Endoscopic bariatric and metabolic therapies

Obesity remains one of the most urgent global health challenges, driving substantial morbidity, mortality, and healthcare expenditure. Although lifestyle modification, pharmacotherapy, and bariatric surgery form the traditional pillars of treatment, each has important limitations. Lifestyle therapy often produces transient weight loss, newer anti-obesity medications are effective but limited by cost and tolerability, and bariatric surgery-while the most durable intervention-continues to reach only a small fraction of eligible patients. Endoscopic bariatric and metabolic therapies (EBMTs) have emerged to bridge this gap, offering incisionless, organ-sparing interventions with efficacy exceeding lifestyle treatment alone and risk profiles generally lower than surgery. Intragastric balloons provide temporary gastric volume occupancy and achieve modest total body weight loss, though durability is limited after device removal. Endoscopic gastric remodeling techniques, particularly endoscopic sleeve gastroplasty (ESG), offer greater and more durable weight loss, with meaningful improvement in obesity-related comorbidities including diabetes, hypertension, dyslipidemia, obstructive sleep apnea, and metabolic-associated steatotic liver disease. Revisional procedures such as revisional ESG and transoral outlet reduction (TORe) address weight regain after sleeve gastrectomy and Roux-en-Y gastric bypass, respectively, providing effective lower-risk alternatives to revisional surgery. Emerging small bowel therapies, including duodenal-jejunal bypass liners and duodenal mucosal ablation platforms, target foregut physiology and insulin resistance, with particular promise for patients with type 2 diabetes and poor glycemic control. With increasing emphasis on chronic, multimodal obesity management, this chapter informs healthcare professionals on the current evidence for primary and revisional EBMTs and how they may fit into the advancing paradigm of individualized obesity care.