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Page 2 of 13 Castro et al. Mini-invasive Surg 2020;4:47 I http://dx.doi.org/10.20517/2574-1225.2020.14

Table 1. Summary of different areas of bariatric endoscopy innovation
Primary procedures Management of complications Management of concomitant conditions
Intragastric balloons Orbera Leaks Septotomy Achalasia POEM
Reshape Double-pigtail stent
Obalon Endoscopic vacuum therapy
Aspiration therapy AspireAssist system Weight TORe Gastroparesis POP
regain ROSE
Endoluminal bypass Duodeno-jejunal bypass sleeve Cholelithiasis EDGE procedure
liners Gastro-duodenal bypass liner
Transpyloric shuttle
Magnetic compression Incisionless magnetic
gastrojejunostomy anastomosis system
Mucosal resurfacing for diabetes
Endoscopic sleeve OverStitch
gastroplasty
TORe: transoral outlet reduction; POEM: per-oral endoscopy myotomy; POP: per-oral pyloromyotomy; EDGE: endoscopic ultrasound-
guided transgastric endoscopic retrograde cholangiopancreatography; ROSE: restorative obesity surgery, endolumenal

[2]
remains the most effective treatment for sustained weight loss and improvement of comorbidities . The
American Society for Metabolic and Bariatric Surgery (ASMBS) reported 252,000 bariatric surgeries
[3]
performed in 2018, an increase of 24,000 cases as compared to 2017 . The steady increase of bariatric
[4]
procedures each year has led to room for innovation. Angrisani et al. reported that 4% of bariatric
procedures corresponded to endoluminal procedures but this percentage may be underestimated.
Endoscopy has become an important tool for evaluation, diagnosis, management of complications,
and even as primary bariatric interventions. Besides gastrointestinal specialists, advanced endoscopic
procedures can be additionally performed by bariatric surgeons who have the knowledge and skills to
perform them. Nonetheless, it is important to emphasize that management of these patients must be done
in a multidisciplinary approach with enough expertise to handle these cases, which includes participation
of both the bariatric and gastrointestinal specialists.

Endoscopy can be applied in various ways in bariatrics, including preoperative evaluation to study
the anatomy, preoperative planning for revisions, intraoperative management to address inadvertent
technical errors, postoperative management for complications, primary bariatric procedures, among
other applications. With the evolution of minimally invasive techniques, endoscopy stands as an attractive
alternative for the management of obesity. Bariatric endoscopy is an essential tool in the armamentarium of
surgeons dedicated to the management of morbid obesity. These less-invasive endoscopic techniques serve
as a promising alternative for the management of bariatric patients.

PRIMARY PROCEDURES
Bariatric surgery stands as the most effective therapy for sustained weight loss and improvement of
[5,6]
comorbidities . The ever-rising epidemic of obesity has led physicians to develop non-surgical alternatives
for the management of these patients. Endoscopic management of obese patients has several benefits over
bariatric surgery such as the less-invasive nature of the procedures and fewer complications. A summary
of available endoscopic therapies can be found in Table 1. Additionally, endoscopic techniques give the
opportunity to patients who are not eligible for surgery or who prefer a less-invasive approach.

Intragastric balloons
Intragastric balloons (IGB) were first used in 1982 with the purpose of inducing a sense of satiety by a
space-occupying device . Various types of IGB have been developed; however, only three of them are
[7]
[8]
FDA approved, the Orbera, ReShape, and the Obalon IGB . The most common intragastric balloon used
worldwide is the Bioenterics Intragastric Balloon which is made of silicone-based material and filled with