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Page 2 of 20 Nwaiwu et al. Mini-invasive Surg. 2025;9:20 https://dx.doi.org/10.20517/2574-1225.2024.112
Keywords: Endoscopic bariatric and metabolic therapies, endoscopic sleeve gastroplasty, primary obesity surgery
endoluminal, intragastric balloons, incisionless magnetic anastomosis system, magnetic system

INTRODUCTION
The global prevalence of obesity [body mass index (BMI) ≥ 30 kg/m in most countries] was estimated to
2
affect nearly 890 million adults in 2022, with incidence rates continuing to rise in both adults and
children . Comprehensive lifestyle management (diet, exercise, behavioral modification) is a cornerstone of
[1]
obesity management, and pharmacotherapy has gained attention in recent years. However, metabolic
bariatric surgery (MBS), such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), has been
shown to be the most effective and durable therapy for obesity and obesity-related comorbidities (e.g.,
hypertension, type-2 diabetes, dyslipidemia, cardiovascular disease, obstructive sleep apnea) .
[2,3]

Despite a low risk of perioperative and postoperative mortality (0.08%-0.31%), MBS continues to be
underutilized. Among individuals with severe obesity (Class III) in the United States, only about 1 in 400
undergo bariatric surgery . Barriers to MBS may include the risk of major (4.3%) and overall adverse
[4]
[5,6]
outcomes (up to 17.3%) , limited access to bariatric surgeons, low referral rates, inadequate social support
systems, irreversibility of some surgeries, and the cost of surgery/lack of insurance, the perceived need for
[7,8]
surgery, as well as fear and beliefs about surgery . This creates a treatment gap in the obesity management.
Furthermore, there are patients who do not meet the BMI threshold for MBS and for whom lifestyle
modifications and pharmacotherapy have not been effective and, therefore, need a different treatment
modality.

Endoscopic interventions for bariatric surgery, also referred to as endoscopic bariatric and metabolic
therapies (EBMTs), offer an opportunity to fill this treatment gap created by non-interventional and
surgical alternatives. As adjunctive therapy, EBMTs have been shown to be more effective than lifestyle
modification and medications, but less effective than MBS. They also represent less invasive options with
lower incidence of complications, which may benefit patients who are not ideal candidates for MBS based
on their comorbidity burden.

The American Society for Gastrointestinal Endoscopy (ASGE) and American Society of Metabolic and
Bariatric Surgery (ASMBS) recommend EBMT for patients for whom lifestyle modification alone has not
resulted in weight loss or weight maintenance, those who meet the BMI criteria for EBMT (criteria may
vary for each therapy), and as bridge therapy for patients with medical conditions that require weight loss in
order to receive additional therapy. EBMT can be used in the primary and secondary management of
obesity. While most of these interventions involve the stomach, others involve the small intestine.

The mechanisms employed by EBMTs result in restriction (reduction of gastric volume by remodeling/
plication or implantation of space-occupying devices), malabsorption (intestinal bypass creation, mucosal
resurfacing, slowing of gastric emptying), or caloric intake reduction via aspiration [9,10] . EBMTs are not
meant to replace bariatric surgery but rather to complement the spectrum of available treatment options.

We categorize the primary endoscopic interventions discussed herein [Table 1] as:
1. Gastric remodeling/endoscopic suturing devices
2. Space-occupying devices
3. Absorption-limiting interventions
4. Others