and improve when weight improves. Fatty liver disease is the clearest example, where weight loss is the treatment that changes the course of the disease. Reflux and Barrett's oesophagus, gallstones and sleep-disordered breathing all follow weight in the same direction. Cancer Council Australia lists bowel cancer among the cancers whose risk rises with overweight and obesity.

The other reason is practical. Endoscopic weight procedures are done through a gastroscope, the complications that matter are gastrointestinal, and the medicines most often used affect the gut and change how an endoscopy has to be planned. That work belongs with someone who does endoscopy anyway.

What the assessment covers

The first consultation is a medical one, not a sales appointment. It covers:

• weight history: what has been tried, what worked, what happened afterwards
• medical conditions that affect weight or are affected by it, including diabetes, blood pressure, sleep apnoea, fatty liver and joint disease
• medicines that make weight loss harder
• previous abdominal or bariatric surgery and any swallowing problems, reflux, hiatus hernia or ulcers
• eating patterns, alcohol, sleep, shift work and activity
• mood and disordered eating, because a weight program is not the right first step for everyone
• blood tests, including thyroid function, liver tests, HbA1c and lipids
• what you want from treatment and what is realistic

Some people leave that appointment with a plan that involves no procedure and no medicine at all.

The options

Diet, activity and behavioural support

This sits underneath everything else. It means a dietitian rather than a diet, resistance exercise as well as walking, so that muscle is kept while fat is lost, and support for the habits that decide whether a change lasts. An exercise physiologist or trainer is often part of it.

Medicines

Medicines that act on the gut-brain appetite pathways, including the GLP-1 receptor agonists, have changed what medical weight management can do. Whether one is appropriate, which one and for how long, is a decision made in consultation and reviewed regularly. Australian law does not allow prescription medicines to be advertised to the public, so they are not described in any detail here. That conversation belongs in the consulting room.

Endoscopic treatment: the intragastric balloon

A balloon occupies part of the stomach, so that meals feel filling sooner. Depending on the device it is either placed through a gastroscope under sedation or swallowed as a capsule that is filled with fluid once it is in the stomach and needs no sedation at all. It stays in place for a set period, then is removed endoscopically or passes naturally, again depending on the device. The systems used in Australia include the Allurion and Orbera balloons.

Surgery

Bariatric surgery is a different order of treatment, and for some people it is the right one. Where that is the case, the referral goes to a bariatric surgeon, and the gastrointestinal follow-up can stay here.

What a balloon course involves

The device is one part of a program that runs for months. In broad terms:

• Before: assessment, blood tests and a discussion of what the months ahead look like. A gastroscopy may be needed first to check the stomach.
• Placement: either a short gastroscopy under sedation or a swallowed capsule with position confirmed before it is filled. Most people go home the same day.
• The first week: nausea, cramping and vomiting are common while the stomach adjusts, and medication is prescribed for it. A small number of people do not settle and the device has to be removed early.
• The months that follow: a staged diet, regular review with the dietitian, and the exercise and behavioural work that decide what happens after the device is gone.
• Afterwards: the balloon is removed or passes, and the plan shifts to holding the change. This is the part that matters most and the part most often skipped.

A balloon is not a substitute for that work and it is not suitable for everyone. It is generally not used where there is a large hiatus hernia, active ulceration, previous gastric surgery, untreated severe reflux, a bleeding disorder or pregnancy. Results differ between people. What any one person can expect is a conversation at a consultation, not a figure on a website.

What are the risks

• Nausea, vomiting and cramping in the first days, sometimes enough to need fluids or early removal
• Reflux, which can be new or worse than before
• Deflation of the device, and rarely migration causing bowel obstruction, which needs urgent treatment
• Gastric ulceration
• Rarely, perforation or pancreatitis
• The usual risks of gastroscopy and sedation where the device is placed or removed endoscopically

Persistent vomiting, severe abdominal pain, black stools or inability to keep fluids down are reasons to phone the rooms the same day or to attend an emergency department if severe.

If you are already taking a weight or diabetes medicine

Two practical points come up constantly.

The first is the gut side of treatment. Nausea, reflux, constipation and a sense of food sitting in the stomach are common on GLP-1 receptor agonists and are worth assessing rather than enduring, because some of them have other causes.

The second is endoscopy. These medicines slow gastric emptying, and food can remain in the stomach despite ordinary fasting, which matters for sedation. Anyone taking one who is booked for a colonoscopy or gastroscopy is asked to take clear fluids only for 24 hours beforehand and nothing by mouth for six hours. Tell the rooms you are taking one when the procedure is booked.

The team and where it happens

Medical weight management is done through Healthy Weight Australia, a multidisciplinary weight management service where the medical, dietetic and behavioural sides sit in one place. Endoscopic procedures are done at accredited day surgery and private hospital facilities, and consultations are at the usual rooms.

Fees depend on what is involved, and endoscopic weight procedures are not covered by Medicare in the way diagnostic endoscopy is. There is more on how billing works on the fees and rebates page, and the rooms will give you a written estimate before anything is booked.

Where weight management is provided in Sydney

A/Prof Viraj Kariyawasam is a consultant gastroenterologist and hepatologist. Medical and endoscopic weight management is assessed at consultation in Norwest, Rouse Hill, Pennant Hills and Macquarie Park.

The intragastric balloon is placed endoscopically at Norwest Private Hospital, Macquarie University Hospital and Pennant Hills Day Surgery. A referral from your GP is needed for a consultation.