Primary endoscopic interventions in bariatric surgery

The global prevalence of obesity [body mass index (BMI) ≥ 30 kg/m2] was estimated to affect nearly 890 million adults in 2022, with increasing rates in both adults and children. While comprehensive lifestyle management (diet, exercise, behavioral modification) and pharmacotherapy are central to obesity treatment, metabolic bariatric surgery (MBS), such as sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), remains the most effective and durable approach for obesity and obesity-related comorbidities, including hypertension, type 2 diabetes, and cardiovascular disease. Despite its effectiveness, MBS is significantly underutilized due to multiple barriers such as the risk of surgery, access limitations, prohibitive social factors, the perceived need for surgery, and fear and beliefs about surgery. Endoscopic bariatric and metabolic therapies (EBMTs) have emerged as an alternative approach to address this gap. While EBMTs are less invasive and have fewer complications than MBS, they are also less effective, though more effective than lifestyle modifications and pharmacotherapy alone. EBMTs, including procedures that involve gastric volume reduction through gastric remodeling or space-occupying devices, malabsorption, or caloric intake reduction, are recommended by the American Society for Gastrointestinal Endoscopy (ASGE) and American Society of Metabolic and Bariatric Surgery (ASMBS) for patients who have not succeeded with lifestyle changes or medications, and as bridge therapies for patients who require weight loss for additional medical treatments. Although EBMTs do not replace bariatric surgery, they complement the existing treatment options, offering patients a less invasive pathway to weight loss and improved metabolic health. Reimbursement models for physicians and the associated financial cost of EBMTs may present inherent complexities. Nevertheless, the prospect of enhanced patient outcomes, substantial reductions in long-term healthcare costs, and expansion of insurance coverage to include these procedures collectively foster optimism for the wider integration of these innovative therapies into clinical practice.