Duodenal-jejunal bypass liner for treatment of T2DM and obesity: 4-year outcomes in the first National Health Service (NHS) EndoBarrier service

Background and aims: EndoBarrier is a 60cm duodenal-jejunal bypass liner endoscopically implanted for up to one year and designed to mimic the bypass part of roux-en-Y bariatric surgery. There is uncertainty concerning the extent to which improvements associated with EndoBarrier treatment are sus-tained once the liner has been removed. We aimed therefore to establish an EndoBarrier service for refractory diabesity and to continue to monitor the people with diabetes after EndoBarrier removal. Methods: Between October 2014 and November 2017, we implanted 62 EndoBarriers in our NHS service. All had been removed by November 2018. Outcomes were monitored in a registry. Results: As of November 2021, all patients reached three years after EndoBarrier removal and of these 43/62 (69%) (mean +/- SD age 51.6 +/- 7.6 years, 55.8% male, 55.8% white ethnicity, median [IQR] diabetes duration 14.6 [8 - 21] years, 62.8% insulin-treated, mean +/- SD BMI 41.7 +/- 7.3 kg/m2) attended follow-up. In those who attended, during EndoBarrier implantation mean +/- SD HbA1c fell by 20.6 +/- 19.6 mmol/mol from 76.3 +/- 19.2 to 55.7 +/- 11.1 mmol/mol (p<0.001) (by 1.9 +/- 1.8% from 9.1 +/- 1.8% to 7.2 +/- 1.0% [p<0.001]), weight fell by 17.4 +/- 9.1 kg from 123.3 +/- 30.0 kg to 105.9 +/- 30.8 kg (p<0.001), BMI fell from 41.7 +/- 7.3 to 35.6 +/- 7.7 kg/m2 (p<0.001), systolic blood pressure from 138.7 +/- 14.4 to 125.4 +/- 14.7 mmHg (p<0.001), cholesterol from 4.6 +/- 1.0 to 3.7 +/- 0.7mmol/L (p<0.001), and serum alanine aminotransferase from 30.8 +/- 17.2 to 19.3 +/- 11.2 U/L (p<0.001). In those taking insulin median (IQR) total daily insulin dose reduced from 114 (54- 180) to 20 (0-65) units (n=27, p<0.001); 10/27 (37%) insulintreated people were able to discontinue insulin. Three years after EndoBarrier removal 33/43 (77%) maintained most of the improvement achieved with EndoBarrier whilst 10/43(23%) reverted to baseline. Of those deteriorating 9/10(90%) had depression and/or bereavement and/or major health problems/disability. 10/62(16%) required early EndoBarrier removal for adverse events or symptoms; all 10 fully recovered after removal and most derived significant benefit. Conclusions: Our data demonstrate that EndoBarrier is highly effective in people with refractory diabesity, with mainte-nance of significant improvement three years after removal in 77% of cases.