Recent advances in bariatric endoscopy for obesity management: expanding the therapeutic spectrum

摘要

INTRODUCTION Obesity is a major risk factor for numerous chronic diseases and continues to pose a growing global health challenge. According to the World Health Organization, one in eight individuals worldwide was living with obesity in 2022. In Singapore, the prevalence has risen to 11.6%, reaching 15.0% among adults aged 40–49 years.[1,2] Conventional treatment strategies, including lifestyle modification, pharmacotherapy and bariatric surgery, have yielded variable success. While lifestyle changes remain the cornerstone of obesity management, sustained weight loss is often difficult to achieve. Bariatric surgery, although highly effective, remains underutilised because of its invasiveness and low patient acceptance. Recent pharmacologic advances have improved outcomes; however, long-term adherence, side effects and cost remain significant barriers. Endoscopic bariatric and metabolic therapies (EBMTs) have emerged as minimally invasive, incisionless and reversible alternatives for weight reduction and metabolic improvement. These interventions range from primary obesity treatment to revision procedures following bariatric surgery. The EBMTs are broadly categorised into gastric and small bowel interventions.[3] Intragastric balloons (IGBs) are among the earliest gastric space-occupying devices used for weight management. Fluid-filled IGBs are more effective in inducing satiety due to greater gastric distension, while air-filled balloons are associated with fewer gastrointestinal side effects.[4] Adjustable IGBs have been developed to enhance both efficacy and patient comfort. Despite their short-term benefits — including 6%–15% total body weight loss (TBWL) and improvements in comorbid conditions at 12 months — weight regain is common following device removal, underscoring their role as a temporary bridge to longer-term strategies.[5] More recently, endoscopic suture-based techniques, such as endoscopic sleeve gastroplasty (ESG), have demonstrated superior and more durable outcomes as compared to IGBs.[6] This commentary highlights recent advances in endoscopic gastric remodelling, discusses clinical outcomes, and explores strategies for optimising patient selection and identifying future directions in EBMTs. GASTRIC REMODELLING TECHNIQUES Gastric remodelling or endoscopic gastroplasty procedures involve endoscopic manipulation of stomach volume under general anaesthesia, altering gastric motility and affecting satiation and the hunger pathway. Commonly performed procedures include ESG and primary obesity surgery endolumenal (POSE-2.0). These interventions are associated with short procedure times, low perioperative complication rates, fewer fluid electrolyte disturbances and rapid recovery post-procedure. The International Federation for the Surgery of Obesity and Metabolic Disorders position statement, National Institute for Health and Care Excellence recommendations and American Society of Gastrointestinal Endoscopy–European Society of Gastrointestinal Endoscopy guidelines[7,8,9] recommend endoscopic gastroplasty as a treatment option to prevent progression of obesity and its associated comorbidities in these cases: (1) body mass index (BMI) >30 kg/m2 for whom non-surgical weight loss treatments have been unsuccessful (in South Asian, Chinese and other Asian populations, BMI >27.5 kg/m2 is the recommended threshold); (2) obesity Class III for whom surgery is considered high risk; (3) those who decline bariatric surgery; and (4) BMI of 27.0–29.9 kg/m2 with at least one obesity-related comorbidity. ENDOSCOPIC SLEEVE GASTROPLASTY The ESG procedure [Figure 1] reduces gastric volume by approximately 85% through the placement of 5–8 full-thickness continuous sutures in a ‘U’ pattern along the gastric body, using a second-generation or OverStitch NXT suturing system (Boston Scientific, Marlborough, MA, USA).[10] The gastric fundus is typically spared to reduce the risk of de novo gastro-oesophageal reflux, a common concern with l