Intragastric Balloon in Obese Adolescents With Comorbidities

After obtaining consent and determining that participants meet the inclusion and exclusion
criteria, participants will have baseline tests and initial visits with a physician,
dietitian, and psychologist. Next, the ORBERA™ Intragastric Balloon (IGB) will be inserted
into the stomach and then removed after 6 months. Participants will continue to be followed
for 6 months after the balloon is removed. Throughout the year, participants will have
additional tests along with ongoing visits with a physician, dietitian, and psychologist.

Inclusion Criteria:

BMI>35 kilogram per square meter (kg/m2) with one of the following severe comorbidities,
both for at least 2 years:

1. Type 2 diabetes mellitus

2. Moderate-to-severe sleep apnea

3. Pseudotumor cerebri

4. Nonalcoholic Steatohepatitis (NASH) based on fatty infiltration of the liver with
transaminitis that cannot be explained by other liver disease

Or,

BMI>40 kilogram per square meter (kg/m2) with two or more of the following mild
comorbidities, all for at least 2 years:

1. Hypertension

2. Dyslipidemia

3. Mild obstructive sleep apnea

4. Chronic venous insufficiency

5. Panniculitis

6. Urinary incontinence

7. Nonalcoholic Steatohepatitis (NASH)

8. Gastroesophageal reflux disease (GERD)

9. Arthropathies related to weight

In addition, all of the following inclusion criteria must be met. The subject must have:

1. attained approximately 95% of adult stature, as demonstrated by Tanner Stage IV or
more and growth charts demonstrating the taper/plateau of height as a marker for
achieving 95% of the subject's adult stature. Height will be measured by trained staff
to the nearest 0.1 cm using a stadiometer attached to a wall and documented in the
subject's electronic medical record (EMR). In the absence of previous growth charts,
skeletal maturity will be documented by a bone age of at least 13 years in girls and
15 years in boys; and

2. failed to attain a healthy weight with at least one experience with medically
supervised lifestyle changes, including physical activity and dietary interventions,
which will be clearly documented in the subject's medical record, and

3. demonstrated commitment to psychological evaluation perioperatively, in which the
pediatric psychologist with expertise in childhood obesity must confirm that the
subject has the maturity and stable psychosocial environment necessary for this
research study and has validated the Center for Epidemiology Study Depression (CES-D)
scale and Spence Children's Anxiety Scale (SCAS) surveys completed by the subject, and

4. agreed to avoid pregnancy for 1 year after intragastric balloon (IGB) placement
through abstinence or approved contraception (female subjects only), and

5. agreed to adhere to nutritional guidelines after intragastric balloon (IGB) placement,
as provided by weight management clinic dietitian, and

6. decisional capacity and desire to provide informed assent in conjunction with
parent/guardian consent, and willingness to comply with all study requirements, and

7. hypertension stage I: systolic blood pressure and/or diastolic blood pressure ≥ 95th
percentile, OR high normal blood pressure between the 90th and 95th percentile.

Exclusion Criteria:

Subjects will be excluded if:

1. they are pregnant or breastfeeding, or

2. there is any other disease, physical examination finding, or clinical laboratory
result that provides a reasonable suspicion of a disease or condition that
contraindicates the use of the investigational device or that may affect the
interpretation of the results or render the subject at high risk for treatment
complications, or

3. there is alcohol, tobacco, or substance use by the subject, or

4. in the opinion of the principal investigator (PI) and/or co-investigators, subject or
parent/guardian may be non-compliant with study schedules or procedures, or

5. there are any endoscopic contraindications, including large hiatal hernia (≥ 2 cm),
esophagitis of any degree, erosive gastritis, or ulceration of the stomach or
duodenum, or

6. Helicobacter pylori (H. pylori) is detected via a fecal antigen study prior to initial
endoscopic assessment (sensitivity > 96.8%); once treated, a repeat fecal antigen must
be performed to document eradication prior to the first endoscopic approach for
balloon placement, or

7. they have hypertension stage II > 99th percentile, unless they had a complete workup
to exclude secondary etiologies other than being overweight, or

8. Gastroesophageal reflux disease (GERD) subjects are on more than one medication or
have a history of erosive esophagitis due to gastroesophageal reflux disease (GERD),
or

9. they have dyslipidemia, if part of hereditary metabolic syndrome or genetic disorder,
or

10. they have any gastrointestinal disease that can result in stomach ulcerations, such as
Crohn's disease, celiac disease, eosinophilic esophagitis, acute or chronic
pancreatitis or gastrinoma, or

11. they have any endocrine disorders that affect metabolic status of the subjects, such
as hypo/hyperthyroidism, type 1 diabetes, Cushing's disease, or adrenal insufficiency,
as documented in the electronic medical record (EMR) through an evaluation by the
pediatric endocrinologist who will order additional testing if needed, or

12. they have prior gastrointestinal surgery with sequelae, i.e. obstruction, and/or
adhesive peritonitis or known abdominal adhesions and/or history of abdominal and/or
pelvic surgery which may cause adhesions (except one of the following: caesarean
section, diagnostic laparoscopy, laparoscopic appendectomy, laparoscopic
cholecystectomy performed 12 or more months prior to balloon implantation), or

13. they have prior open or laparoscopic bariatric surgery, or

14. they have prior surgery of any kind on the esophagus, stomach or any type of hiatal
hernia surgery, or

15. they have any inflammatory disease of the gastrointestinal tract including
esophagitis, Barrett's esophagus, cancer or specific inflammation such as Crohn's
disease, or

16. they have potential upper gastrointestinal bleeding conditions such as esophageal or
gastric varices, congenital or acquired intestinal telangiectasis, or other congenital
anomalies of the gastrointestinal tract such as atresias or stenoses, or,

17. they have a gastric mass, or

18. they have acid reflux symptoms to any degree that require more than one medication for
symptom control, or

19. they have a structural abnormality in the esophagus or pharynx such as a stricture or
diverticulum that could impede passage of the balloon alongside the endoscope, or

20. they have achalasia or any other severe esophageal motility disorder that may pose a
safety risk during the removal of the device, or

21. they have severe coagulopathy, or

22. they have poorly controlled diabetes, defined as having a Hemoglobin A1c (HgA1c) > 10,
or

23. they have serious health conditions unrelated to their weight that would increase the
risk of endoscopy, or

24. they have chronic abdominal pain, or

25. they have motility disorders of the gastrointestinal (GI) tract such as gross
esophageal motility disorders, gastroparesis, or intractable constipation, or

26. they have hepatic insufficiency or cirrhosis, or

27. they have serious or uncontrolled psychiatric illness or disorder that could
compromise their understanding of, or compliance with, follow-up visits and removal of
the device, or

28. they are receiving daily prescribed treatment with aspirin, anti-inflammatory agents,
anticoagulants or other gastric irritants, or

29. they are taking medications on specified hourly intervals that may be affected by
changes to gastric emptying, such as anti-seizure or anti-arrhythmic medications, or

30. they are taking corticosteroids, immunosuppressants, or narcotics, or

31. they are unable or unwilling to take prescribed proton pump inhibitor medication, or

32. they are known to have, or suspected to have, an allergic reaction to materials
contained in the system, or

33. they have ever developed a serotonin syndrome and are currently taking any drug known
to affect the levels of serotonin in the body (e.g. selective serotonin reuptake
inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase
inhibitors), or

34. they have a medically identifiable cause of obesity (specific diagnosed genetic or
hormonal case for obesity such as hypothyroidism or Prader Willi syndrome), or

35. they have known history of endocrine disorders affecting weight, or

36. they use any medications, except for Metformin, known to affect body weight and
carbohydrate or lipid metabolism, or

37. they used an intragastric device prior to this study, or

38. they participated in any clinical study which could affect weight loss within the past
6 months, or

39. they have symptomatic congestive heart failure or cardiac arrhythmia, or

40. they have a diagnosis of an autoimmune connective tissue disorder (e.g. lupus,
erythematous, scleroderma), or immunocompromised, or

41. they are on insulin for type 2 diabetes and not proficient in self-monitoring
capillary blood glucose testing.