Bariatric Endoscopy in 2025: New Evidence Changes Everything We Knew

Bariatric Endoscopy in 2025: New Evidence Changes Everything We Knew

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Introduction

Bariatric endoscopy has undergone a remarkable transformation over the past two decades, evolving from a niche procedure into an established component of mainstream obesity management. In 1997, approximately 40,000 bariatric metabolic surgeries were performed worldwide. By 2018, the global volume had risen dramatically to more than 696,000 procedures, reflecting a 17-fold increase in just over twenty years. Importantly, the overwhelming majority of these operations, nearly 99.3 percent, were performed using laparoscopic techniques, underscoring both the rapid adoption of minimally invasive surgical strategies and the technological advances that have shaped this field.

The year 2023 marked two decades since the first application of endoscopic suturing for the treatment of obesity, an innovation that paved the way for a new era of minimally invasive approaches. During this period, traditional bariatric surgery endoscopy procedures have advanced considerably, and new endoscopic bariatric techniques have achieved broad acceptance in clinical practice. These developments are particularly relevant as the global obesity epidemic continues to escalate. Current estimates indicate that more than 650 million individuals worldwide are living with obesity, a figure that continues to climb and is projected to affect an estimated 213 million adults by 2025. In response, the Association for Bariatric Endoscopy has increasingly recognized endoscopic procedures as valuable components of the therapeutic armamentarium for obesity management.

While traditional surgical approaches remain effective, they are not without challenges. One of the most significant concerns is weight regain, which occurs in up to one-third of patients after bariatric surgery. Endoscopic techniques offer a less invasive alternative and have shown promise in addressing this limitation. Endoscopic sleeve gastroplasty, for example, has demonstrated clinically meaningful outcomes, with studies reporting an average of 16 percent total body weight loss and approximately 60 percent excess body weight loss at 12 months. These results are achieved with a favorable safety profile, as adverse event rates remain relatively low, ranging from 1.5 to 2.3 percent.

The evidence accumulated to date suggests that bariatric endoscopy is reshaping the treatment landscape for obesity. Beyond standalone procedures, emerging research is exploring combination therapies that integrate endoscopic interventions with pharmacological and behavioral approaches to enhance durability and long-term outcomes. These innovations are expanding the role of bariatric endoscopy from a revisional or adjunctive strategy to a primary therapeutic option for selected patients.

As the global burden of obesity continues to rise, the field of bariatric medicine is advancing at an unprecedented pace. With expanding clinical experience, ongoing technological refinement, and an increasing body of high-quality evidence, bariatric endoscopy is poised to play an integral role in the multidisciplinary management of obesity in the coming years.

Keywords: bariatric endoscopy, obesity treatment, endoscopic sleeve gastroplasty, metabolic surgery, weight loss outcomes, minimally invasive therapy

 

The Shift from Surgery to Endoscopy in Obesity Treatment

Traditional bariatric surgery remains the gold standard for obesity treatment, yet a profound shift toward endoscopic alternatives has been gaining momentum. This evolution represents a critical advancement in addressing the needs of patients seeking effective weight loss solutions without the drawbacks associated with conventional surgical approaches.

Limitations of traditional bariatric surgery

Traditional bariatric procedures such as laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) demonstrate impressive long-term results, with 10-year follow-up studies showing mean percent excess weight loss of 57% following LSG and 60% following RYGB. Nevertheless, these surgical interventions come with substantial drawbacks. Patients face possible complications including anastomotic ulceration, stenosis, gastro-gastric fistulas, surgical leaks, intestinal obstruction, and choledocholithiasis. Moreover, bariatric surgery requires multiple physician visits over extended periods, creating a complex process that many find daunting.

Perhaps most telling is the fact that fewer than 1% of eligible patients ultimately undergo bariatric surgery annually. This startlingly low adoption rate persists despite the proven efficacy of these procedures, indicating major barriers to access. Additionally, weight regain occurs in up to 30% of bariatric surgery patients, who experience clinically significant weight regain (defined as >15% from nadir weight).

The surgical approach also carries a rare but measurable risk of severe morbidity (approximately 4%) and mortality (approximately 0.1%) for what remains an elective procedure. Consequently, many patients who could benefit from weight loss intervention fall into a treatment gap—they experience limited success with conservative approaches yet are unwilling to accept the risks associated with surgery.

Rise of minimally invasive endoscopic alternatives

Bariatric endoscopy has emerged as a middle ground between medications and surgery. These procedures achieve better weight loss than medications alone without their associated side effects, yet are less invasive than surgical options. Primarily, they offer four distinct advantages: easier recovery, reduced discomfort, absence of abdominal scars, and faster return to normal activities.

The endoscopic approach to obesity treatment has evolved into several categories: space-occupying devices (intragastric balloons), restrictive procedures (endoscopic sleeve gastroplasty), bypass liners, electrical stimulation, aspiration therapy, and other specialized therapies. Among these, restrictive procedures have demonstrated the most effective outcomes for weight loss at 12 months.

Endoscopic sleeve gastroplasty (ESG), first introduced in 2013, represents a major advancement in this field. This technique reduces the size of the gastric reservoir using a full-thickness endoscopic suturing device, creating a tubular structure similar to that achieved by LSG but without incisions. ESG has shown promising results with pooled adverse event rates of just 1.5% to 2.3%, substantially lower than traditional surgery. Additionally, the procedure can typically be performed on an outpatient basis, allowing patients to return home the same day.

For patients with a BMI of 30-40 who do not qualify for or prefer not to undergo weight-loss surgery, bariatric endoscopy fills a crucial gap in the treatment spectrum. Moreover, these procedures often serve as interim treatments for patients needing weight loss to qualify for other surgeries like joint replacement or organ transplant.

The Association for Bariatric Endoscopy recognizes the growing importance of these alternatives, particularly as preliminary clinical studies confirm their encouraging weight loss effects. Some endoscopic approaches have shown weight loss results potentially comparable to bariatric surgery, especially when combined with minimally invasive bariatric procedures.

This evolution toward less invasive options reflects the continued refinement of obesity treatment, offering alternatives that balance effectiveness with patient safety and accessibility. As evidence mounts regarding their efficacy, these endoscopic interventions are increasingly positioned to address the substantial unmet need in obesity care.

 

Clinical Evidence Supporting Endoscopic Sleeve Gastroplasty (ESG)

Endoscopic sleeve gastroplasty (ESG) has emerged as a frontrunner among bariatric endoscopy procedures, with a growing body of clinical evidence supporting its efficacy and safety profile. Research over the past decade has yielded valuable insights into both short-term outcomes and long-term durability of this minimally invasive approach.

12-month %TBWL and %EWL outcomes

Initial results from ESG demonstrate robust weight loss metrics at the one-year mark. Multiple studies consistently report percent total body weight loss (%TBWL) ranging from 15.1% to 17.5% at 12 months post-procedure. Correspondingly, percent excess weight loss (%EWL) at the same timepoint ranges from 59.1% to 64.4%[74]. These outcomes position ESG as a viable intervention for patients seeking substantial weight reduction.

In the landmark MERIT trial, which compared ESG to lifestyle modification alone, patients who underwent the procedure achieved a mean %EWL of 49.2% versus just 3.2% in the control group. This translated to a %TBWL of 12.6% compared to a mere 0.8% with lifestyle changes alone. Importantly, 77% of ESG patients achieved 25% or more EWL at 52 weeks, a clinically meaningful threshold.

A retrospective cohort study of 160 patients with an initial BMI averaging 35.9 kg/m² found that participants lost an average of 16.1 kg by 12 months post-ESG. These patients demonstrated progressive improvements in %TBWL from 11.74% at 3 months to 18.39% at 12 months. Beyond weight reduction, ESG produced noteworthy metabolic benefits, including reductions in blood glucose and total cholesterol at all follow-up points.

Comparison with laparoscopic sleeve gastrectomy

When contrasting ESG with laparoscopic sleeve gastrectomy (LSG), several key differences emerge. A meta-analysis of 6,775 patients (3,413 ESG vs. 3,362 LSG) revealed that LSG produced greater %TBWL at all measured timepoints: 6 months (7.48% higher), 12 months (9.90% higher), and 24 months (7.63% higher). At the 12-month mark, pooled data shows LSG achieving approximately 30.3% %TBWL compared to 17.5% with ESG.

Although ESG produces less dramatic weight loss, it offers a markedly improved safety profile. The pooled rate of all adverse events with ESG was just 3.2% compared to 11.8% with LSG. Likewise, procedural advantages include shorter hospital stays (0.49 days vs. 1.43 days) and slightly reduced operative time (63.9 minutes vs. 69.8 minutes).

Perhaps most striking is the difference in new-onset gastroesophageal reflux disease (GERD). Studies consistently demonstrate lower GERD incidence following ESG compared to LSG (1.3% vs. 17.9%). Another analysis reported even more dramatic differences, with post-procedure GERD rates of 1.9% for ESG versus 14.5% for LSG.

Long-term durability: 5-year follow-up data

The durability of ESG outcomes represents a critical consideration for practitioners. A prospective 5-year analysis demonstrated consistency in weight loss maintenance. At 1, 3, and 5 years, mean %TBWL values were 15.6%, 14.9%, and 15.9% respectively. Furthermore, 90% of patients maintained at least 5% TBWL at the 5-year mark, while 61% maintained at least 10% TBWL.

The stability of these results is notable given that 5% TBWL represents the threshold for clinically meaningful improvement in obesity-related comorbidities according to prior studies. At 5 years, the mean %EWL was 45.3%, with 74% of patients maintaining at least 25% EWL.

Recent data extending to 10 years post-procedure further confirms ESG’s long-term efficacy. Among 110 patients evaluated at the decade mark, mean %TBWL was 10.5%, with 53% maintaining at least 5% TBWL and 42% maintaining at least 10% weight loss. A separate analysis reported even more favorable 10-year outcomes, with mean %TBWL of 15.8% and 70% of patients maintaining at least 10% TBWL.

Long-term follow-up reveals that approximately 10.9% of patients required endoscopic revision via retightening or resuturing at 10 years. Yet even with this consideration, ESG demonstrates an excellent safety record, with only 0.01% moderate adverse events and no severe or fatal complications reported.

 

Intragastric Balloons in 2025: Updated Safety and Efficacy Data

Intragastric balloons (IGBs) have steadily evolved since their initial European introduction in 1991, offering a minimally invasive alternative within the bariatric treatment spectrum. Recent data from 2025 provides fresh insights into their comparative effectiveness, safety profile, and specialized applications.

Orbera, Obalon, and Elipse comparative outcomes

Currently, three primary IGB systems dominate the market, each with distinct design characteristics and weight loss profiles. The FDA-approved fluid-filled Orbera system consistently demonstrates robust outcomes, with a meta-analysis of 16 studies involving 3,608 patients revealing a mean BMI reduction of 5.7 kg/m² and 32.1% excess weight loss (%EWL) at balloon removal. A separate Italian retrospective study examining 2,515 cases reported a mean BMI loss of 4.9 kg/m² over the standard 6-month placement period.

In contrast, the Obalon system employs multiple swallowable gas-filled balloons placed sequentially. The Elipse represents the newest generation with a swallowable design that requires no endoscopy for insertion or removal, as it self-deflates after approximately four months. Direct comparison between these systems reveals noteworthy differences—Elipse demonstrates superior outcomes with 49.3% excess body weight loss compared to Obalon’s 31.5%. Similarly, Elipse achieves 9.6% total body weight loss (%TBWL) versus Obalon’s 7.1%.

Meta-analyzes consistently favor fluid-filled balloons over gas-filled alternatives, with fluid-filled systems producing nearly 3% greater weight loss. For newer 12-month Orbera balloons, median TBWL reaches 11.11% with 36.58% excess BMI loss. Interestingly, increased patient engagement with post-procedural follow-up correlates directly with enhanced weight loss outcomes.

Adverse event rates and patient tolerability

The tolerability profile of IGBs remains relatively consistent across systems. Approximately 91% of patients experience gastrointestinal symptoms following implementation. The most frequently reported adverse events include nausea and vomiting (23.3%), abdominal pain (19.9%), gastroesophageal reflux (14.3%), and constipation or diarrhea (10.4%).

In a study of 57 patients, symptom duration averaged 24.8 days before resolution. Early balloon removal due to intolerance occurs in approximately 3.5% of cases. For the Korean End-ball system, 68.6% of patients experienced nausea and vomiting, yet these symptoms typically responded well to short-term medication management.

Serious adverse events remain uncommon but require careful consideration. Migration occurs in 1.4% of cases, small bowel obstruction in 0.3%, and gastric perforation in 0.1% of patients. The mortality rate reaches 0.05% in some analyzes. For the Spatz Adjustable Balloon System, specific complications include gastric ulcer/erosion (27.7%), balloon deflation (5.3%), and gastrointestinal bleeding (3.2%).

Newer balloon designs aim to reduce these complications. The swallowable nitrogen-mix gas-filled balloons potentially double weight loss compared to lifestyle interventions alone while maintaining a low incidence of major complications. Self-degradable balloons designed to empty autonomously after 4-5 months may offer improved safety profiles.

Use as bridge-to-surgery in super-obese patients

One of the most valuable applications for IGBs emerges in their role as a bridge to definitive bariatric surgery for super-obese patients (BMI >50 kg/m²). In this population, IGBs help mitigate surgical risks through preoperative weight reduction.

Studies show that even modest preoperative weight loss of 5% substantially decreases postoperative mortality. A comparison of laparoscopic sleeve gastrectomy following either preoperative liraglutide therapy or IGB placement strongly favored the IGB approach. At 12 months, the IGB group maintained higher %EWL (39.9 vs. 25) and %EBWL (71.2 vs. 42).

Beyond weight metrics, IGB therapy produces notable improvements in obesity-related comorbidities, with 44.3% resolving completely and another 44.8% showing substantial improvement. Several studies report achieving more than 10% preoperative weight loss in 90% of super-obese patients following IGB placement.

This staged approach not only reduces technical challenges during subsequent surgery but simultaneously improves cardiopulmonary function and metabolic parameters. For patients with BMI exceeding 50 kg/m², this bridging strategy offers a practical pathway to safer definitive bariatric intervention.

 

Revisional Endoscopy After Failed Bariatric Surgery

Weight recidivism represents a considerable challenge after bariatric surgery, affecting between 20-30% of patients who undergo Roux-en-Y gastric bypass (RYGB) and up to 20% following laparoscopic sleeve gastrectomy (LSG). Revisional endoscopy has emerged as a minimally invasive solution that addresses anatomical changes contributing to weight regain without subjecting patients to the increased morbidity associated with surgical reintervention.

TORe for dilated gastrojejunal anastomosis

Transoral outlet reduction (TORe) addresses dilated gastrojejunal anastomosis (GJA), a common anatomical factor contributing to weight regain after RYGB. This endoscopic procedure aims to reduce the diameter of the GJA, thereby delaying gastric emptying and enhancing satiety. Currently, full-thickness endoscopic suturing represents the primary TORe approach, typically employing the OverStitch™ suturing device (Apollo Endosurgery).

The efficacy of TORe has been demonstrated across multiple studies. In procedures targeting GJA reduction from an average pre-intervention diameter of 27.9 mm to approximately 9.5 mm, practitioners generally place an average of 2.9 endoscopic sutures. Long-term outcomes remain encouraging—five-year data reveals total body weight loss (TBWL) of 8.5% at 1 year, 6.9% at 3 years, and 8.8% at 5 years post-procedure. Notably, 77% of patients experience complete cessation of weight gain, and 62% maintain TBWL exceeding 5% at the five-year mark.

Beyond weight management, TORe proves effective for treating dumping syndrome, with 84.6% of affected patients experiencing persistent symptom improvement. The procedure demonstrates an excellent safety profile with primarily minor complications (11.3%), including transient dysphagia, hematemesis, and occasional superficial lesions.

R-EndoSleeve after sleeve gastrectomy

Revisional endoscopic sleeve gastroplasty (R-ESG) offers a solution for patients experiencing weight regain following primary sleeve gastrectomy. Often referred to as endoscopic sleeve-in-sleeve (SIS), this technique employs full-thickness suturing to reduce the diameter of a dilated sleeve.

The Apollo endoscopic system produces intragastric plication without abdominal incisions, creating a reduced gastric volume through vertically placed interrupted sutures along the greater curvature. Comparative studies between R-ESG and revisional surgical sleeve gastrectomy (R-SG) demonstrate similar efficacy—at one year, patients achieve nearly identical total weight loss percentages (9.75% with R-ESG versus 9.87% with R-SG).

Prospective analyzes reveal that patients achieve mean total body weight loss of 6.6% at one month and 15.7% at twelve months following R-ESG. Excess weight loss (EWL) correspondingly reaches 18.5% at one month and 47.6% at twelve months. Therefore, R-ESG represents a viable alternative for high-risk surgical patients or those preferring less invasive approaches.

APC and cryoablation techniques

Argon plasma coagulation (APC) serves as both a standalone technique and complementary method for revisional endoscopy. First, it functions as a preparatory step before suturing in TORe procedures, creating controlled mucosal injury that promotes subsequent healing and fibrosis. High-dose APC (70-80W) appears more effective than low-dose applications (45-55W), with patients achieving 10% TBWL at one year compared to 5.1% in the low-dose group.

Alternatively, cryoablation employs a specialized balloon to deliver circumferential freezing to the GJA and gastric pouch, inducing fibrosis that reduces anatomical dimensions. Following cryoablation, GJA size typically decreases from 24mm to 17mm, while pouch size contracts from 5cm to 4cm. This technique yields approximately 8.1% TBWL at eight weeks post-procedure.

In recent developments, combining thermal ablation techniques with endoscopic suturing has shown promising results. For instance, APC with subsequent endoscopic suturing has demonstrated 6.5% TBWL at two months in revisional cases.

 

New Bariatric Endoscopy Surgery Devices and Techniques

Technological innovation continues to propel bariatric endoscopy forward with novel platforms that offer improved precision, simplified technique, and enhanced patient outcomes. These cutting-edge devices expand treatment options beyond traditional approaches, addressing the growing demand for minimally invasive weight loss solutions.

Endomina and EndoZip platforms

The Endomina™ triangulation platform (Endo Tools, Goseelies, Belgium) represents a major advancement in endoscopic gastric reduction technology. This innovative system assembles to a forward-viewing scope, providing degrees of freedom comparable to a surgeon’s hands while enabling tissue manipulation through the oral cavity. Unlike conventional endoscopic tools, the platform can be assembled and disassembled at will inside the stomach, creating greater working space for precise interventions.

Clinical studies demonstrate promising results with Endomina-assisted gastroplasty. A European multi-center evaluation reported excess weight loss of 29% and total body weight loss of 7.4% at one-year follow-up, with 88% of sutures remaining intact. Subsequently, a randomized controlled trial found 25% improved excess weight loss at 6 months compared with lifestyle modification alone. Ongoing research evaluating different plication patterns revealed mean total body weight loss of 10.11% and excess weight loss of 42.56%.

In comparison, the EndoZip™ system (Nitinotes Ltd, Cesarea, Israel) offers a fully automated, operator-independent approach to endoscopic suturing. Specifically designed to overcome the learning curve associated with manual techniques, this platform enables consistent, full-thickness plications in a single-operator setting. Indeed, while traditional systems require approximately 20 cases to achieve proficiency, EndoZip mastery requires only three procedures.

A first-in-human study involving 45 patients with BMI 30-40 kg/m² achieved 13.21% total body weight loss and 51.4% excess weight loss at 12 months. Beyond weight reduction, researchers observed improvements in waist circumference, glycated hemoglobin, and alanine aminotransferase levels. Serious adverse events occurred in merely 4.4% of cases, with an average hospital stay of just one day.

Incisionless Magnetic Anastomosis System (IMAS)

The Incisionless Magnetic Anastomosis System™ (IMAS; GI Windows, West Bridgewater, MA, USA) offers a revolutionary approach to creating anastomoses without surgical incisions. This innovative technology employs self-assembling magnets delivered through the working channel of a colonoscope to establish a partial jejunal diversion (PJD).

Initially, in human pilot studies, the system was deployed under laparoscopic supervision. Once positioned, the magnets compress the intestinal wall, inducing controlled necrosis that creates a permanent fistula between the jejunum and ileum. After the anastomosis forms, the magnets naturally pass through stool.

Clinical outcomes remain impressive—a study of ten obese patients with diabetes demonstrated 14.6% total weight loss (40.2% excess weight loss) at 12 months. Importantly, patients experienced substantial reductions in glycated hemoglobin (1.9% decrease in diabetic patients, 1.0% in prediabetic individuals) while reducing or eliminating diabetes medications. The anastomosis remained widely patent throughout the one-year follow-up period with no device-related serious adverse events.

RESET device for duodenal bypass

The RESET® device (Morphic Medical) provides a novel approach to metabolic management through an endoscopically-placed duodenal-jejunal bypass liner. This thin, flexible 60cm sleeve anchors in the upper small intestine, creating a physical barrier between intestinal wall receptors and ingested food.

Upon CE mark approval in Europe, clinical data revealed patients achieved an average weight reduction of 17.4kg at three-year follow-up after treatment. Additionally, participants experienced a 1.9% reduction in blood glucose levels, alongside improvements in blood pressure and cholesterol profiles.

The device appears to work through mechanisms similar to Roux-en-Y gastric bypass, enhancing natural gut hormones in a manner comparable to GLP-1 agonists. Treatment duration extends to nine months, after which removal occurs through an outpatient endoscopic procedure.

Common complications include mild to moderate gastrointestinal symptoms (nausea, vomiting, upper abdominal pain), primarily occurring in the early post-placement period. Uncommon risks encompass liver abscess, device-related bleeding, migration, and pancreatitis—all resolvable through endoscopic or surgical device removal.

 

 

Mechanisms of Action: How Endoscopic Therapies Induce Weight Loss

The efficacy of bariatric endoscopy procedures extends beyond mere anatomical alterations. These interventions induce weight loss through intricate physiological pathways that fundamentally alter digestive function, hormone secretion, and neural signaling.

Delayed gastric emptying in ESG

Endoscopic sleeve gastroplasty (ESG) creates substantial changes in gastric emptying dynamics. Clinical studies demonstrate that ESG reduces stomach capacity by approximately 80%, thereby altering normal gastric physiology. This anatomical restriction directly impacts food transit times—at three months post-procedure, half-emptying time (T1/2) reaches 152.3 minutes in ESG patients versus 89.1 minutes in lifestyle intervention subjects. After a full year, this delay persists (137 minutes versus 90.1 minutes), indicating a durable physiological change.

The measured percentage of food emptied at two hours drops remarkably after ESG (42.5% versus 66.6% at three months), maintaining this pattern at twelve months (46.1% versus 66.8%). Hence, food remains in the stomach considerably longer following this procedure. Importantly, greater delays in gastric emptying at three months correlate directly with enhanced weight loss outcomes throughout the first year.

Hormonal modulation in DMR and bypass liners

Duodenal mucosal resurfacing (DMR) and duodenal-jejunal bypass liners modify weight through distinct hormonal mechanisms. These procedures primarily affect the duodenum—the key site for nutrient sensing and incretin production. DMR achieves remarkable HbA1c reductions (pooled reduction of 1.2% at six months) that appear largely independent of weight loss.

For duodenal bypass liners, hormonal changes occur rapidly after implantation. The postprandial GLP-1 response increases substantially within one week and remains elevated throughout the treatment period. Additionally, these devices trigger opposing effects on various gut hormones—increasing postprandial PYY and ghrelin responses while simultaneously decreasing CCK and GIP responses. These changes together modify appetite regulation and metabolic homeostasis.

Neurohormonal feedback and satiety signals

The neurohormonal gut-brain axis forms the foundation for satiety regulation in bariatric endoscopy. This complex network involves continuous synchronization between short-term signals (PYY, GLP-1, CCK) secreted when nutrients reach the gut and long-term metabolic signals from adipose tissue. Together, these influences coordinate feeding behavior through reciprocal interaction between homeostatic and hedonic neural systems.

Mechanical stimuli likewise play crucial roles—gastric distension following ESG directly activates vagal afferents. Meanwhile, PYY reduces food intake through Y2 receptors on vagal pathways, inhibiting neuropeptide Y activation in the hypothalamic arcuate nucleus. GLP-1 works through multiple mechanisms—enhancing insulin secretion, slowing gastric emptying, and directly suppressing appetite through central nervous system action.

Enhanced understanding of these complex mechanisms continues to inform development of more effective bariatric endoscopy procedures tailored to specific patient populations.

 

Combination Therapies: Endoscopy Plus Pharmacology

Recent advancements in bariatric medicine have revealed powerful synergies between endoscopic interventions and pharmacological agents. This integrative approach addresses multiple physiological pathways simultaneously, potentially enhancing overall efficacy beyond what either modality achieves independently.

ESG with liraglutide or semaglutide

Endoscopic sleeve gastroplasty (ESG) combined with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) demonstrates enhanced weight loss outcomes compared to monotherapy. In a prospective, randomized, double-blind study, patients receiving semaglutide one month after ESG achieved superior mean percent total body weight loss (%TBWL) at 12 months—25.21% versus 18.65% with ESG alone. These patients concurrently experienced greater reductions in percent body fat mass (12.69% versus 9.04%) and lower mean HbA1c levels.

Timing of medication initiation apparently influences outcomes. Research indicates that patients who initiated anti-obesity medications (AOMs) after the 12-month post-ESG mark achieved the greatest total body weight loss, with over 20% TBWL at 24 months. Conversely, patients already taking AOMs before ESG experienced the least favorable weight loss results.

Throughout clinical practice, ESG plus pharmacotherapy necessitates more intensive follow-up. Patients undergoing combined therapy required more visits per year (5.7) compared to ESG alone (4.1), particularly with increased gastroenterology physician visits.

IGB with GLP-1 receptor agonists

Intragastric balloons (IGBs) paired with GLP-1 RAs yield compelling results. Among 50 patients studied, those receiving both IGB and liraglutide experienced substantially greater weight reduction at balloon removal—median weight change of 13.8 kg versus 7.9 kg with IGB alone. BMI reduction was correspondingly more pronounced (4.9 versus 3.13).

The Elipse swallowable gastric balloon combined with liraglutide produced approximately 19% weight loss, with patients achieving 99.4% excess body weight loss and mean BMI reduction of 6.4 kg/m². Throughout studies, most balloon-related adverse events remained manageable with medications, while only 1.1% of patients discontinued liraglutide due to gastrointestinal symptoms.

Clinical outcomes from combination trials

Cost-effectiveness analyzes favor certain combinations over others. ESG proved more cost-effective than semaglutide over a 5-year horizon, adding 0.06 quality-adjusted life years while reducing total costs by $33,583. To achieve cost parity, the annual price of semaglutide ($13,618) would need to decrease by more than threefold.

Weight loss trajectories differ between therapies—ESG typically induces more rapid weight loss initially, whereas GLP-1 RAs provide slower but more consistent results. After 12 months, these differences often diminish. Preliminary data suggests combining IGBs with lower-dose GLP-1s may improve long-term tolerability and adherence to GLP-1 therapy, addressing the high discontinuation rates (30% within the first month) associated with GLP-1 monotherapy.

 

Bariatric Endoscopy in Adolescents and Special Populations

The application of bariatric endoscopy in pediatric populations has expanded considerably amid rising adolescent obesity rates. Clinical evidence now supports endoscopic approaches as potential middle-ground interventions between medical management and traditional surgery.

Safety profile in pediatric patients

Endoscopic sleeve gastroplasty (ESG) has demonstrated remarkable safety in adolescents. In the first pediatric ESG study involving 109 patients (average age 17.6 years), no significant morbidity, mortality, blood transfusions, or emergency admissions occurred. Only 14 adolescents required clinic visits for abdominal pain during the first postprocedure week, with just one patient requesting suture removal due to discomfort. Importantly, all obesity-related comorbidities, including obstructive sleep apnea, hypertension, and prediabetes, achieved complete remission by the three-month follow-up.

Nutritional considerations and growth impact

Nutritional vigilance remains paramount in adolescent bariatric interventions. Studies reveal concerning post-procedural deficiencies, particularly in iron and vitamin B12. These deficiencies occur more commonly after Roux-en-Y gastric bypass than sleeve gastrectomy, with hypoferritinemia affecting nearly twice as many RYGB recipients by year five. Vitamin D deficiency persists both pre- and post-operatively, raising concerns about long-term bone health. Lifelong supplementation with vitamins and minerals is essential for adolescents undergoing any bariatric procedure. Bone mineral density requires careful monitoring, as decreases across two years post-procedure have been documented, though values typically remain within normal ranges.

Association for Bariatric Endoscopy recommendations

Expert recommendations suggest considering bariatric procedures for adolescents with BMI ≥35 kg/m² with severe comorbidities or BMI ≥40 kg/m² with minor comorbidities. Candidate selection requires physical maturity, absence of medically correctable causes of obesity, emotional stability, and failed organized weight loss attempts. Procedures must occur within multidisciplinary programs specifically experienced in pediatric obesity, bariatric interventions, nutrition, and psychology. Regular follow-up with this multidisciplinary team is mandatory throughout the patient’s developmental years.

 

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Conclusion

Bariatric endoscopy has undergone remarkable transformation over the past two decades, establishing itself as a vital component of the obesity treatment spectrum. Recent evidence confirms these procedures fill the critical therapeutic gap between lifestyle modifications and traditional bariatric surgery. ESG stands out as a particularly promising intervention, demonstrating impressive weight loss metrics with 15-17% total body weight loss at 12 months while maintaining these results through five-year follow-up studies. Though laparoscopic sleeve gastrectomy produces greater weight reduction, ESG offers substantially improved safety profiles with minimal adverse event rates and virtually no GERD complications.

Accordingly, intragastric balloons continue evolving with newer generation devices showing enhanced tolerability and effectiveness. The comparative analysis between Orbera, Obalon, and Elipse systems reveals fluid-filled balloons generally outperform gas-filled alternatives. These devices serve multiple purposes beyond primary weight loss, including bridge-to-surgery applications for super-obese patients who face prohibitive surgical risks without preliminary weight reduction.

Patients experiencing weight regain after bariatric surgery now benefit from targeted revisional endoscopic approaches. TORe effectively addresses dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass, while revisional endoscopic sleeve gastroplasty offers comparable outcomes to surgical revision but with decreased invasiveness. These techniques preserve the original anatomic alterations while reinforcing their restrictive components.

Technological advancements drive the field forward through platforms like Endomina, EndoZip, IMAS, and RESET. These innovative systems enable previously unattainable interventions without conventional surgical access. Essentially, they expand treatment options while reducing procedural complexity and associated risks.

The mechanisms underlying endoscopic weight loss extend beyond mechanical restriction. Delayed gastric emptying, hormonal modulation, and neurohormonal feedback pathways represent crucial physiological changes triggered by these procedures. Understanding these mechanisms helps optimize patient selection and predict therapeutic responses.

Combination therapies pairing endoscopic interventions with pharmacological agents like GLP-1 receptor agonists represent perhaps the most promising frontier. This multi-modal approach addresses different physiological pathways simultaneously, potentially achieving superior outcomes compared to either modality alone. ESG combined with semaglutide demonstrates particularly robust results with 25% total body weight loss at 12 months.

Meanwhile, bariatric endoscopy applications continue expanding to special populations, including adolescents with severe obesity. Though safety profiles appear favorable in younger patients, nutritional considerations require vigilant attention throughout development.

Bariatric endoscopy has fundamentally altered the obesity treatment paradigm. Rather than competing with traditional approaches, these procedures complement existing options while expanding access to effective interventions. The growing body of evidence supports their integration into comprehensive obesity management programs. Thus, practitioners must remain familiar with this rapidly evolving field to provide optimal care across the full spectrum of patients struggling with obesity.

Key Takeaways

Bariatric endoscopy has evolved from experimental procedures to mainstream obesity treatments, offering effective alternatives between lifestyle changes and traditional surgery with compelling clinical evidence.

• ESG delivers sustained results: Endoscopic sleeve gastroplasty achieves 15-17% total body weight loss at 12 months with excellent 5-year durability and minimal complications compared to surgical alternatives.
• Combination therapy maximizes outcomes: Pairing endoscopic procedures with GLP-1 medications like semaglutide can achieve up to 25% total body weight loss, surpassing either treatment alone.
• Revisional endoscopy addresses surgical failures: TORe and R-ESG effectively treat weight regain after failed bariatric surgery without requiring invasive reoperation procedures.
• New devices expand treatment options: Innovative platforms like Endomina, IMAS, and RESET enable previously impossible interventions while reducing procedural complexity and patient risk.
• Safety profiles favor endoscopic approaches: Adverse event rates remain consistently low (1.5-3.2%) across procedures, with faster recovery times and outpatient feasibility for most patients.

These advances position bariatric endoscopy as a cornerstone of modern obesity treatment, filling critical gaps in care while offering patients safer, more accessible pathways to meaningful weight loss and metabolic improvement.

 

 

Frequently Asked Questions:

FAQs

Q1. What is endoscopic sleeve gastroplasty (ESG) and how effective is it for weight loss? Endoscopic sleeve gastroplasty is a minimally invasive bariatric procedure that reduces stomach size using endoscopic suturing. Studies show it can achieve 15-17% total body weight loss at 12 months, with results maintained for up to 5 years in many patients.

Q2. How does ESG compare to traditional bariatric surgery in terms of safety and outcomes? While ESG produces less dramatic weight loss than laparoscopic sleeve gastrectomy, it offers a significantly improved safety profile. ESG has a lower rate of adverse events (3.2% vs 11.8%) and much lower incidence of post-procedure GERD (1.3% vs 17.9%).

Q3. What are the potential side effects of endoscopic sleeve gastroplasty? Common side effects include temporary nausea, vomiting, and abdominal pain in the early post-procedure period. Serious complications are rare but can include bleeding, infection, or stomach tears. Most patients experience a quick recovery with minimal downtime.

Q4. How long do the effects of endoscopic sleeve gastroplasty last? Long-term studies show that ESG can produce durable results. At 5 years post-procedure, 90% of patients maintained at least 5% total body weight loss, and 61% maintained at least 10% weight loss. Some patients may require endoscopic revision after several years.

Q5. Can endoscopic bariatric procedures be combined with weight loss medications? Yes, combining endoscopic procedures like ESG with GLP-1 receptor agonists (e.g. semaglutide) has shown promising results. Studies report that this combination approach can achieve up to 25% total body weight loss at 12 months, surpassing the results of either treatment alone.

 

 

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