The role of bariatric metabolic endoscopy in 2026 and beyond

The global burden of obesity continues to rise, with over one billion people affected worldwide. Obesity is a chronic, complex disease whereby excess adiposity leads to adverse health outcomes, and the associated metabolic dysfunction is closely linked to type 2 diabetes mellitus and other cardiometabolic complications. Incretin-based pharmacotherapies have transformed obesity management, but uncertainties remain regarding long-term durability, treatment adherence, weight regain after discontinuation and healthcare affordability. These challenges highlight the need for additional minimally invasive treatment strategies that bridge the gap between pharmacological interventions and bariatric surgery. Metabolic and bariatric endoscopy has emerged as an intermediary therapeutic domain, aiming to modulate gastrointestinal anatomy, nutrient flow and metabolic signalling through a range of endoscopic procedures and devices that are currently available or undergoing investigation. These approaches broadly target different components of the gut–metabolic axis, including gastric, small bowel and pancreatic pathways. In this narrative review, we summarise the current evidence across gastric-directed, small bowel-directed and pancreatic-directed endoscopic therapies and discuss their evolving position within the wider obesity treatment landscape. We then consider the trajectory of the field in the context of highly effective incretin-based pharmacotherapies and outline its potential role in the future of obesity care.