The position of endoscopic procedures in the treatment of obesity.

Obesity is a worldwide health problem associated with substantial morbidity and cost. Lifestyle modification and pharmacotherapy for obesity have limited benefit. Bariatric surgery is effective but with substantial risks, considerable cost and limited patient applicability. Endoscopic approach to obesity has evolved as a result of an attempt to replicate some of the anatomical manipulations and the physiological effects of the traditional weight loss surgery in a minimally invasive manner. Endoscopic interventions performed entirely through the GI tract offer the potential for an ambulatory weight loss procedure that is more cost-effective compared with current surgical approaches. There are two main endoscopic weight loss modalities - restrictive and malabsorptive. Restrictive procedures act to decrease gastric volume by space-occupying prosthesis and/or by suturing or stapling devices that alter gastric anatomy while malabsorptive procedures tend to create malabsorption by preventing food contact with the duodenum and proximal jejunum. Restrictive endoscopic procedures include intragastric balloon treatment, endoluminal vertical gastroplasty, transoral gastroplasty (TOGA) and transoral endoscopic restrictive implant system (TERIS). The duodenojejunal bypass sleeve (DJBS) is a malabsorptive device that mimics such surgical procedure. Gastroduodenojejunal bypass sleeve is a combination of both procedures. Except for intragastric balloon all mentioned procedures are rather novel, tested on a small number of subjects and with limited knowledge on safety and long-term efficacy. Owing to evolving field of evidence-based medicine with demand for rigorous evaluation of the scientific evidence these therapies need to be carefully tested in a randomized controlled manner to determine their safety and efficacy in the short and long-term. This review is aimed to compare endoscopic bariatric interventions with each other and with other weight loss modalities including conventional treatment and surgical procedures.