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Endoscopic suturing has been described in many applications, including the approximation of tissue defects, anchoring stents, hemostasis, and primary and secondary bariatric interventions. Primary endobariatric procedures use endoscopic suturing for gastric remodeling with the intention of weight loss. Currently, the only commercially available device in the United States is the OverStitch endoscopic suturing system (Apollo Endosurgery). We describe devices of potential that are currently in design and/or trials as devices for weight loss by gastric remodeling, including USGI incisionless operating platform used for the primary obesity surgery endoluminal 2.0 procedure, Endomina used for the Endomina endoscopic sleeve gastroplasty, and EndoZip.

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With the growing global burden of obesity, the field of endobariatrics has emerged as a promising alternative, filling the void between lifestyle interventions with modest efficacy and more invasive surgical procedures. This article explores the latest advancements in endobariatric therapies, encompassing endoscopic sleeve gastroplasty (ESG), intragastric balloons (IGB), endoscopic metabolic therapies, and promising pharmacologic and surgical combination approaches that integrate multiple therapeutic modalities. It also outlines the critical factors and strategic considerations necessary for the successful integration of endobariatric interventions into clinical practice.

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The escalating obesity pandemic and its comorbidities necessitate adaptable and versatile treatment strategies. Endobariatric and metabolic therapies (EBMTs) can be strategically employed in a multipronged approach to obesity management, analogous to the way chess systems are employed to seize opportunities and thwart threats. In this review, we explore the spectrum of established and developing EBMTs, examining their efficacy in weight loss and metabolic improvement and their importance for a tailored, patient-centric approach. The complexity of obesity management mirrors the intricate nature of a chess game, with an array of tactics and strategies available to address the opponent's moves. Similarly, the bariatric endoscopist employs a range of EBMTs to alter the gastrointestinal tract landscape, targeting critical anatomical regions to modify physiological reactions to food consumption and nutrient assimilation. Gastric-focused EBMTs aim to reduce stomach capacity and induce satiety. Intestinal-focused EBMTs target hormonal regulation and nutrient absorption to improve metabolic profiles. EBMTs offer unique advantages of reversibility, adjustability and minimal invasiveness, allowing them to be used as primary treatments, adjuncts to pharmacotherapy or tools to address post-bariatric surgery weight recidivism. However, sub-optimal adoption of EBMTs due to lack of awareness, perceived costs and limited training opportunities hinders their integration into standard obesity management practices. By strategically integrating EBMTs into the broader landscape of obesity care, leveraging their unique advantages to enhance outcomes, clinicians can offer a more dynamic and personalized treatment paradigm. This approach, akin to employing chess systems to adapt to evolving challenges, allows for a comprehensive, patient-centric management of obesity as a chronic, complex and relapsing disease.

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PURPOSE OF REVIEW: The data on preventive measures for managing obesity prior to surgery is limited. This review highlights the role of stopgap measures for managing obesity before surgery. RECENT FINDINGS: Body weight regulation to achieve sustainable weight loss is a gradual process. Regular aerobic exercises, transformative yoga and restrained eating can contribute to a calorie deficit. Behavioural strategies aim to raise awareness, set goals, manage stress, and support adherence to healthier lifestyles. Pharmacotherapy can be adjunctive in inducing weight loss but could be better at maintaining weight. Intragastric balloon and endoscopic sleeve gastroplasty are restrictive procedures for patients before surgery. Obesity is a multifaceted chronic disease with adverse health consequences. There is a need to identify contributors to weight gain and treatment should target the cause of obesity. Utilize stop-gap measures and monitor progress for step-up or more intensive treatment. Structured weight loss needs lifelong commitment.

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The obesity epidemic in the USA and worldwide is well documented and continues to grow. Endoscopic metabolic and bariatric therapies may offer a less invasive approach than surgical intervention. This article will review advances in endobariatrics over the last several decades, addressing the past and current state of bariatric and metabolic endoscopy. Food and Drug Administration-cleared devices and interventions currently under investigation are described including gastric devices, gastric remodeling procedures, small-bowel devices, duodenal ablation, as well as procedures to address weight regain after bariatric surgery. Future studies evaluating gastric and duodenal combination therapy, adjunctive pharmacotherapy, as well as individualized precision-health algorithms are underway.

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BACKGROUND: Endoscopic sleeve gastroplasty (ESG) is an effective therapy for class I-II obesity, but there are knowledge gaps in the published literature about its implementation in patients with class III obesity [body mass index (BMI) ≥ 40 kg/m2]. AIM: To evaluate the safety, clinical efficacy, and durability of ESG in adults with class III obesity. METHODS: This was a retrospective cohort study that used prospectively collected data on adults with BMI ≥ 40 kg/m2 who underwent ESG and longitudinal lifestyle counseling at two centers with expertise in endobariatric therapies from May 2018-March 2022. The primary outcome was total body weight loss (TBWL) at 12 mo. Secondary outcomes included changes in TBWL, excess weight loss (EWL) and BMI at various time points up to 36 mo, clinical responder rates at 12 and 24 mo, and comorbidity improvement. Safety outcomes were reported through the study duration. One-way ANOVA test was performed with multiple Tukey pairwise comparisons for TBWL, EWL, and BMI over the study duration. RESULTS: 404 consecutive patients (78.5% female, mean age 42.9 years, mean BMI 44.8 ± 4.7 kg/m2) were enrolled. ESGs were performed using an average of 7 sutures, over 42 ± 9 min, and with 100% technical success. TBWL was 20.9 ± 6.2% at 12 mo, 20.5 ± 6.9% at 24 mo, and 20.3 ± 9.5% at 36 mo. EWL was 49.6 ± 15.1% at 12 mo, 49.4 ± 16.7% at 24 mo, and 47.1 ± 23.5% at 36 mo. There was no difference in TBWL at 12, 15, 24, and 36 mo from ESG. TBWL exceeding 10%, 15%, and 20% was achieved by 96.7%, 87.4%, and 55.6% of the cohort at 12 mo, respectively. Of the cohort with the relevant comorbidity at time of ESG, 66.1% had improvement in hypertension, 61.7% had improvement in type II diabetes, and 45.1% had improvement in hyperlipidemia over study duration. There was one instance of dehydration requiring hospitalization (0.2% serious adverse event rate). CONCLUSION: When combined with longitudinal nutritional support, ESG induces effective and durable weight loss in adults with class III obesity, with improvement in comorbidities and an acceptable safety profile.

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BACKGROUND: We conducted this study to compare the weight loss outcome of intragastric balloons (IGBs) in conjunction with pharmacotherapy vs IGB and intensive lifestyle changes alone. METHODS: This was a multicenter, non-randomized, retrospective study involving 4 academic hospitals. Patients underwent IGB placement with or without concomitant anti-obesity pharmacotherapy. The primary outcome was percent total weight loss (TBWL) after IGB placement at 6 and 12 months. RESULTS: This study included 102 patients, with 23 patients (mean age 46.6 years, 82.6% female) treated with IGB/pharmacotherapy and 79 patients (mean age 46.0 years, 88.6% female) treated with IGB/lifestyle modifications. Patients had a 100% follow-up rate at 6 and 12 months. At 6 months following IGB placement, both groups achieved a similar %TBWL. At 12 months, %TBWL was greater in the IGB/pharmacotherapy group (12.6% ± 1.2 vs 9.7% ± 0.7, P = .04). 65.2% of patients achieved ≥10% TBWL at 12 months in the IGB/pharmacotherapy group, compared to 38.0% in the IGB/lifestyle group (P < .05). The proportion of patients that achieved ≥15% weight loss at 12 months was also significantly different between the IGB/pharmacotherapy and IGB/lifestyle groups (30.4% vs 20.3%, P < .05). DISCUSSION: IGB with concomitant use of pharmacotherapy did not improve weight loss while the IGB was in place compared to IGB and lifestyle changes. However, patients receiving IGB with pharmacotherapy did have greater weight loss and diminished weight regain after balloon removal compared to those receiving just IGB and lifestyle changes.

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The gastrointestinal endoscopy paradigm is rapidly changing, and technological advancements are largely responsible. In tandem, anesthesia providers are adapting to the changing needs and demands. The challenges are unique. Complications arising from the procedures are both routine, such as aspiration and hypoxia, and procedure specific, such as bleeding, pneumothorax, pneumopericardium, and pneumoperitoneum. It is crucial for the anesthesia provider to have a good understanding of the techniques employed by the endoscopist. A higher index of suspicion is also essential to diagnose and appropriately manage many of the complications. In this review, an effort is made to discuss both procedural aspects and anesthesia challenges. We hope that both endoscopists and anesthesia providers will benefit from this review.

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PURPOSE OF REVIEW: Obesity is associated with multiple gastrointestinal and liver diseases such as gastroesophageal reflux disease, Barrett's esophagus, esophageal adenocarcinoma, cholelithiasis, colon polyps, and fatty liver disease. To effectively manage obesity, it is imperative to understand current and emerging therapies and procedures. FINDINGS: Obesity is becoming increasingly prevalent and is associated with a growing monetary health care burden. Cardiac disease, cerebrovascular disease, and diabetes are among the leading causes of preventable and premature death of Americans related to obesity. In addition to behavioral modification (diet and exercise) and bariatric surgery, multiple pharmacotherapies and endoscopic procedures are newly approved and available for the management of obesity. This paper reviews the current literature on the treatments available for the management of obesity including behavior modification, pharmacotherapy, endoscopic weight loss procedures (endobariatrics), and bariatric surgery.

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Although diet and exercise have been the cornerstone of therapy for obesity, efficacy is suboptimal and short lived. Surgical procedures are durable but invasive therapy for obesity. Supplemental therapies for obesity that are minimally invasive, low risk, and effective are needed. Several therapeutic options are being developed that offer obese patients and their health care providers alternatives to what is currently available.

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