Bariatric endoscopy: Keep it simple and smart

Abstract

Although not yet fully elucidated, the science behind the mechanisms of energy homeostasis has advanced significantly in recent decades. Current treatment paradigms, however, have not taken advantage of this evolving body of knowledge. The use of the scalpel to treat obesity is historically rooted in society's perception of obesity as the result of inadequate willpower—and not a “disease.” It is an individual's choice to eat excessively that leads to obesity and not a disease state to which the individual has fallen victim. Hence, to lose weight, the patient's anatomy must be surgically altered to either restrict nutrient intake or absorption. Endoscopic treatments have been modeled after this surgical paradigm. It is time for a new paradigm and the development of endoscopic treatments that apply our current understanding of the physiological mechanisms that control energy homeostasis. The author reviews the relevant aspects of the new science and offers a new treatment paradigm that is both simple and smart. A duodenal insert that slows the passage of ingesta through the proximal small bowel is described. The device triggers both early satiation and a continuing sense of fullness to assist in the reduction of caloric intake.