“Without data, you are just another person with an opinion”, concluded R. Cohen MD his attack and critique of the novel weight loss procedure, endoscopic sleeve gastroplasty also known as Endosleeve. Cohen et al conducted a systemic review regarding the efficacy and safety of endoscopic sleeve gastroplasty. The authors found no supporting scientific evidence to recommend the use of endoscopic sleeve gastroplasty for treatment of obesity in clinical practice.

I agree with Cohen et al that there are no serious studies yet to support endoscopic sleeve gastroplasty as an effective weight loss procedure. The concept of sleeve gastroplasty is itself, however, flawed and makes no sense. Gastric mechanical restriction that does not alter gastro-intestinal neuro-hormonal signals, like lap band procedure, is not an effective and durable weight loss solution. Obesity is a metabolic problem that requires a metabolic procedure to achieve durable weight loss.

Endoscopic sleeve gastroplasty decreases gastric emptying contrary to gastric sleeve surgery and gastric bypass surgery. Increased gastric emptying has been the most important mechanism of action of effective weight loss procedures. Rapid food transit time and increased nutrient absorption across the intestinal surface stimulates the secretion of intestinal hormones like GLP-1 and PYY that promote weight loss and increase satiety. Those in support of sleeve gastroplasty naively believes that food stasis in the stomach increases satiety leading to decreased caloric intake and weight loss. This theory is outdated and no longer valid. Unless, they provide a more logical and reasonable mechanism of action, sleeve gastroplasty proponents ought to reconsider their position.

Weight loss procedure development should no longer be guided by the erroneous concept of mechanical restriction. I developed gastric fundus invagination based on careful analysis of the literature and a number of observations that demonstrate the role of gastric fundus in gastric emptying, satiety and weight loss. The theoretical basis for gastric fundus invagination is solid and hopefully additional studies in the near future demonstrate its effectiveness and safety.