The liver adventures of bariatric endoscopy

In the past few decades, endoscopy has overtaken many procedures that were routinely done surgically; the list is impressively long. With the advent of suturing devices, endoscopists are not only capable of closing defects, fixing stents, etc. but are also capable of suturing and remodeling organs such as the stomach. Bariatric endoscopy is a newborn that already runs by its own legs. The massive expansion of bariatric endoscopy is driven by need: today, one-third of the world’s population is overweight or obese and has associated nonalcoholic fatty liver disease (NAFLD) [1]. Bariatric surgery is very effective but invasive; thus, more and more patients and physicians are looking into less invasive treatments such as bariatric endoscopy, specialized diets, lifestyle coaching, and glucose-dependent insulinotropic polypeptide–glucagon-like peptide-1 (GLP-1) receptor agonists [2]. Bariatric endoscopy intended as gastric plication, or better, endoscopic sleeve gastroplasty (ESG), is becoming very attractive to patients; it is scarless, gives less pain, and is associated with fewer short- and long-term complications, and recovery is fast. However, procedures are less effective in patients with higher body mass index (BMI) and more effective in those with lower BMIs. ESG fits vast types of patients, for example, those in whom conservative medical interventions have failed but who are unfit for or decline bariatric surgery, and also pediatric and geriatric populations [3] [4] where surgery is unsuitable.