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intra-gastric balloons, endoscopic sleeve gastroplasty (ESG) procedure as well as the ability to manage
post-bariatric surgery complications.

[9]
The endoscopic IGB was first proposed in the 1980s . The most used IGB is the Orbera IGB system
(Apollo Endosurgery, Inc., Austin, TX, USA). ESG is the most offered endoscopic irreversible bariatric
procedure. This procedure is performed with the use of an endoscopic suture system. The most widely
used and available system is the OverStitch system (Apollo Endosurgery, Inc., Austin, TX, USA). The
POSE procedure requires the incisionless operating platform (USGI Medical, Inc., San Clemente, CA,
USA) for performing the procedure. We suggest that it is essential to have the commitment of the division
and institutional leadership to provide financial support to have all available equipment prior to starting a
bariatric endoscopy program.

Process of setting up a team and patient recruitment
Optimal patient selection is crucial in optimizing clinical outcomes. Patients that are referred to our center
are usually BMI > 30 patients that are not candidates for bariatric surgery or a looking for minimally
invasive procedures due to fear of surgical complications or long term post-bariatric surgery syndromes.
All patients meet with our multidisciplinary team and undergo a comprehensive evaluation and education
regarding the different endoluminal therapies available tailoring for the patient’s ultimate goals. Lastly,
meeting with a dietitian before and after the procedure is crucial in educating patients of the long
lifestyle changes required to make durable long-lasting changes. Our program offers monthly nursing
and dietitian visits as part of our comprehensive 1-year care program. Establishing a self-pay price from
a large institution can take time and best to begin these conversations early with the administration with
value analysis planning. Lastly, given the need for more long-term data in patients underwent bariatric and
metabolic endoscopy, we also suggest developing infrastructure to carry out research studies.

TYPES OF PROGRAMS
Academic medical center vs. community practice
While a majority of the new bariatric and metabolic endoscopy therapies are being performed at large
tertiary referral academic medical centers, there has been a growing amount of these procedures being
performed in smaller community hospitals. Not only are some of these procedures technically feasible
in the outpatient setting such as endoscopic sleeve gastroplasty with similar procedure times, they also
[10]
have parallel clinical outcomes with respect to percentage of total and excess body weight loss . While
the clinical outcomes are similar, some challenges that community gastroenterologist will encounter in its
widespread implementation is the reluctance on the part of payors to cover new procedures mentioned
above as well as the infrastructure required. As the field of bariatric endoscopy continues to evolve and
more studies show durable clinical outcomes with favorable safety profiles, we will see increased adoption
of these procedures in the outpatient setting.

Training of the endoscopist
Given that there are limited formal bariatric endoscopy training programs available, the training of
[11]
endoscopist can be challenging . To undertake bariatric endoscopy as an integral part of your practice,
needs long-term commitment by the endoscopist and self-driven training. Prior to performing the first case
in a human, it is advisable to practice on mechanical and ex-vivo simulators. Animal laboratories can often
[10]
be set-up with the help of companies manufacturing endoscopic bariatric devices . In addition, there are
several courses sponsored by gastroenterological organizations such as the ASGE. After basic understanding
of bariatric endoscopic procedures and post-bariatric surgery anatomy is obtained, we suggest in-person
shadowing at a high-volume bariatric endoscopy center. This includes shadowing the bariatric endoscopist
in the office as well as during endoscopy. This allows first-hand experience of observing intra-procedural
challenges and trouble shooting. In addition, for programs starting their bariatric endoscopy training