Surgery has always been a field in evolution. Surgical procedures and techniques have greatly evolved over the past 100 years. The most dramatic change has been the advent of minimally invasive and endo-luminal surgery. Large incisions and long hospital stays have quickly been replaced with small ones with minimal postoperative pain and very short hospital stays. Just few years ago, as a surgery resident in training, I was performing open gastric bypass procedures. Large deep incisions, wound infections, significant pain, limited mobility, thromboembolic events… crippled weight loss surgery patients and prolonged their hospital stay. The advent of laparoscopy has deeply changed this situation leading to a rapid rise in bariatric surgery popularity.

Currently, the mortality rate of laparoscopic gastric bypass surgery is 0.15% and gastric sleeve mortality is even lower. Laparoscopic gastric sleeve and bypass surgery patients spend on average one night at the hospital prior to discharge. Weight loss surgery patients are able to ambulate and start liquid diet on the same day of surgery. Bariatric surgery became less scary and more appealing to many patients. Yet, only 2% of eligible patients who are morbidly obese opt for surgical treatment each year.

There are many factors contributing to this low percentage. The stigma of undergoing surgery is one of them. Endoscopic bariatric procedures seem like an attractive alternative to laparoscopic surgery. Patients like the concept of “weight loss surgery without the surgery”. Weight loss surgeons are equally eager to jump on the bandwagon. However, adopting new fads without substantial evidence of their effectiveness seems irrational to me. This is especially true when the underlying mechanism of these new endoscopic weight loss techniques contradict everything we have learned so far about metabolic surgery. The best example is gastric balloon placement. A purely restrictive procedure that is doomed to fail simply based on its mechanism of action. The procedure was approved by the FDA but most bariatric surgeons in Houston did not embrace it. Endoscopic bariatric procedures have to mimic the metabolic effects of gastric sleeve surgery to be adopted. A purely restrictive endoscopic sleeve that does not alter blood Ghrelin level or increase gastric emptying and post-prandial GLP-1 levels is unlikely to result in durable and significant weight loss. Should we be early adopters of new bariatric treatments that rely on purely restrictive mechanisms of action? The answer is clearly NO. Instead, we ought to investigate and better understand bariatric surgery mechanism of action and accordingly develop endoscopic procedures. It is no longer accepted to develop a weight loss procedure based on mechanical restriction and expect weight loss surgeons to adopt it.