Advances in Endoscopic Bariatric Therapies: Who Should Perform These?

Advances in Endoscopic Bariatric Therapies: Who Should Perform These?

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Abstract

Endoscopic bariatric and metabolic therapies (EBMTs) represent a rapidly advancing field that fills the treatment gap between lifestyle or pharmacological interventions and traditional bariatric surgery in the management of obesity. EBMTs encompass devices that are inserted or removed through flexible endoscopy as well as endoscopic procedures designed to achieve weight loss or treat obesity-related comorbidities [1] [2]. These therapies are minimally invasive and have consistently demonstrated clinically meaningful weight reduction in individuals with obesity. In addition, a growing body of evidence supports their beneficial impact on metabolic parameters and obesity-associated conditions.

As the clinical role of EBMTs continues to expand, important questions arise regarding the qualifications and training required to perform these procedures safely and effectively. This analysis examines the current landscape of EBMTs, including procedural techniques, safety outcomes, institutional frameworks, and practitioner training pathways. The available evidence indicates that successful integration of EBMTs into clinical practice requires a multidisciplinary approach that incorporates structured training, institutional support, and comprehensive patient care protocols [3].

Both gastroenterologists and bariatric surgeons have been shown to perform EBMTs safely when they receive appropriate training and operate within accredited centers that emphasize multidisciplinary collaboration. Optimal implementation also depends on robust institutional infrastructure, standardized credentialing processes, and ongoing outcome monitoring to ensure patient safety and long-term efficacy. Ultimately, the evolution of EBMTs highlights the importance of building specialized teams that combine technical expertise, coordinated care, and evidence-based practice to maximize benefits for patients with obesity.

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Introduction

The global obesity epidemic has reached unprecedented proportions, creating an urgent need for innovative therapeutic strategies that extend beyond conventional medical management and surgical interventions. Obesity, along with its associated comorbidities such as type 2 diabetes, cardiovascular disease, and nonalcoholic fatty liver disease, continues to rise worldwide, placing a major burden on healthcare systems. While lifestyle modification, pharmacologic therapy, and bariatric surgery remain central to obesity treatment, there is a growing population of patients who fall between these options. Many are either not eligible for surgery, decline operative interventions, or experience inadequate outcomes with medical therapy alone. This gap in care has fueled the development of endoscopic bariatric and metabolic therapies (EBMTs) [4].

EBMTs were originally designed to replicate the physiological benefits of bariatric surgery in a minimally invasive manner, providing a treatment pathway for patients who are not, or who choose not to be, surgical candidates. Over the past decade, the field has expanded rapidly. What began primarily as an endoscopic solution for managing weight regain following bariatric surgery has evolved into a diverse set of primary treatment options that complement or serve as alternatives to pharmacologic and surgical approaches [5] [6]. This evolution has been driven by advances in technology, improved safety and efficacy data, and an expanding range of clinical indications.

Today, EBMTs are increasingly recognized as a safe and effective option for selected patients with obesity, particularly those who do not qualify for bariatric surgery [7]. Early studies demonstrate favorable outcomes in terms of weight loss and metabolic improvement, with lower complication rates and reduced healthcare costs compared with surgery. However, the absence of randomized controlled trials directly comparing EBMTs with bariatric surgery highlights the need for further high-quality evidence to define their relative role in obesity management.

Alongside these clinical developments, the rapid adoption of EBMTs raises critical questions about the standards required to ensure their safe and effective implementation. The success of these therapies depends not only on technological innovation but also on the qualifications of practitioners, the quality of their training, and the institutional infrastructure supporting their practice. Unlike bariatric surgery, which has well-established training pathways and credentialing frameworks, EBMTs remain in the early stages of developing standardized requirements. Ensuring patient safety and optimizing outcomes will require clear guidelines regarding practitioner competencies, structured training programs, and institutional oversight [8].

This paper provides a comprehensive and objective analysis of the current evidence related to practitioner qualifications, training standards, and institutional frameworks for EBMTs. It also explores safety considerations, drawing on existing literature to highlight both the opportunities and challenges associated with integrating these therapies into mainstream obesity care. The central research question guiding this analysis is: What qualifications, training, and institutional support are necessary for practitioners to safely and effectively perform endoscopic bariatric and metabolic therapies?

 

Current Landscape of Endoscopic Bariatric Therapies

Types and Classifications of EBMT

EBMTs may be categorized in several ways. First, they may be divided based on the primary purpose of the procedure, which includes primary therapy, bridge therapy, revisional procedure, and management of complications of bariatric surgery. Depending on the anatomical location of the procedure, EBMTs may be categorized into gastric and small bowel therapies. When the complexity of the procedure is taken into account, EBMTs may be divided into level I procedures (less complex procedures that may be trained during the standard gastroenterology fellowship) and level II procedures (more complex procedures that require more advanced endoscopy training) [9].

EBMT has been categorized based on its therapeutic target (stomach or small intestine), but innovations have expanded to include extraintestinal organs including the pancreas [10] [11]. The current FDA-approved devices include 5 EBMT devices that are Food and Drug Administration (FDA)-approved for use in the United States. Of these 3 are intragastric balloons (IGBs)—the Orbera balloon (Apollo Endosurgery, Austin, TX), the ReShape Duo balloon (Reshape, San Clemente, CA), and the Obalon balloon (Obalon Therapeutics, Carlsbad, CA) [12].

Efficacy and Safety Profile

Many randomized controlled trials have been performed, including both open label and sham-controlled, which have demonstrated safety and efficacy of EBMT over lifestyle therapy alone. In addition, emerging evidence from clinical experience further supports EBMT for treatment of obesity [13]. Recent data indicates that interest in endoscopic bariatric techniques has increased over the years, as they have been shown to be efficacious, reversible, relatively safe, and cost effective. Further, these techniques offer a therapeutic window for some patients who may otherwise be unable to undergo bariatric surgery [14].

The safety profile of specific procedures has been well-documented. For endoscopic sleeve gastroplasty (ESG), the safety profile of ESG is consistently supported in the literature. Surgical complications after ESG, ranging from 1.5 to 2.3%, such as bleeding, perforation, fistula, or upper bowel obstruction, are rare and typically managed endoscopically [15].

Compared to traditional surgical therapies, endoscopic approaches may potentially speed recovery with decreased pain, incisional hernia development, and surgical site infections. Primary endoscopic bariatric procedures can be classified as space-occupying, restrictive, or bypass [16].

Current Utilization Trends

Recent data from the American Society for Metabolic and Bariatric Surgery shows significant growth in endoscopic procedures. Intragastric balloon placement increased from the previous year. Endoscopic sleeve gastroplasty increased in numbers [17], indicating growing adoption of these techniques alongside traditional bariatric surgery.

 

Training Requirements and Professional Guidelines

Current Training Standards

The question of who should perform endoscopic bariatric procedures has been addressed by professional societies through formal position statements. ABE/ASGE position statement on training and privileges for primary endoscopic bariatric therapies [18] provides guidance on appropriate training pathways and credentialing requirements.

Bariatric endoscopy is an emerging subspecialty for gastroenterologists encompassing a broad array of procedures including primary endoscopic bariatric and metabolic therapies and the treatment of complications of bariatric surgery. In addition, comprehensive understanding of lifestyle intervention and pharmacotherapy are essential to successful outcomes. This review summarizes goals and steps of training for this emerging field [19] [20].

Training Complexity and Requirements

The complexity of training varies based on procedure type. Previous questionnaire study of the bariatric endoscopy experts revealed that on average the trainee were able to independently perform TORe and primary bariatric endoscopic suturing cases after 15 and 22 supervised procedures, respectively [21]. However, there have been no objective tools to assess cognitive or technical aspects of bariatric endoscopy skills. Additionally, competency thresholds for EBMTs have not been formally established. Previous questionnaire study of the bariatric endoscopy experts revealed that on average the trainee were able to independently perform TORe and primary bariatric endoscopic suturing cases after 15 and 22 supervised procedures, respectively [22].

The training process should involve preparing trainees to be comfortable with both cognitive and technical aspects of bariatric endoscopy. To gain this well-rounded and comprehensive training experience, trainees should be exposed to patient care in outpatient clinical setting, ideally at a multidisciplinary environment, and during bariatric endoscopic cases. The cognitive aspects of bariatric endoscopy are critical [23].

Multidisciplinary Training Requirements

Lifestyle intervention and pharmacotherapy, which are essential components to training in bariatric endoscopy and obesity medicine, will not be covered in detail in this article. The training program should define specific goals for providing training and education in management of patients with obesity [24]. This highlights the broader educational requirements beyond technical procedural skills.

Trainees should be exposed to patients with obesity and its related comorbidities in a clinical setting. Knowledge on the mechanisms of how obesity occurs, including neurohormonal changes, gastrointestinal motility [25] represents essential cognitive competencies.

Simulation and Training Tools

Simulators for training in bariatric endoscopy are an emerging field. A mechanical endoscopic suturing simulator has recently been developed. The simulator allows the trainee to familiarize himself or herself with the endoscopic suturing device and to learn stitch placement to complete purse string TORe. Other simulators for training in EBMTs include an ex vivo model, which have been used at most hands-on sessions [26].

 

Practitioner Qualifications: Surgeon vs. Gastroenterologist

Historical Perspectives and Current Practice

The evolution of endoscopic bariatric procedures has involved practitioners from multiple specialties. Beyond the acute perioperative period, the most common complications of weight loss surgery relate to GI tract structure, function, and mucosal integrity. As a result, gastroenterologists have a major role in the management of patients undergoing these procedures [27] [28].

The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation [29] [30].

Practitioner Survey Data

Research examining practitioner perspectives reveals interesting patterns. Of the respondents, 69% had credentials to perform endoscopy and 52% performed endoscopic procedures regularly (average of ≥1–2/wk). For those who did not perform endoscopy, 91% referred their bariatric patients to a gastroenterologist for endoscopic procedures, and 9% referred their patients to another surgeon who performed endoscopy [31].

This data suggests a collaborative approach where bariatric surgeons recognize the value of endoscopic expertise, whether developed internally or through referral to gastroenterologists.

Complementary Skill Sets

Both gastroenterologists and surgeons bring unique advantages to endoscopic bariatric practice. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population [32] [33].

In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population [34] [35].

 

Institutional Requirements and Accreditation

Accreditation Standards for Bariatric Centers

The institutional framework supporting endoscopic bariatric procedures is critical for safety and outcomes. The American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) combined their bariatric surgery accreditation programs into the joint Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) in 2012. The newly formed MBSAQIP carries the original objectives of the two programs, including the improvement of the quality of bariatric services as well as enhancing of the use of a multidisciplinary approach to treat obese patients using unified standards [36].

The requirements for this designation entail structural and process reforms including the availability of appropriate surgical infrastructure and the ability to manage critical patients [37]. These requirements have demonstrated measurable impacts on outcomes.

Quality Improvement and Outcomes

The benefits of accreditation are well-documented. Thirty-day surgical (6%vs.2.9%,p < 0.01) and medical (3.4%vs.1.7%,p < 0.01) complications rates were reduced over the period 2007 through 2018. The proportion of patients who were discharged early continued to rise (9.8%vs.46.9%,p < 0.01) from 2007 to 2018. The MBSAQIP period was associated with reduced odds for 30-day surgical (OR = 0.86,CI = [0.81–0.91]) and medical (OR = 0.81,CI = [0.75–0.88]) complications [38] [39].

Common Deficiencies in Accreditation

Analysis of accreditation surveys reveals common areas requiring improvement. The results of this study demonstrate that nearly a quarter of centers seeking MBSAQIP accreditation had one or more standard deficiencies at the time of their site survey. Furthermore, the standards most often cited as deficient were typically related to quality improvement processes or data monitoring and reporting [40].

With the exception of Standard 3.1: Facilities, Equipment, and Instruments, the top 10 deficiencies corresponded to standards for Commitment to Quality Care, Continuous Quality. This study is first to describe common deficiencies that deny or delay accreditation of bariatric centers seeking to participate in MBSAQIP. In addition, the results of this study demonstrate that most centers required to complete corrective action were able to gain or maintain their accreditation, which exemplifies the role and utility of accreditation as a mechanism for continuously improving the provision of bariatric care [41].

Endoscopic-Specific Requirements

For endoscopic bariatric procedures specifically, institutional requirements extend beyond traditional surgical capabilities. Multidisciplinary care for patients undergoing ESG should be provided in an accredited center authorized to perform bariatric and metabolic surgery, with validation through a multidisciplinary consultation meeting (RCP). ESG must be performed by a practitioner trained in endoscopy and obesity management, capable of ensuring thorough preoperative care and comprehensive postoperative follow-up, supported by an experienced multidisciplinary team [42] [43].

 

Safety Considerations and Complication Management

Complication Rates and Types

Understanding the safety profile of endoscopic bariatric procedures is essential for determining appropriate practitioner requirements. Complications, although few, can be life threatening. One of the most dreaded acute complication is the anastomotic/staple line leak. If left undiagnosed or untreated they can lead to sepsis, multi organ failure, and death. Smaller or contained leaks can develop into fistulas [44].

However, specific endoscopic procedures have demonstrated excellent safety profiles. They are considered safe with low morbidity and mortality. Leaks and bleeding are early complications after surgery. Endoscopy plays an important role in the diagnostic and therapeutic management of these complications [45] [46].

Management of Complications

Bariatric surgery is recognized as the most effective treatment against obesity as it results in noteworthy weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention [47] [48] [49].

Advanced Endoscopic Techniques

Endoscopic suturing has come into clinical practice in recent years and represents a true revolution in the field of endoscopy. A commonly used device is the OverStitch™ (Apollo Endosurgery Inc, Texas, United States). Endoscopic sleeve gastroplasty is a novel technique that utilizes the endoscopic suturing to plicate the stomach as a primary bariatric procedure. Initial reports show that it produces efficacious weight loss but more large-scale international multi-center studies are required to understand the long-term efficacy. The evidence for use of this tool in managing complications of bariatric surgery is currently limited to small series [50].

 

Multidisciplinary Team Requirements

Essential Team Components

The complexity of obesity management necessitates a comprehensive team approach. Endoscopic bariatric therapies should be offered in conjunction with lifestyle modification and with nutritional guidance, as part of a multidisciplinary approach in obesity management. They require a formal training process for endoscopists and bariatric surgeons to obtain the endoscopic skills needed before performing these procedures [51] [52].

The treatment of patients with obesity is complex, and a multidisciplinary approach is essential. Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications, and therefore, must be part of the armamentarium in the fight against this disease [53].

Team Effectiveness and Outcomes

Research demonstrates the value of multidisciplinary approaches. Use of a single-day MDT clinic format resulted in a change in plan for a significant number of patients. This can be interpreted as improved quality of care for these patients, and we conclude the MDT approach is valuable [54].

It is uncertain if the difference in weight loss outcomes between different endoscopic bariatric therapies (EBTs) is technique-related or multidisciplinary team (MDT) follow-up-related. We hypothesized that at 1 year, the weight loss is determined more by adherence to MDT follow-up than by procedure type [55] [56].

Nutritional Management and Follow-up

While the technical aspects of EBTs have been well explained, the nutritional management surrounding EBTs and the effectiveness of multidisciplinary team for maximizing weight loss is less described. There is considerable variation in post-EBT care between studies and centers. In this paper, we review the existing literature and share our experience on nutrition and the role of multidisciplinary management of obesity following EBT [57].

Intragastric devices may be of benefit to patients who are unable to achieve weight loss through lifestyle modification and pharmaceuticals. With the help of every member of a multidisciplinary team and ongoing commitment from patients, small, practical steps and goals can lead to long-lasting, healthy weight loss [58].

Multidisciplinary Collaboration in Complications

Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge [59] [60].

 

Risk Assessment and Patient Selection

Risk Stratification Tools

Modern bariatric practice increasingly relies on sophisticated risk assessment. The MBSAQIP bariatric surgical risk/benefit calculator is publicly available, with the intent to be integrated into healthcare practice to guide bariatric surgical decision-making and care planning [61] [62]. Predicted BMI closely aligned with actual BMI values across the 12-month postoperative period. The MBSAQIP Bariatric Surgical Risk/Benefit Calculator is publicly available with the intent to facilitate patient-clinician communication and guide surgical decision making [63].

Specific Considerations for Endoscopic Procedures

Procedures performed on patients with obesity are usually considered high risk owing to their medical comorbidities and potential difficult airway management. Therefore, consultation with the anesthesia colleagues is usually required and most procedures should be performed in the hospital setting [64].

The patient selection process for endoscopic procedures requires understanding of both inclusion and exclusion criteria, risk stratification, and appropriate expectations for outcomes.

 

Current Challenges and Future Directions

Evidence Gaps

Despite growing experience, significant gaps remain in the evidence base. Despite favorable results for the endoscopic treatment of obesity, prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies [65]. This limitation affects practitioners’ ability to provide fully informed consent and optimal patient counseling.

Training Standardization

Longer follow-up and larger trials are needed to validate current evidence, in order to enhance the process of standardization of these techniques [66]. The lack of standardized training curricula and competency assessments represents a notable challenge for the field.

Technology Evolution

As the field continues to grow, small bowel interventions are evolving that may have some effect on weight loss but focus on the treatment of obesity-related comorbidities. Future implementation of combination therapy that utilizes both gastric and small bowel interventions offers an exciting option to further augment weight loss and alleviate metabolic disease [67].

Integration with Broader Obesity Care

Obesity treatment is a multidisciplinary and complex process that requires maximum patient compliance. Endoscopic treatments of obesity are less invasive than surgical options, and are associated with fewer complications and nutritional deficits. Currently, there is a large spectrum of endoscopic methods based on the principles of gastric volume reduction, size restriction and gastric or small bowel bypass being explored with only few available in routine practice [68] [69].

 

 

Analysis and Discussion

Practitioner Requirements: A Multifaceted Question

The question of who should perform endoscopic bariatric therapies cannot be answered simply by specialty designation. The evidence suggests that successful EBMT practice requires:

1. Technical Proficiency: EBMTs demand advanced endoscopic skills, particularly in endoscopic suturing, tissue manipulation, and the use of specialized bariatric devices. Practitioners must be capable of performing these procedures with precision and safety, while also managing intra-procedural complications should they arise. These technical abilities often build on a foundation of advanced therapeutic endoscopy training and may require additional targeted instruction specific to bariatric interventions.

1. Clinical Knowledge: Practitioners must possess a deep understanding of obesity as a complex, multifactorial disease. This includes knowledge of its pathophysiology, associated metabolic disorders such as type 2 diabetes and dyslipidemia, and the criteria that guide patient selection for EBMTs. A strong grasp of perioperative and long-term management is also critical, as EBMTs are not stand-alone interventions but part of an integrated approach to weight management and metabolic health.
2. Institutional Support: Successful programs are typically embedded within centers that provide multidisciplinary care, including input from dietitians, psychologists, endocrinologists, and surgeons. Access to appropriate facilities, anesthesia services, and protocols for managing emergencies such as bleeding or perforation is essential. Without these resources, even the most skilled practitioner may face limitations that compromise patient outcomes.
3. Ongoing Education: EBMT is a rapidly evolving field with continuous innovation in devices, techniques, and patient care strategies. Practitioners must demonstrate a commitment to continuous learning through participation in training programs, workshops, professional societies, and evidence-based practice updates. This ensures not only maintenance of technical skill but also alignment with emerging standards of care and evolving safety guidelines.

Specialty-Agnostic Competencies

Both gastroenterologists and surgeons can develop the necessary competencies, but the path may differ. Gastroenterologists bring extensive endoscopic experience and understanding of GI physiology, while surgeons contribute surgical judgment and familiarity with obesity surgery complications. The key lies not in specialty background but in comprehensive training and institutional support.

Institutional Framework as the Foundation

The evidence strongly suggests that the institutional framework may be more critical than individual practitioner specialty. Multidisciplinary care for patients undergoing ESG should be provided in an accredited center authorized to perform bariatric and metabolic surgery, with validation through a multidisciplinary consultation meeting [70]. This requirement ensures:

• Appropriate patient selection through multidisciplinary evaluation
• Access to specialists for complications management
• Quality assurance and outcome monitoring
• Comprehensive pre- and post-procedural care

Training Evolution and Standardization

The current training landscape reveals both progress and gaps. While Previous questionnaire study of the bariatric endoscopy experts revealed that on average the trainee were able to independently perform TORe and primary bariatric endoscopic suturing cases after 15 and 22 supervised procedures, respectively [71], the lack of objective assessment tools and standardized competency thresholds represents a key limitation.

Professional societies have begun addressing these gaps through position statements and training guidelines, but more work remains to establish universal standards that ensure patient safety while allowing appropriate specialty flexibility.

Safety Profile Considerations

The safety data for endoscopic bariatric procedures is encouraging, with complication rates generally lower than traditional surgery. However, when complications do occur, they can be serious and require immediate recognition and management. This reinforces the importance of:

• Institutional capabilities for emergency management
• Multidisciplinary team availability
• Practitioner competence in both prevention and management of complications

The Multidisciplinary Imperative

Perhaps the most consistent finding across the literature is the critical importance of multidisciplinary care. It is uncertain if the difference in weight loss outcomes between different endoscopic bariatric therapies (EBTs) is technique-related or multidisciplinary team (MDT) follow-up-related. We hypothesized that at 1 year, the weight loss is determined more by adherence to MDT follow-up than by procedure type [72].

This finding suggests that the practitioner performing the procedure, while important, is just one component of successful EBMT implementation. The broader team structure, follow-up protocols, and institutional support systems may be equally or more important for patient outcomes.

Cost-Effectiveness and Access Considerations

EBTs are more cost effective and have fewer complications [73] compared to traditional surgery. This advantage could improve access to obesity treatment, but only if practitioners are appropriately trained and distributed. The question of who should perform these procedures thus has implications beyond safety to include healthcare access and equity.

Future Trajectory and Implications

The field is clearly expanding, with Intragastric balloon placement increased from the previous year. Endoscopic sleeve gastroplasty increased in numbers [74]. This growth creates both opportunities and responsibilities for the medical community to establish appropriate standards while ensuring patient access.

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Conclusion

The question of who should perform endoscopic bariatric therapies requires a nuanced answer that transcends simple specialty distinctions. The evidence indicates that both gastroenterologists and surgeons can safely and effectively perform these procedures when properly trained and supported by appropriate institutional frameworks.

Key findings from this analysis include:

1. Training Requirements: Successful EBMT practice requires specialized training that goes beyond basic endoscopic or surgical skills to include obesity medicine, patient selection, and complication management.
2. Institutional Support: The safety and efficacy of EBMT procedures depend heavily on institutional capabilities, including multidisciplinary teams, emergency management resources, and comprehensive patient care protocols.
3. Multidisciplinary Care: Evidence consistently demonstrates that outcomes are influenced more by the quality of multidisciplinary follow-up than by the specific procedure or even the specialty of the performing physician.
4. Evolving Standards: Professional societies are actively developing training guidelines and position statements, but more work is needed to establish standardized competency assessments and universal training requirements.
5. Safety Considerations: While complication rates are generally low, the potential severity of complications requires practitioners to have both preventive and management capabilities, supported by institutional resources.

The optimal answer to “who should perform these procedures” appears to be: appropriately trained practitioners working within accredited institutions with comprehensive multidisciplinary support systems, regardless of their primary specialty background. The focus should shift from specialty gatekeeping to ensuring universal standards for training, competency assessment, and institutional support.

As the field continues to evolve, the medical community must balance the goals of ensuring patient safety, maintaining quality outcomes, and preserving access to these promising therapeutic options. This balance can best be achieved through continued collaboration between specialties, rigorous training standards, and robust institutional frameworks that support comprehensive obesity care.

Future research should focus on developing objective competency assessments, establishing standardized training curricula, and conducting long-term outcome studies that can further inform practice guidelines. The ultimate goal should be ensuring that patients have access to safe, effective endoscopic bariatric therapies performed by qualified practitioners, regardless of their specialty background, within institutions capable of providing comprehensive obesity care.

 

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