Bariatric and metabolic endoscopy: ESGE Technical Review

The "Bariatric and Metabolic Endoscopy: ESGE Technical Review" provides a detailed and comprehensive overview of endoscopic bariatric and metabolic therapies (EBMTs), which are minimally invasive treatment options for obesity and related metabolic diseases. The review focuses on the latest advancements in this field, offering clinicians practical guidance on the use, safety, and effectiveness of these therapies.

### Key Highlights of the Review:

#### 1. **Types of Endoscopic Bariatric and Metabolic Therapies (EBMTs):**

• **Stomach-Based Therapies:**
• **Intragastric Balloons (IGBs):** These devices occupy space in the stomach, causing a feeling of fullness and reducing food intake.
• **Endoscopic Sleeve Gastroplasty (ESG):** A procedure that uses sutures to reduce stomach volume and mimic the effects of surgical sleeve gastrectomy.
• **Aspiration Therapy:** A reversible technique that involves placing a device to aspirate ingested food from the stomach, reducing calorie absorption.
• **Small-Bowel–Based Therapies:**
• **Duodenal Mucosal Resurfacing (DMR):** A procedure that modifies the duodenal lining, potentially improving glucose metabolism and insulin sensitivity.
• **Bypass Sleeves (Endoluminal Sleeves):** Devices that act as a barrier to prevent contact between food and the proximal small intestine, mimicking the effects of surgical bypass.

#### 2. **Mechanisms of Action:**

• The review explains how each therapy works to promote weight loss and improve metabolic health. These mechanisms include:
• Restriction of food intake.
• Alteration of gut hormones.
• Changes in nutrient absorption and metabolism.

#### 3. **Indications and Patient Selection:**

• EBMTs are recommended for patients with obesity (BMI ≥ 30 kg/m²) who have not achieved sufficient results with lifestyle modifications or pharmacotherapy. They may also be suitable for patients who are not candidates for bariatric surgery or prefer less invasive options.
• Patient selection is critical, and the review emphasizes the importance of multidisciplinary care, including dietitians, psychologists, and medical professionals.

#### 4. **Effectiveness and Safety:**

• EBMTs demonstrate promising outcomes for weight loss and metabolic improvements, particularly in controlling type 2 diabetes and other obesity-related conditions.
• While they carry a lower risk compared to surgical interventions, common adverse events include nausea, vomiting, abdominal pain, and, in rare cases, more serious complications.
• The review discusses strategies to manage complications and prevent weight regain, which remains a challenge in some patients.

#### 5. **Evidence and Research Gaps:**

• The review highlights the need for more high-quality, randomized controlled trials and long-term follow-up studies to better understand the durability of outcomes and to establish the precise role of EBMTs in clinical practice.
• There is a call for standardized protocols and guidelines to optimize the use of these therapies.

#### 6. **Practical Guidance for Clinicians:**

• The review serves as a technical guide for healthcare providers, detailing the proper techniques for performing EBMTs and offering recommendations for their safe and effective application.
• It underscores the importance of individualized treatment plans and the integration of EBMTs into a comprehensive obesity management strategy.

### Conclusion:

The ESGE Technical Review positions EBMTs as an emerging and valuable tool in the fight against obesity and metabolic diseases. While these therapies show significant potential due to their minimally invasive nature and favorable safety profile, their long-term efficacy and role in the broader treatment pathway require further investigation. This review provides clinicians with the knowledge and framework necessary to incorporate EBMTs into modern obesity care, ensuring patient safety and optimal outcomes.