LAUSR

The recent publication by Alsohaibani et al. [1] in your esteemed journal provided us with an incentive to express our concerns about the unexpected rise of publications related to new cases of acute pancreatitis (AP) after intragastric balloon (IGB) placement in obese individuals. More detailed, from 2008 to 2015, only six cases were reported, while from 2016 till today, there have been a further 20, including the 10 cases of the recent study from Saudi Arabia. Based on these, we are tempted to think that this exponential increase is rather a matter of fashion—Blet’s publish our case^—rather than a real need to inform the medical community of a serious complication. The abovementioned argument is reinforced by the fact that, from a total of 26 cases, the 16 come from Saudi Arabia, while the remaining 10 are from all over the world, including one from Brazil. How many balloons have been placed in Saudi Arabia to account for 16 cases of AP? And why are there no published cases, apart from one, from Brazil where at least 41,863 IGB had been placed by June 2016? Were there no other cases in Brazil? One can safely assume there were, especially since the related consensus about IGB guidelines and adverse effects explicitly and in detail states that BIGB removal is recommended by consensus in cases of moderate or severe pancreatitis; when pancreatitis is classified as mild, removal is not mandatory^ [2]. There is, apparently, significant experience of cases of AP of varying severity, and one could also assume that the appearance of post-IGB acute pancreatitis is an accidental event, whose incidence cannot be predicted. Likewise, such cases have been reported even after a diagnostic colonoscopy [3]. Furthermore, since the Brazilian consensus is that Bmild^ AP be regarded as a separate entity that does not require Bmandatory^ balloon removal [2], it should be stated here that, by analyzing 24 out of 26 cases of AP due to balloon pressure on the pancreas, only 7 were conservatively treated and one of them was eventually removed at a second time. On the other hand, from the data given by all authors about the severity of AP in their cases, 16 were classified as mild and 3 as moderate; for the remaining 5 (out of the 10 cases of the last publication) no such information is given. However, these authors reported that of the 10 cases, only one had a Bedside Index of Severity Acute Pancreatitis (BISAP) score 2, in which the IGB was removed, while in the remaining cases the score was 0 [1]. In regard to the etiology of AP induction, 24 were attributed by the authors to the direct pressure of the IGB on the soft pancreatic tissue. The other 2 cases were related to a Spatz adjustable balloon, the catheter of which was dislodged and impacted into the duodenum; these 2 cases will not be further discussed because the etiology of pancreatitis is different. This explanation of direct pressure on the pancreatic body or tail sounds reasonable at first reading, but the IGB is typically placed in the gastric fundus, which has no direct anatomic relation to the pancreas. So, it is difficult to see how a balloon mounted in the fundus exerts pressure on the pancreatic tail. It has been reported that in some cases, even at the time of insertion, the IGB does not remain in the fundus and slips to the antrum. In a series of 668 IGB, 509 were placed and Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-019-03973-7) contains supplementary material, which is available to authorized users.