Are We Missing Another Opportunity?

| November 1, 2023

by Adam B. Smith, DO, DFACOS, FASMBS, and Robert G. Snow, DO, FACOS, FASMBS

Dr. Smith is Adjunct Clinical Professor, University of North Texas Health Science Center in Fort Worth, Texas. Dr. Snow is with University of North Texas Health Science Center and Ultimate Bariatrics in Fort Worth, Texas.

Funding: No funding was provided for this article.

Disclosures: Dr. Snow is faculty/consultant for Boston Scientific, Endobariatric Division. Dr. Smith has no conflicts of interest relevant to the contents of this article.

Bariatric Times. 2023;20(7–12):28–29.

Our group has been doing surgery for almost 30 years. During that time, we have seen changes in the field—many good, but some troubling. We were trained by the old guard surgeons who did it all. Our mentors came from a variety of disciplines, such as gynecology, otorhinolaryngology, abdominal, vascular, thoracic, and even orthopedics. We were fortunate to work with gastroenterologists who gave us extensive opportunities to log hundreds of upper and lower endoscopic procedures. Like others at the time, we transitioned to training in laparoscopic procedures in the 1980s, but we watched some of our prior procedures of focus disappear in the process.

As time has passed, the bulk of general surgery training has transitioned to abdominal, vascular, and endoscopic procedures. After residency, we did everything we were trained to do and built successful practices, but when pressure mounted from the other specialties to relinquish certain turf, we have opted to focus on laparoscopic abdominal surgery and endoscopy. In doing so, we have given up much of what we were originally trained to do.

We can all think of examples of specialties that came head-to-head over a particular disease treatment or area of practice. Generally, the proceduralists that champion a successful, less-invasive approach start to capture a significant portion of the specialty and change the status quo. By being even just a few years ahead with data collection, procedural refinement, and implementation of training programs for their successors, interventional medical specialties, such as interventional cardiology, can shift the surgical landscape permanently.1

This and other examples might foreshadow a similar scenario in bariatric surgery. Bariatric surgery has advanced significantly since the emergence of laparoscopic surgical procedures. It has been refined and perfected thanks largely to the considerable time, effort, and resources we have invested in developing comprehensive bariatric practices and the Center of Excellence (now Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program [MBSAQIP]) model.2

Our bariatric societies have stressed the fundamental importance of comprehensive aftercare. This includes developing a thorough postprocedural follow-up plan, which is critical for excellent patient results and few complications. Quality outcomes in this disease space require a coordinated team effort to prepare for a successful procedure and execute a sound postprocedural plan.3 To take this one step further, bariatric surgeons have implemented a formal process of evaluating our programs. With good outcomes, we can become MBSAQIP-accredited centers, a designation that was historically rare in surgical specialties.4 Studies confirm this impacts patient care positively and elevates the standard of care in our field.5,6 As a specialty, we have taken the responsibility for patient safety, surgical outcomes, and standardization of postoperative aftercare for bariatric surgery through society guidelines developed through high-quality data capture and analysis.7,8

The stakes have been raised now, with a new group of players entering the weight loss arena: gastroenterologists. Through the innovation of endoscopic technologies, new minimally invasive approaches have improved the results achievable with an endoscope. This innovation has been the direct result of the commitment of industry, surgeons, and gastroenterologists. While the entrance of gastroenterologists into obesity care might not affect our practice directly, concerns have been raised regarding the experience and training a gastroenterologist receives on postprocedural obesity care and long-term patient management.9

After discussing with several gastroenterologists, even they agree that though they have the skills to perform the procedure, they are often limited, if not flat out restricted, in the comprehensive, postprocedural care of the bariatric patient. There is also little guidance or description in the literature on how to construct an endobariatric program model successfully as a gastrointestinal specialist, with the exception of a few academic examples.10,11 It is likely that continued difficulty in constructing a successfully comprehensive program will result in suboptimal outcomes in the community, and if they do succeed, what will be the role of our bariatric societies, evaluation entities, and hospitals in accrediting an entirely different specialist?

The time is now for bariatric surgeons to get involved with endoscopic bariatric procedures. Numerous innovations over the past several years that utilize an endoscopic approach have emerged.12 Bariatric surgeons and bariatric endoscopists from the rest of the world have been developing techniques and technologies that have pushed the envelope beyond what anyone could imagine just a decade ago. From gastric balloons to endoluminal suturing devices and mucosal therapies, the rest of the world has published data reinforcing that endoscopic bariatric procedures are safe, effective, and here to stay.13,14 In the United States (US), our innovation with new procedures and technology is unfortunately limited by the US Food and Drug Administration (FDA) and their historically restrictive attitude toward new technology development, but even here we have achieved a major milestone. The collaboration of interventional gastroenterologists and bariatric surgeons in the execution of the MERIT study,15 a randomized, controlled trial demonstrating the efficacy and safety of the endoscopic sleeve gastroplasty (ESG) in obesity management, ultimately resulted in the first FDA authorization of a device indicated to perform ESG.16

Currently, in the US as well as internationally, there are many opportunities for surgeons to train in advanced endoscopic bariatric procedures. Endobariatric companies have taken the lead to develop comprehensive training opportunities, guidelines for care, proctoring, and receiving feedback from expert endoscopic bariatric surgeons for evaluation of programs, but practitioner attitudes remain divided on standardized techniques, indications, and postprocedural care.17

It is imperative that bariatric surgeons work with industry to properly develop endobariatric technologies, train our peers, and publish data to validate new procedures and standardize care protocols. Take the opportunity now to be a leader in endoscopic bariatric procedures; there aren’t many in the world at the moment, but the window of opportunity will close. If bariatric surgeons do not help lead the way in technical innovation and commitment to quality outcomes in endoscopic bariatrics, we could find ourselves standing on the sidelines and watching yet another era pass us by, like our general surgery predecessors before us.

See the response, titled “Letter to the Editor: A Response to ‘Are We Missing Another Opportunity?’,” here.


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  13. Alqahtani AR, Elahmedi M, Aldarwish A, et al. Endoscopic gastroplasty versus laparoscopic sleeve gastrectomy: a noninferiority propensity score-matched comparative study. Gastrointest Endosc. 2022;96(1):44–50.
  14. Neto MG, Silva LB, Grecco E, et al. Brazilian Intragastric Balloon Consensus Statement (BIBC): practical guidelines based on experience of over 40,000 cases. Surg Obes Relat Dis. 2018;14(2):151–159.
  15. Abu Dayyeh BK, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of Class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet. 2022;400(10350):441–451.
  16. Brooks M. FDA clears endoscopic devices for sleeve gastroplasty, bariatric revision. 20 July 2022. Accessed 29 Mar 2023
  17. Badurdeen D, Farha J, Fayad L, et al. The attitude of practitioners towards endoscopic sleeve gastroplasty. J Clin Gastroenterol. 2022;56(9):756–763.


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