Endoscopic Intragastric Balloon Placement for Weight Loss in Liver Transplant Waitlist Candidates

The prevalence of obesity and non-alcoholic steatohepatitis (NASH) in the general population
is increasing. More and more patients with underlying NASH-related cirrhosis are now being
referred to transplant centers but are not candidates for a potentially lifesaving liver
transplantation due to their obesity and comorbidities related to the obesity.

The investigators proposed a clinical pilot study using the new FDA approved intragastric
balloon in obese patients (BMI >35) with cirrhosis in need of liver transplantation, to
assess weight loss and metabolic improvement.

The ORBERA™ Intragastric Balloon is an elastic spherical balloon made of silicone, filled
with 650ml of saline solution. The deflated balloon comes preloaded on a catheter, which is
advanced transorally into the stomach. An endoscope is then advanced alongside it to ensure
accurate placement of the balloon in the fundus. Under direct visualization, the balloon is
then inflated by injecting saline solution mixed with methylene blue through the external
portion of the catheter. The ORBERA™ Intragastric Balloon is implanted for 6 months and then
retrieved endoscopically by puncturing the balloon with a needle, emptying the fluid content,
and removing it through the mouth. Both placement and removal of the ORBERA™ Balloon are done
as an outpatient procedure with monitored or general anesthesia.

Inclusion Criteria:

- Adults with end-stage liver disease who are listed for liver transplant

- Have failed the non-invasive approach to weight loss to be actively listed for
transplant (requiring 2 clinical return visits without weight loss of >5 kg)

- Body Mass Index (BMI) >35

- Negative pregnancy test for females who are able to get pregnant and are of
child-bearing age

Exclusion Criteria:

- A previous history of gastric or bariatric surgery

- Current or recent (within 6 months) gastric or duodenal ulcers

- Moderate to severe Portal hypertension defined as portal gastropathy graded as >= to
moderate/severe, gastric varices, or esophageal varices graded > = moderate/large
(Patients with varices which have been obliterated may be included).

- Calculated Model of End-stage Liver Disease (MELD) score >25 or childs score >10

- The presence of more than one gastric balloon at the same time

- Any inflammatory disease of the gastrointestinal tract including esophagitis, gastric
ulceration, duodenal ulceration, cancer or specific inflammation such as Crohn's
disease.

- A large hiatal hernia or >5 cm hernia or ≤5 cm with associated severe or intractable
gastro-esophageal reflux symptoms.

- A structural abnormality in the esophagus or pharynx such as a stricture or
diverticulum that could impede passage of the delivery catheter and/or an endoscope.

- Achalasia or any other severe motility disorder that may pose a safety risk during
removal of the device.

- Gastric mass

- Severe coagulopathy

- Patients who are known to have or suspected to have an allergic reaction to materials
contained in ORBERA.

- Serious or uncontrolled psychiatric illness or disorder that could compromise patient
understanding of or compliance with follow up visits and removal of the device after 6
months.

- Alcoholism or drug addiction

- Patients who are unable or unwilling to take prescribed proton pump inhibitor
medication for the duration of the device implant

- Patients unwilling to participate in an established medically-supervised diet and
behavior modification program, with routine medical follow-up.

- Patients receiving aspirin, anti-inflammatory agents, anticoagulants or other gastric
irritants, not under medical supervision.