Advances and future directions in endoscopic bariatric therapies

Table 1 A summary of endoscopic bariatric therapies in obese patients

Methods	Advantages	Disadvantages	Limitations	Compared with surgery
IGB	The short-term effects are significant, typically lasting for about 6 months (TBWL: 10%-15%, EWL: 20%-30%)	This treatment carries a high risk of weight regain with limited weight loss efficacy. Common adverse effects include mild gastrointestinal discomfort, with potential risks of IGB migration and rupture	Long-term effects are uncertain; post-operative outcomes rely on patient cooperation (diet and behavior); they are not suitable for severely obese patients	This approach is minimally invasive and reversible, making it more suitable for patients with mild obesity. However, those with severe obesity and no contraindications are more suitable for traditional bariatric surgery. Additional advantages include shorter hospitalization, quicker recovery, and lower costs relative to surgical interventions
ESG	ESG demonstrates effective weight reduction with sustained efficacy for 24 months (TBWL: 15%-20%, EWL: 50%-60%), applicable to class I and class Ⅱ obesity, including patients with class III obesity who are unwilling or ineligible for conventional metabolic and bariatric surgery	The procedure is technically demanding with higher procedural costs. Common postoperative effects include gastrointestinal discomfort, with additional risks of suture-related complications
DJBS	DJBS provides effective weight loss, typically achieving 30%-40% EWL over 12 months without requiring permanent anatomical changes	As the common channel length shortens, so do diarrhea and severe vitamin A and vitamin D deficits, and there are risks such as sleeve migration
TOGA	TOGA delivers effective weight loss (30%-40% EWL), typically achieved within 12 months	Postoperative gastrointestinal discomfort may occur, with risks including gastric perforation. Some patients experience weight regain at 24-month follow-up
BTX-A	BTX-A demonstrates short-term efficacy and is indicated for patients with mild obesity	BTX-A demonstrates limited efficacy with ongoing debate in the medical community, showing only short-term effects (typically lasting 3-6 months). Potential complications include infection or toxicity
GES	GES demonstrates significant short-term efficacy, typically achieving 25%-35% EWL within 12 months	The technical requirements are high, and new systems need to be developed

IGB: Intragastric balloon; ESG: Endoscopic sleeve gastroplasty; DJBS: Duodenal-jejunal bypass sleeve; TOGA: Transoral gastroplasty; BTX-A: Botulinum toxin A; GES: Gastric electrical stimulation; TBWL: Total body weight loss; EWL: Excess weight loss.

Table 2 A quick-reference summary of endoscopic bariatric therapies in obese patients

	IGB	ESG	DJBS	TOGA	BTX-A	GES
EWL%	20%-30%	50%-60%	30%-40%	30%-40%	Uncertain	25%-35%
Reversible	Yes	Partially	Yes	No	Yes	Yes
Difficulty1	1	4	2	4	1	2
Metabolic effect	Moderate	Significant	Marked	Good	Limited	Mild
Safety	High	Medium-high	Moderate	Moderate	High	Moderate

¹Difficulty rating scale is based on technical complexity, instrument coordination, and training experience (number of procedures performed); the levels from 1 to 4 correspond to basic, intermediate, advanced, and expert, respectively.

IGB: Intragastric balloon; ESG: Endoscopic sleeve gastroplasty; DJBS: Duodenal-jejunal bypass sleeve; TOGA: Transoral gastroplasty; BTX-A: Botulinum toxin A; GES: Gastric electrical stimulation; EWL: Excess weight loss.

Table 3 Rare complications after intragastric balloon therapy

Number	Gender	Age	Initial BMI (kg/m2)	Complication	Timeframe	Adverse reaction	Symptoms	Ref.
1	Female	22	33	None	6 weeks	Non-biliary pancreatitis	Persistent, sharp pain in the upper abdomen, with progressive exacerbation and a severity of 8/10 (VAS), without diurnal variation or radiation, which later spreads to the entire abdomen. The pain is aggravated by movement and slightly relieved by rest	[35]
2	Male	31	NA	None	10 weeks	Gastric perforation	Intermittent colicky pain in the left upper abdomen, which was exacerbated in anteflexion	[36]
3	Female	35	34	Hepatomegaly, leiomyoma, and a small sliding-type hiatal hernia	2 weeks	Gastric dilation and gastric outlet obstruction	Intractable nausea and vomiting with postprandial exacerbation. Nausea was initially managed with a liquid diet. Subsequently, the patient developed persistent vomiting accompanied by non-radiating retrosternal burning pain	[37]
4	Male	29	38	None	5.5 years	None	The IGB has been present in the body for 5.5 years without any abnormalities, and the BMI is 37.3 kg/m2	[38]
5	Female	46	NA	Gastritis	10 months	Small bowel obstruction (with the balloon 40 cm from the ileocecal valve)	Abdominal distension and excessive salivation accompanied by nausea	[39]
6	Female	23	NA	None	12 months	Mall bowel obstruction caused by a migrating IGB	Non-radiating generalized abdominal pain, recurrent vomiting, and constipation with flatus	[40]
7	Male	34	41	None	20 months	Gastroenteritis	Severe, progressive, generalized, cramping abdominal pain, localized to the lower abdomen, accompanied by anorexia, nausea, and vomiting	[41]
8	Female	30	NA	None	18 months	Small bowel obstruction	The diffuse abdominal pain is progressively worsening, primarily in the upper abdominal region, and radiating to the right upper abdomen associated with vomiting	[42]
9	Female	58	42	None	10 months	Gastric outlet obstruction caused by IGB impaction	Postprandial vomiting and abdominal distension	[43]
10	The overall complication rate was 2.8% (70/2515), including: 5 cases of gastric perforation, 19 cases of gastric obstruction, 9 cases of device rupture, 32 cases of esophagitis and 5 cases of gastric ulceration							[44]

BMI: Body mass index; NA: Not available; IGB: Intragastric balloon; VAS: Visual analogue scale.

Table 4 Rare complications after endoscopic sleeve gastroplasty therapy

Number	Gender	Age	Initial BMI (kg/m2)	Complication	Timeframe	Adverse reaction	Measures	Symptoms	Ref.
1	Female	55	44.6	Stress urinary incontinence, back pain, and nephrolithiasis	During the operation	Dilated bowel loops and acute respiratory failure	High-flow nasal cannula oxygen therapy	Hypoxemia with abdominal distension	[75]
2	Female	34	30	None	1 months	Gallbladder folding secondary to ESG therapy	Laparoscopic cholecystectomy	Hematemesis, somnolence and positive Murphy’s sign	[76]
3	Female	31	Obesity (class I)	None	2 weeks	Liver abscess	Endoscopic drainage to gastric cavity	Epigastric pain and fever (39.3 °C)	[77]
4	Female	53	NA	None	1 days	Gastrointestinal symptoms and acute hypoxemic respiratory failure (7 days later)	Remove all sutures on post-op day 1; lovenox, apixaban and other supportive therapy	Refractory nausea, vomiting, abdominal pain, tachycardia and hypertension (BP 160/102 mmHg)	[78]
5	Female	40	NA	None	1 days	Intestinal obstruction with spontaneous resolution and pulmonary embolism (12 days later)	Apixaban and other supportive therapy	Severe epigastric pain, nausea and vomiting	[78]
6	Male	64	35.8	Hypertension, hyperlipidemia, and gastroesophageal reflux disease	9 hours	Gastric perforation	Exploratory laparotomy	Acute abdominal pain, abdominal distension and respiratory distress	[79]
7	Male	53	43.6	None	1 days	Umbilical hernia-induced small bowel obstruction, pneumoperitoneum and acute kidney injury	Emergent surgery	Abdominal pain, nausea and vomiting	[80]
8	Among 1000 enrolled patients: 924 (92.4%) experienced medication-controlled nausea or abdominal pain. Overall complication rate: 2.4% (24/1000), comprising: 8 cases of severe abdominal pain requiring intervention, 7 cases of postoperative hemorrhage, 4 cases of perigastric collection with pleural effusion and 5 cases of postoperative fever								[81]

BMI: Body mass index; NA: Not available; ESG: Endoscopic sleeve gastroplasty; BP: Blood pressure.