BACKGROUND:Metabolic and bariatric surgery (MBS) is the most effective treatment for severe obesity, producing durable weight loss and improvement in obesity-related comorbidities. However, a subset of patients experience inadequate weight loss (non-response, NR) or weight recurrence (WR), which can lead to persistence or recurrence of metabolic disease, diminished quality of life, and warrants for further treatment interventions. OBJECTIVES:This review summarizes current treatment options for NR and WR after MBS, including surgical revisions, endoscopic therapies, and obesity modifying medications (OMMs). METHODS:A comprehensive literature review was performed, incorporating recent systematic reviews, meta-analyses, and retrospective series evaluating outcomes of revisional procedures, endoscopic approaches, and pharmacotherapy for patients with NR and WR following MBS. RESULTS:Revisional surgical options after Roux-en-Y gastric bypass (RYGB) include pouch revision, banding, distalization, and conversion to biliopancreatic diversion-duodenal switch or single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). After sleeve gastrectomy, revisional strategies include re-sleeve, conversion to RYGB, SADI-S, or one-anastomosis gastric bypass. Endoscopic therapies such as transoral outlet reduction and argon plasma coagulation offer modest but clinically meaningful weight loss with low complication rates. OMMs, particularly glucagon-like peptide-1 (GLP-1) receptor agonists (semaglutide) and dual gastrointestinal peptide/GLP-1 receptor agonists (tirzepatide), have demonstrated weight loss in post-MBS patients. Across all modalities, variability in outcomes and high loss to follow-up limit data quality. CONCLUSIONS:NR and WR after MBS require individualized, multidisciplinary management on a case-by-case basis. Surgical, endoscopic, and pharmacologic options all play important roles, and emerging OMMs represent a major advance. Standardized outcome reporting and prospective studies are needed to refine treatment algorithms.

BACKGROUND:There is a dearth of research inclusive of African American adults living with obstructive sleep apnea (OSA) despite differences in symptom presentations compared to non-Hispanic White patient populations. Less is known regarding the potential effect of comorbidities, including hypertension, on commonly reported symptoms, such as fatigue, and their association with inflammatory biomarkers. OBJECTIVE:This longitudinal pilot study aimed to characterize fatigue symptom presentations among African American adults newly diagnosed with OSA and discern peripheral blood analytes linked to symptoms while accounting for co-occurring hypertension. METHODS:African American adults newly diagnosed with OSA with and without co-occurring hypertension were approached by study staff and recruited following their diagnostic visit with sleep medicine clinicians at two health systems and followed over 6 months after commencing continuous positive airway pressure treatment. Patient-Reported Outcomes Measurement Information System Fatigue surveys and plasma were collected every 3 months from 29 participants. Mixed-effects models examined changes in fatigue symptom presentations over time while accounting for plasma-based analytes and hypertension status. RESULTS:Despite higher fatigue symptom severity upon diagnosis, participants with co-occurring hypertension reported greater improvements in fatigue scores after commencing continuous positive airway pressure treatment for up to 6 months than those without hypertension. Inverse correlations were observed between fatigue scores, C-reactive protein, matrix metalloproteinase-8, and osteoprotegerin analyte levels among participants with/without hypertension. Across all participants, changes in interleukin-6 were associated with changes in fatigue scores in the first 3 months after diagnosis. DISCUSSION:Findings indicate that hypertension is linked to increased fatigue upon diagnosis of OSA in this sample of African American adults. Fatigue in persons with hypertension improved after treatment in this sample. These hypothesis-generating findings can inform future interventional studies aimed at improving fatigue among persons with OSA while leveraging markers linked to fatigue symptom severity as potential objective markers of improvements. Further research on the role of inflammatory markers, such as IL-6, on fatigue symptom presentations is warranted in persons with OSA.

While metabolic and bariatric surgery effectively aids weight loss, many individuals can benefit from the use of obesity management medications (OMMS). However, the timing of OMM utilization remains uncertain. With the increasing usage of OMMs, there is interest in combining OMMs with MBS in the adjuvant and neoadjuvant setting. However, there is no algorithm to assist physicians in this. The purpose of this article is to review and grade the current literature following a systematic review to formulate an algorithm to guide usage of neoadjuvant and adjuvant OMMs along with bariatric surgery.

Background: Venous Thromboembolic events (VTE) after Metabolic and Bariatric Surgery (MBS) result in significant morbidity and are the leading cause of mortality. Objective: The objective of this study was to identify patients who are at a high risk for developing VTE and who may benefit from extended chemoprophylaxis following MBS. Setting:Multi-institutional study. Methods: Using the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participant user file (PUF), we identified 696,069 patients who completed 30-day follow-up data and met the inclusion criteria. Using logistic regression analysis, we identified preoperative and postoperative risk factors associated with VTE and validated our model externally using the MBSAQIP 2020-2021 datasets (N = 273,692). The Hosmer- Lemeshow test was used for goodness of fit and calibration. We also compared our model's discriminatory capability with that of other VTE risk assessment tools. We then used these risk factors to create an online open source application. Results: The overall incidence of VTE after MBS in the 696,069 (MBSAQIP 2015-2019 database) patients included in our analysis was .40% (2759 patients). Our model had a good predictive capability, with a C-statistic of .66. Our model also demonstrated good fit with a Hosmer-Lemeshow chi-square of 11.06 (P = .198). A cut-off point of .4% resulted in a sensitivity of 48.28%, with 24% of patients having a VTE risk greater than .4% within the 2015-2019 MBSAQIP dataset. Among all the perioperative factors selected in the PUF, high risk for VTE included African American race (adjusted odds ratios [AOR] 1.625, P <.0001), operation length in minutes (AOR: 1.003, P <.0001), preop functional status (AOR 1.012, P = .007), procedure type (Roux en Y Gastric Bypass; AOR .768, P <.0001 and RBS; AOR .758, P = .019 with respect to sleeve), preop body mass index (BMI) (AOR 1.012, P <.001), history of pre-op vein thrombosis requiring therapy (AOR 5.041, P <.0001), post-op superficial or organ space surgical site infection (AOR 2.713, P <.0001), preop venous stasis (AOR 1.425, P = .019),at least one readmission within 30 days(AOR 1.583, P < .0001), or at least one reoperation within 30 days (AOR 4.399, P < .0001). Conclusion: VTE after MBS can result in increased mortality rates. High-risk patients might benefit from extended chemoprophylaxis. Our model suggests that patients with a VTE risk >= .4% in the first 30 days following surgery may benefit from extended chemoprophylaxis. (Surg Obes Relat Dis 2025;21:228-239.) (c) 2025 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Study Objectives Mindfulness-based interventions (MBI) have been shown to improve psychosocial functioning in medical populations but have not been studied in narcolepsy. This study examined the feasibility and acceptability of an MBI that was adapted for narcolepsy, including three variations in program length.Methods Adults with narcolepsy (N = 60) were randomized to MBI groups of varying durations: brief (4 weeks), standard (8 weeks), or extended (12 weeks). Participants completed assessments at baseline, 4, 8, and 12 weeks. To assess feasibility and acceptability, primary outcomes included attendance, meditation practice, and data completeness. Additionally, participants completed measures of mindfulness, self-compassion, mood, sleep, psychosocial functioning, and cognition. An effect size of Cohen's d >= 0.5 was used as the prespecified benchmark for a minimal clinically important difference (MCID).Results The attendance, meditation, and data completeness benchmarks were met by 71.7%, 61.7%, and 78.3% of participants, respectively. Higher proportions of the brief and extended groups met these benchmarks compared to the standard group. All groups met the MCID for mindfulness, self-compassion, self-efficacy for managing emotions, positive psychosocial impact, global mental health, and fatigue. Standard and extended groups met the MCID for anxiety and depression, and extended groups met the MCID for additional measures including social and cognitive functioning, daytime sleepiness, hypersomnia symptoms, and hypersomnia-related functioning.Conclusions Results suggest that the remote delivery and data collection methods are feasible to employ in future clinical trials, and it appears that the extended MBI provides the most favorable clinical impact while maintaining attendance and engagement in meditation practice.Clinical Trial Registration Awareness and Self-Compassion Enhancing Narcolepsy Treatment (ASCENT), NCT04306952, https://clinicaltrials.gov/ct2/show/NCT04306952 Graphical Abstract

Background Predicting the risk of complications is critical in metabolic and bariatric surgery (MBS). Objectives To develop machine learning (ML) models to predict serious postoperative complications of MBS and evaluate racial fairness of the models. Setting Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national database, United States. Methods We developed logistic regression, random forest (RF), gradient-boosted tree (GBT), and XGBoost model using the MBSAQIP Participant Use Data File from 2016 to 2020. To address the class imbalance, we randomly undersampled the complication-negative class to match the complication-positive class. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), precision, recall, and F1 score. Fairness across White and non-White patient groups was assessed using equal opportunity difference and disparate impact metrics. Results A total of 40,858 patients were included after undersampling the complication-negative class. The XGBoost model was the best-performing model in terms of AUROC; however, the difference was not statistically significant. While the F1 score and precision did not vary significantly across models, the RF exhibited better recall compared to the logistic regression. Surgery type was the most important feature to predict complications, followed by operative time. The logistic regression model had the best fairness metrics for race. Conclusions The XGBoost model achieved the highest AUROC, albeit without a statistically significant difference. The RF may be useful when recall is the primary concern. Undersampling of the privileged group may improve the fairness of boosted tree models.

BackgroundMetabolic and bariatric surgery (MBS), despite being the most effective durable treatment for obesity, remains underused as approximately 1% of all qualified patients undergo surgery. The American Society for Metabolic and Bariatric Surgery established a Numbers Taskforce to specify the annual rate of obesity treatment interventions utilization and to determine if patients in need are receiving appropriate treatment.ObjectiveTo provide the best estimated number of metabolic and bariatric procedures being performed in the United States in 2022.SettingUnited States.MethodsWe reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and National Surgical Quality Improvement Program. In addition, data from industry and state databases were used to estimate activity at non-accredited centers. Data from 2022 were compared mainly with data from the previous 2 years.ResultsCompared with 2021, the total number of MBS performed in 2022 increased from approximately 262,893 to 280,000. The sleeve gastrectomy (SG) continues to be the most commonly performed procedure. The gastric bypass procedure trend remained relatively stable. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Intragastric balloon placement increased from the previous year. Endoscopic sleeve gastroplasty increased in numbers.ConclusionsThere was a 6.5% increase in MBS volume from 2021 to 2022 and a 41% increase from 2020, which demonstrates a recovery from the COVID-19 pandemic. SG continues to be the most dominant MBS procedure.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m 2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m 2 . Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Introduction and BackgroundSleeve Gastrectomy (SG) is the most commonly performed Metabolic and Bariatric Surgery (MBS) procedure. Technical considerations related to the performance of SG are well-established and reported in the literature but not in relation to Robotic Assisted (RA) SG. We report the results of the First Modified Delphi Consensus addressing technical considerations of robotic assisted daVinci (dV)-SGMethodologyA Consensus Building Committee (CBC) was created and comprised 10 experts in the field of RA- Surgery and MBS based on strict selection criteria. The CBC developed 49 consensus statements which were then shared with 240 experts in RA-surgery. Our stopping criterion was stability in responses (15% or less). The consensus cutpoint was 70%ResultsThe overall response rate was 49%. In the first round of voting, there was consensus agreement on 25 statements ( 51%) and consensus disagreement on 14 (28%) and no consensus on the remaining statements (21%). In the second round of voting we reached agreement on three additional statements. Experts recommended the use of the number of pauses generated by the stapler to guide choice of staple height (91.2%) and to upsize the size of the staple height when using buttressing (92%). There was also consensus (81.4%) that the use of closed staple height of 1.00 mm (white) is acceptable and that stapling of antrum using 1.5 mm (blue load) is also acceptable (73%).ConclusionCollective expert opinion structured through a modified delphi consensus statement present a practical guide for surgeons interested in performing dV-SG

To describe residual arterial supply to the stomach after bariatric surgery via a systematic arterial-phase CT assessment approach that can aid in diagnosis and treatment of postoperative complications and facilitate planning for future procedures. Arterial-phase CT of 46 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at 3 academic institutions were retrospectively reviewed to assess patency of left gastric artery (LGA), right gastric artery (RGA), gastroepiploic artery (GEA), and left inferior phrenic artery (LIPA) and presence of gastric perforators. In 25 RYGB and 21 SG patients, mean diameters were LGA 2.2 ± 0.4 mm, RGA 1.6 ± 0.5 mm, and GEA 1.7 ± 0.4 mm. On RYGB scans, all LGAs, RGAs, and 24/25 (96

Background: Predicting operative time is essential for scheduling surgery and managing the operating room. This study aimed to develop machine learning (ML) models to predict the operative time for metabolic and bariatric surgery (MBS) and to compare each model. Methods: The authors used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2016 and 2020 to develop ML models, including linear regression, random forest, support vector machine, gradient-boosted tree, and XGBoost model. Patient characteristics and surgical features were included as variables in the model. The authors used the mean absolute error, root mean square error, and R 2 score to evaluate model performance. The authors identified the 10 most important variables in the best-performing model using the Shapley Additive exPlanations algorithm. Results: In total, 668 723 patients were included in the study. The XGBoost model outperformed the other ML models, with the lowest root mean square error and highest R 2 score. Random forest performed better than linear regression. The relative performance of the ML algorithms remained consistent across the models, regardless of the surgery type. The surgery type and surgical approach were the most important features to predict the operative time; specifically, sleeve gastrectomy (vs. Roux-en-Y gastric bypass) and the laparoscopic approach (vs. robotic-assisted approach) were associated with a shorter operative time. Conclusions: The XGBoost model best predicted the operative time for MBS among the ML models examined. Our findings can be useful in managing the operating room scheduling and in developing software tools to predict the operative times of MBS in clinical settings.

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Abstract Introduction Narcolepsy is a chronic sleep disorder that can greatly inhibit sleep quality, daytime functioning, and health-related quality of life. Although medication is the first-line treatment to manage narcolepsy symptoms, behavioral interventions may provide additional benefits. We examined the impact of varying lengths of a group mindfulness-based intervention on symptoms of hypersomnia among participants diagnosed with narcolepsy. Methods We randomized 60 participants to 3 versions of a mindfulness-based intervention: brief (4 weeks), standard (8 weeks), or extended (12 weeks). Groups of four participants met weekly or biweekly with a trained instructor via videoconference. Participants completed the Hypersomnia Severity Index (HSI) at baseline, 4 weeks, 8 weeks, and 12 weeks to assess hypersomnolence severity and related impairment. Paired samples t-tests were conducted to examine differences from baseline to post-treatment for the HSI total score, symptoms subfactor, and impairment subfactor. Linear mixed models (LMM) were conducted on the HSI total score to examine changes in the three groups across each assessment time point. Analyses were conducted using an intent-to-treat approach with the last observation carried forward for participants who had missing data after the baseline assessment (brief, n = 1; standard, n = 5; extended, n = 3). Results There were no significant group differences on the HSI total score or subfactor scores at baseline. Analyses revealed a significant decrease in HSI total scores from baseline to post-treatment (d=.533, p Conclusion This preliminary report suggest that mindfulness programs can reduce hypersomnia symptoms for individuals with narcolepsy over a 12-week period, regardless of the duration of treatment. Additional analyses are being examined to determine ideal treatment duration to maximize benefits and minimize costs. Support (if any) This research was supported by a grant from NCCIH (R34AT009551)

The construct of food addiction (FA) has been highly debated in recent years particularly in the fields of disordered eating, medical weight management, and bariatric surgery. Some researchers have argued that FA symptoms are distinct, highly prevalent, and present a barrier for patients seeking medical treatment for obesity. The purpose of this study is to evaluate the cross-sectional associations between FA symptomatology, binge eating disorder (BED) and other appetitive traits, as well as dietary quality in a sample of adults with obesity seeking bariatric surgery. This post hoc analysis was conducted on a prospectively collected dataset from August 2020 to August 2022 at a single academic medical center. Descriptive statistics were used to characterize the sample. Additional analyses included: correlation coefficients, multivariable linear regression, and analysis of variance. A total of 587 patients were included in this analysis with low average scores for FA symptoms (mean: 1.48; standard deviation (SD): 2.15). Those with no BED symptoms had the lowest average FA symptoms scores (mean: 0.87; SD: 1.52) and those with both bingeing and LOCE had the highest average scores (mean: 3.35; SD: 2.81). This finding supports the hypothesis that, while related, FA and BED may represent different cognitions and behaviors.

Abstract Objectives Bariatric surgery can lead to postoperative nutritional deficiencies due to restrictive and malabsorptive mechanisms, but there is limited literature quantifying this risk. Methods Patients who underwent Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB) in the IBM® MarketScan® Commercial Database (2006–2016) were identified. Nutritional deficiencies (anemia, protein malnutrition, vitamin B12 deficiency, vitamin D deficiency, other) were assessed at 1 year prior to surgery and at 3 years post-surgery. Multivariable logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) across bariatric surgery types after adjusting for potential confounders (demographics, lifestyle, and comorbidities). Interactions of bariatric surgery types with age, sex, and baseline nutritional deficiencies in relation to post-surgery nutritional deficiencies risk were assessed by likelihood ratio tests. Results A total of 82,885 patients (mean (SD) age of 44.5 (9.5) years) were identified with 38.8% (n = 32,190) undergoing RYGB, 33% (n = 27,388) undergoing SG, and 28.1% (n = 23,307) undergoing LAGB. The most common 3-year postoperative nutritional deficiencies were anemia (28%), vitamin D (24%), protein malnutrition (9%), and vitamin B12 (9%). Relative to the LAGB group, the adjusted OR of developing any 3-year nutritional deficiency postoperatively was 3.03 (95% CI, 2.92–3.15) for the RYGB group and 2.45 (95% CI, 2.36–2.55) for the SG group. These associations were stronger among patients younger than 45 years, men, and those without baseline nutritional deficiency (P‐interaction < 0.05 for all). Baseline nutritional deficiencies were independently associated with higher odds of postoperative nutritional deficiencies. Similar results were observed for anemia, protein malnutrition, and vitamin B12 deficiency. Conclusions RYGB and SG were associated with two- to three-fold odds of developing postoperative nutritional deficiencies compared to LAGB, independent of baseline nutritional deficiency status. Pre- and postoperative nutritional assessment are recommended for all bariatric surgery patients to optimize postoperative outcomes. Funding Sources None.

The growing prevalence of obesity and its increasing burden on society, in both economic and health-related terms, behoove us to find additional treatments. Obesity therapies and devices need to be appealing to patients and their doctors for their efficacy and low rate of adverse events but also must be approved by the U.S. Food and Drug Administration (FDA) and insurance providers. A 2013 study of the University HealthSystem Consortium database showed that bariatric operations are by far the most common elective surgical procedures performed at academic medical centers.1Nguyen N.T. Nguyen B. Shih A. et al.Use of laparoscopy in general surgical operations at academic centers.Surg Obes Relat Dis. 2013; 9: 15-20Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Despite this, surgery remains grossly underused in the management of obesity, with <1% of the eligible population undergoing bariatric surgery.2Altieri M.S. Irish W. Pories W.J. et al.Examining the rates of obesity and bariatric surgery in the United States.Obes Surg. 2021; 31: 4754-4760Crossref PubMed Scopus (17) Google Scholar The reasons for this are numerous and include physician skepticism that obesity is even a disease, lack of primary care provider (PCP) awareness of candidacy guidelines, PCP concern about having to manage post–bariatric surgery care, lack of PCP comfort in discussing obesity treatments, health policy/insurance/financial issues, patient concerns about potential adverse events, lack of patient recognition of even having obesity, and many others.3Funk L.M. Jolles S.A. Voils C.I. Obesity as a disease: has the AMA resolution had an impact on how physicians view obesity?.Surg Obes Relat Dis. 2016; 12: 1431-1435Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 4Balduf L.M. Farrell T.M. Attitudes, beliefs, and referral patterns of PCPs to bariatric surgeons.J Surg Res. 2008; 144: 49-58Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 5Afonso B.B. Rosenthal R. Li K.M. et al.Perceived barriers to bariatric surgery among morbidly obese patients.Surg Obes Relat Dis. 2010; 6: 16-21Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Having additional tools in the arsenal to fight severe obesity can only be beneficial, and endoscopic bariatric therapies (EBTs) represent such tools. As conceptualized, EBTs are easy to perform, relatively safe, relatively effective, potentially repeatable or reversible, and of lower cost when compared with obesity surgeries. Any EBT that meets these criteria would be an ideal alternative to a formal surgical intervention, making it attractive to patients, physicians, and payors. Unfortunately, the recent history of EBTs has been that of devices and procedures failing to meet the mark. Physicians in the United States waited almost 25 years for an FDA-approved intragastric balloon, only to see modest uptake. The endoluminal duodenal jejunal bypass liner is not currently available for sale in the United States and can therefore be offered only in investigational trials. The previously FDA-approved gastric aspiration therapy device was withdrawn from the market in February 2022 because of the company’s financial failure in the COVID-19 pandemic. As such, the field remains open for safe, effective, and available endoscopic alternatives to both surgery and lifestyle interventions for obesity. Endoscopic sleeve gastroplasty (ESG) is an emerging EBT that currently uses an endoscopic suturing device (Overstitch or Overstitch SX, Apollo Endosurgery, Austin, Tex, USA) to significantly reduce the gastric volume in a manner that emulates a surgical sleeve gastrectomy (SG). Although the procedure is transoral (and therefore incisionless), it requires the ability to endoscopic free suture, which increases the needed endoscopic skillset over those of other EBTs. The feasibility of ESG was first described in 2013 by Abu Dayyeh et al6Abu Dayyeh B.K. Rajan E. Gostout C.J. Endoscopic sleeve gastroplasty: a potential endoscopic alternative to surgical sleeve gastrectomy for treatment of obesity.Gastrointest Endosc. 2013; 78: 530-535Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar in 4 patients with obesity. Since that time, various publications have addressed the safety and efficacy of ESG, but few studies have directly compared ESG with SG in a prospective fashion. The study by Gudur et al7Gudur A.R. Geng C.X. Kshatri S. et al.Comparison of endoscopic sleeve gastroplasty versus surgical sleeve gastrectomy: a metabolic and bariatric surgery accreditation and quality improvement program database analysis.Gastrointest Endosc. 2023; 97: 11-21Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar compared outcomes of ESG and SG by using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry participant use data files. MBSAQIP works to advance safe, high-quality care for bariatric surgical patients through the voluntary, independent, peer-reviewed accreditation of inpatient and outpatient bariatric surgery centers in the United States and Canada. Every metabolic and bariatric procedure (open, laparoscopic, hand-assisted, robotic, or endoscopic) performed for the treatment of metabolic or obesity-related diseases at an MBSAQIP-accredited center must be entered into the MBSAQIP registry. As such, the analyzed dataset contains audited, mandatory-reported outcomes from 885 high-volume bariatric centers interested in quality improvement. The primary aim of the study by Gudur et al7Gudur A.R. Geng C.X. Kshatri S. et al.Comparison of endoscopic sleeve gastroplasty versus surgical sleeve gastrectomy: a metabolic and bariatric surgery accreditation and quality improvement program database analysis.Gastrointest Endosc. 2023; 97: 11-21Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar was to compare the short-term (30-day) outcomes in 6054 ESG patients from the MBSAQIP registry and to 597,463 SG patients. A secondary aim was to determine if race had any impact on these short-term outcomes. As seen in most EBTs, percentage of total body weight loss and body mass index reduction were higher for SG compared to ESG. Additionally, major adverse events occurred at a statistically similarly low rate after both procedures. However, the rates of readmission, reintervention, and reoperation were statistically higher after ESG. Race did not appear to have any effect on ESG outcomes in this analysis, although black race did predispose to more adverse events after SG. The finding of a higher rate of readmission and reinterventions is difficult to explain but could have been due to heightened concern by endoscopists on the grounds that this is a newer procedure than SG. It will be interesting to observe the trends of such outcomes over time as ESG use increases, as it likely will. Overall, this study confirms that at the very least, ESG has early outcomes that are comparable with those of SG and that it therefore represents a viable alternative to a surgical procedure for obesity. Questions about comparative durability, differences in hormonal changes after each procedure, and long-term issues related to anatomic rearrangements remain to be answered. However, the authors are to be congratulated on bringing the current answers to light. One great unknown of this study is whether the data represent a best-case or worst-case scenario. Sleeve gastrectomy has been the most common bariatric procedure in the United States for almost a decade, the techniques are well defined, and the nearly 600,000 SG procedures in this study are likely being performed by surgeons well past their learning curve. ESG represented only 1% of the patients included in the study. Were they performed by a wide array of gastroenterological and surgical endoscopists still learning ESG or by a select few who had already mastered the procedure? Studies have suggested that an endoscopist may need 29 to 38 ESG procedures to become efficient in the procedure and as many as 55 ESGs to master the technique.8Saumoy M. Schneider Y. Zhou X.K. et al.A single-operator learning curse analysis for the endoscopic sleeve gastroplasty.Gastrointest Endosc. 2018; 87: 442-447Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar There is no way to know the skillset of the endoscopists in the study or whether mastery of the method will influence the short- or long-term outcomes of ESG. The past few months have seen a flurry of excitement around ESG. On July 13, 2022, the FDA approved the Apollo Endosurgery (Austin, Tex, USA) suturing systems for ESG in patients with a body mass index of 30 to 50 kg/2. Within 2 weeks of this announcement, the Multicenter ESG Randomized Interventional Trial was published online in the Lancet.9Abu Dayyeh B.K. Bazerbachi F. Vargas E.J. et al.Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomized trial.Lancet. 2022; 400: 441-451Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar That study evaluated the long-term outcomes in 85 patients randomized to ESG and compared them with the outcomes in 124 patients assigned to a control group. At 52 weeks, patients undergoing ESG achieved a 12.6% decrease in percentage of total body weight compared with control patients. Additionally, 80% of the ESG patients had improvement in ≥1 metabolic comorbidity. At 104 weeks, 68% of the ESG group maintained ≥25% excess weight loss. ESG-related serious adverse events occurred in 2% of participants, without mortality or need for surgery. Taken together, the available evidence suggests that ESG is ready for prime time, but with some caveats. First, SG still appears to outperform ESG for total weight loss, and patients should be counseled about the advantages and disadvantages of each procedure; this ideally happens at a center that can offer the patient the most appropriate bariatric intervention for their comorbidities. Second, ESG should be performed by appropriately trained endoscopists (be they surgeons or gastroenterologists) to assure that patients receive a safe, efficient, and effective EBT. Physicians performing ESG must be capable of managing the uncommon adverse events that do occur. Already, bariatric social media forums contain reports of ESG being performed at outpatient facilities by endoscopists without admitting privileges at nearby hospitals offering bariatric surgical care. This is a recipe for disaster, and it is certainly an issue the FDA will be looking at during postmarket surveillance. Finally, longer-term outcomes of ESG need to be reported and tracked to permit a better understanding of the remote outcomes, adverse events, reintervention, and conversion rates. Dr Rogers is a speaker and teacher for Medtronic and Ovesco; a speaker, teacher, and DSMB member for Davol (Becton Dickinson); is a consultant for Boston Scientific, Actuated Medical, Baxter, Wells Fargo, Cook Biotech, CMR Surgical, Neptune Medical, Surgimatix, Boehringer Laboratory, Allergan, and Noah Medical; is a recipient of royalties from UpToDate and Springer; and has financial interests in Springer and IHC Inc.