How to establish an endoscopic bariatric practice

Table 1 Current commercially-available endoscopic bariatric therapies within the United States

Endoscopic bariatric therapies
Food and Drug Administration authorized
ESG with Apollo ESGTM
Transoral outlet reduction with Apollo reviseTM
Orbera® intragastric balloon
Spatz3 intragastric balloon
Off-label or experimental procedures
Endoscopic gastroplasty with Endomina®*
Primary obesity surgery endoluminal 2.0 procedure with incisionless operating platform®*
Endoscopic revision of vertical sleeve gastrectomy (with Apollo OverStitchTM, Endomina®, or the incisionless operating platform®)

ESG: Endoscopic sleeve gastroplasty.

Table 2 Common barriers to establishing an endoscopic bariatric therapy program

Common barriers
Lack of practice, administration, departmental, or partner support
Endoscopist skillset, specifically endoscopic suturing
Facility limitations, particularly the need for general anesthesia capability
Cost-prohibitive facility fees
Difficulty establishing a cash-pay model
Need for nutrition support
Inadequate marketing (limited patient awareness)
Poor patient intake process
External pressures (anti-obesity medication growth and competitive forces)

Table 3 Key components of an endoscopic bariatric therapy program

Key components
Medical personnel
Bariatric endoscopist with obesity medicine certification and sufficient procedural training
Advanced practice provider(s)
Longitudinal nutrition support
Licensed and registered dietitian(s)
Certified health and wellness coach(es)
Patient intake coordinator(s)
Marketing support
Facilities
General anesthesia capability
Experienced pre-op and recovery nurses
Anesthesiologist/anesthetists skilled in managing patients with obesity
Endoscopy technician

Table 4 Equipment commonly used in endoscopic bariatric therapy

Equipment commonly used
Required
Dual-channel endoscope(s) or single-channel gastroscope(s) (if using OverStitch SXTM)
Carbon dioxide insufflator
Argon plasma coagulation
Endoscopic scissors
Hemostatic clips for control of intraprocedural bleeding
Endoscopic retrieval net (for removal of foreign bodies or large clots)
Through-the-scope esophageal balloons (for transoral outlet reduction and subsequent dilations of stenotic outlets if needed)
Grasping forceps (for foreign body removal or suturing assistance)
Optional but recommended
Endoscopic overtube
Hemostatic powder or similar agent (e.g., Hemospray®, PuraStat®)
Infiltration pump for intragastric balloon insertion
Sequential compression devices for venous thromboembolism prevention