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Table 1. Summary of early lessons in assembling a bariatric endoscopy center
Institutional financial backing of the baratric center
Multidisciplinary team effort including gastroentrologist, bariatric surgeons, gastrointestinal radiologists, nurses, behavioral psychologists as well
as registered dieticians
Robust endoscopic training in numerous endoscopic tencniques with surgical backup on hand
Minimize barriers for short and long term follow up for procedural complications

currently reserved for patients with a BMI of 40 or greater or those with a BMI of 35 or greater with obesity
[4]
associated comorbid conditions. Only 1% of morbidly obese individuals undergo bariatric surgery . Some
factors related to this include patients fear of complications, financial constraints, and long term post-
[5]
bariatric surgery syndromes .

Over the past decade, this has paved the way for numerous innovations in endoscopic bariatric therapies.
These non-surgical therapies include intragastric balloons, endoscopic sleeve gastroplasty, gastrointestinal
[6]
bypass sleeves and aspiration devices as well as other novel devices . These minimally invasive therapies
can be used for patients who do not qualify or are unwilling to undergo bariatric surgery. Currently, there
is extremely limited formal training in bariatric endoscopy. In this commentary, we discuss our experience
in establishing a center for bariatric endoscopy at a large academic medical center.

STARTING A PROGRAM
Training and team
Creating an effective endo-bariatric center requires a truly interdisciplinary team effort [Table 1]. This
multidisciplinary team includes bariatric endoscopists (gastroenterologists in our center), bariatric
[7]
surgeons, gastrointestinal radiologists, nurses, behavioral psychologists as well as registered dieticians .
This team should have a comprehensive understanding of the pathophysiology of obesity in addition to the
mastery of endoluminal device and procedure specific knowledge with respect to the mechanism of action
and possible complications. A comprehensive and cohesive team allows for the successful utilization of the
different endoluminal therapies that may be appropriate for different patient sub-populations in achieving
long term weight loss. This is also helpful in the minimization and effective troubleshooting of post-
procedural complications that may arise.

While many endoscopic bariatric therapies are extensions of the current endoscopic skills gastroenterologist
use daily, a bariatric endoscopist should ideally be trained in many complex endoscopic techniques
including endoscopic suturing and luminal stenting. At our program we provide a strong foundation and
incorporate formal didactic lectures on primary obesity therapy management [i.e., intragastric balloon
(IGB), endoscopic sleeve gastroplasty (ESG)] as well as managing complications of bariatric surgery and
weight regain (transoral outlet revision). We also require a minimum of 10 h of wet lab training followed
by exposure to basic uses of endoscopic suturing (defect closure, stent fixation, fistula closure) of > 5
in number prior to assisting on their first ESG. Observing several ESG cases prior to trainees assisting
with a hands-on role is also critical. We additionally believe that the first independent 5 ESG cases be
proctored. While we do not have a set number of procedures trainees are required to complete, at present
they are exposed to approximately over 400 ERCP and 400 EUS procedures per year. Lastly, to help with
the implementation of bariatric endoscopy in clinical practice the American Society for Gastrointestinal
[8]
Endoscopy (ASGE) has published a position paper to help provide guidance on the effective utilization
of these therapies in clinical practice. It is important to recognize that this is just based on our early
experience, and training in bariatric endoscopy can vary at each institution, depending on the endoscopist’s
and center’s experience in training in bariatric endoscopy.

Equipment
Prior to starting a bariatric endoscopy program, it is essential to have all equipment that may be needed.
A successful bariatric endoscopy program should offer patients multiple treatment options. These include