Endoscopic management in the bariatric surgical patient

Benjamin E. Levitzky and Wahid Y. Wassef

Department of Gastroenterology and Hepatology,
University of Massachusetts Medical Center,
Worcester, Massachusetts, USA
Correspondence to Wahid Y. Wassef, MD, MPH,
Division of Gastroenterology, 55 Lake Avenue North,
Worcester, MA 01655, USA
Tel: +1 508 856 2846;
e-mail: wahid.wassef@umassmemorial.org
Current Opinion in Gastroenterology 2010,
26:632–639
Purpose of review
Morbid obesity is a global health epidemic. As the prevalence of bariatric surgery rises, it
becomes increasingly important for gastroenterologists to understand their role in the
perioperative care of bariatric surgical patients, to recognize potential complications of
surgery that can be addressed endoscopically, and to learn about endoluminal
approaches that may provide alternatives to bariatric surgery in the future.
Recent findings
Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric band account
for more than 80% of weight loss procedures performed worldwide. Over two-thirds
of patients with upper gastrointestinal symptoms following RYGB will have one or
more abnormalities on endoscopy, including anastomotic strictures (53%), marginal
ulcers (16%), functional obstructions (4%), and gastrogastric fistulas (2.6%).
Intraoperative endoscopy can detect early leaks in over 7% of patients during RYGB
surgery. Single-center experience finds that endoscopic repair of small gastrogastric
fistulas is technically feasible in 95% of patients; however, durability of closure remains
limited. Pooled data demonstrate that balloon-assisted endoscopic retrograde
cholangiopancreatography can achieve papillary cannulation in 80% of patients with
RYGB anatomy.
Summary
The gastroenterologist can improve outcomes in bariatric surgical patients by
understanding the issues of care that present themselves perioperatively and that lend
themselves to minimally invasive endoscopic treatments.

Keywords
bariatric surgery, laparoscopic adjustable gastric band, Roux-en-Y gastric bypass,
surgical complications, therapeutic endoscopy

Curr Opin Gastroenterol 26:632–639

ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
0267-1379

review issues of long-term care relevant to the gastroen-

Background
Morbid obesity is an epidemic health problem responsible
for more than 300 000 deaths annually in the US [1,2].
Weight loss surgery remains the only therapy that reliably
achieves sustained weight loss and significant reduction in
obesity-related comorbidities such as diabetes mellitus,
hypertension, and congestive heart failure [1,3]. An esti-
mated 220 000 bariatric surgeries were performed in the
US and Canada during 2009 [4,5]. The role of the gastro-
enterologist has been gradually increasing in the manage-
ment of bariatric surgical patients in recent years. This
involves preoperative and intraoperative evaluations, the
postoperative recognition and management of compli-
cations, as well as the long-term downstream care of these
patients. It is therefore essential for the gastroenterologist
to be knowledgeable in all areas of their care.
The article will start by discussing the gastroenterologist’s
role preoperatively, intraoperatively, and postoperatively
emphasizing the early recognition and management of
bariatric surgical complications. Subsequently, we will
0267-1379 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
terologist. Finally, we will conclude by raising the concept
of bariatric endoscopy which may provide alternatives to
bariatric surgery in the future.
Preoperative endoscopy
Preoperative esophagogastroduodenoscopy (EGD) should
be performed for all patients prior to Roux-en-Y gastric
bypass (RYGB) or laparoscopic adjustable gastric band
(LAGB) [6,7]. EGD prior to RYGB is crucial to look
for potential disease processes in the distal stomach and
proximal small bowel which will be difficult to access
postoperatively [8]. Endoscopy prior to LAGB is needed
to look for large hiatal hernias since they are associated
with higher rates of band slippage and may warrant alterna-
tive bariatric intervention [8]. In patients who are to
undergo bariatric procedures other than RYGB or LAGB,
preoperative EGD is warranted if they are symptomatic
since endoscopy may alter the planned surgical procedure
or timing of surgery in 4–12% of patients [7]. If patients
are asymptomatic, the need for EGD is somewhat
DOI:10.1097/MOG.0b013e32833f1239

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 Bariatric endoscopy Levitzky and Wassef 633

controversial as data in this population remain limited Figure 1 Roux-en-Y gastric bypass anatomy
[6,7]. In light of this, radiographic studies and evaluation
for Helicobacter pylori by serology should be considered
since they provide an alternative means for preoperative
risk stratification. These recommendations are further
elaborated in a position statement by the American Society
for Gastrointestinal Endoscopy [9].

Intraoperative endoscopy
Gastroenterologists may be asked by their surgical col-
leagues to perform intraoperative endoscopy during
RYGB. EGD in this setting helps the surgeon immedi-
ately assess staple lines for hemorrhage, evaluate pouch
size, measure stomal diameter, and test for integrity of
the gastrojejunal anastomosis and pouch to help prevent
early postoperative leaks [7]. During leak testing, the
surgeon clamps the Roux limb and submerges the
gastrojejunal anastomosis and pouch in saline while
the endoscopist pneumatically insufflates the lumen.
Leaks may be identified as bubbles emanating from a
staple line and promptly repaired by the surgeon.
Pooled data from 1930 patients undergoing intraopera-
tive pneumatic testing successfully identified leaks in
7.3% of patients, with a subsequent postoperative leak
rate of 0.7% [7]. This postoperative leak rate is notably
lower than the estimated leak rate of 1.4% to 2% for
(Courtesy of Ethicon Endo-Surgery, Inc; with permission).
all RYGB procedures that were not evaluated intra-
operatively [10].
LAGB consists of an adjustable gastric band, a subcu-
taneous port, and tubing connecting the band and port
Postoperative management (Fig. 2). The band is secured laparoscopically around the
Bariatric surgical complications may occur early or late in proximal stomach just distal to the gastroesophageal junc-
the postoperative course in up to 40% of patients [11,12]. tion. The anterior aspect of the band is sutured in the
Early complications such as bleeding, infection, and region of the cardia to reduce band slippage [8]. When
anastomotic leaks are traditionally managed surgically saline is infused into the port, it passes through the tubing
[13]. Some late complications such as anastomotic stric- and expands the band’s reservoir, thereby increasing
tures and marginal ulcers can be managed endoscopically. gastric restriction.
This section will review the postsurgical anatomy of the Symptoms
gastrointestinal tract following LAGB and RYGB, outline Common postoperative symptoms include inadequate
common symptoms which may herald a postoperative weight loss, nausea and vomiting, and abdominal or
complication, and then discuss the recommended endo- retrosternal pain [8,14].
scopic approach to these complications.
Inadequate weight loss
Postsurgical anatomy Up to 25% of patients undergoing bariatric surgery experi-
It is essential for the gastroenterologist to fully under- ence inadequate weight loss, thus extensive preoperative
stand postoperative gastrointestinal tract anatomy in counseling is mandatory to help establish realistic weight
order to recognize potential symptoms and complications loss goals. It can be a diagnostic challenge to determine if
that may arise. The RYGB is formed by partitioning the inadequate weight loss is due to operative failure or dietary
stomach into a proximal gastric pouch and distal gastric noncompliance. Endoscopy remains the best way to assess
remnant by means of a laparoscopic stapling device the integrity of the postoperative anatomy and is indicated
(Fig. 1). The jejunum is incised 10–30 cm distal to when weight loss is less than anticipated despite appro-
the ligament of Treitz and the distal jejunal ‘Roux’ priate dietary habits [8]. Anatomic disturbances that may
limb is anastomosed to the gastric pouch. The proximal cause inadequate weight loss include pouch dilation,
‘biliopancreatic’ limb is attached downstream, creating a dilation of the gastrojejunal anastomotic aperture, and
separate jejunojejunal anastomosis. gastrogastric fistula formation.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 634 Stomach and duodenum
Figure 2 Laparoscopic adjustable gastric band anatomy
(Courtesy of Ethicon Endo-Surgery, Inc; with permission).
Nausea and vomiting
Nausea and vomiting are common postoperative symp-
toms and are often due to dietary indiscretion, which may
include rapid or large-volume food intake or inadequate
mastication [8]. An initial management strategy should
include dietary counseling and modification if dietary
indiscretions are identified. However, nausea and vomit-
ing may also be hallmark symptoms of an anatomic
problem such as an anastomotic stricture, reflux esopha-
gitis, marginal ulcer, band erosion or slippage, or gastro-
gastric fistula [15]. When nausea and vomiting are
particularly relentless, endoscopy is warranted [9]. Endo-
scopy is also indicated in patients who experience a
dramatic change in their ability to tolerate food and in
patients who experience ongoing nausea despite appro-
priate dietary habits [15].
Abdominal pain and retrosternal pain
Epigastric abdominal pain and retrosternal pain are
abnormal postoperative complaints which may indicate
a wide variety of pathologic causes including band ero-
sion, bile or acid reflux, development of an abscess or
seroma, or mucosal ulceration. If a patient’s history
suggests that dietary factors are playing a role, dietary
counseling is a reasonable first step. Endoscopy is war-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ranted for moderate-to-severe pain or when dietary
changes fail to alleviate pain in order to evaluate for
stomal stenosis, marginal ulceration, and other structural
abnormalities. If abscess or seroma formation is of con-
cern, prompt abdominal CT scan is indicated [15].
Endoscopic management of complications
common to Roux-en-Y gastric bypass and
laparoscopic adjustable gastric band
Luminal stenosis and gastrointestinal bleeding are post-
operative complications that are common to RYGB and
LAGB.
Stenosis
The gastrojejunal anastomosis is the most common site of
stenosis following bariatric surgery. Stenosis may also
occur at the region of a gastric band, at sites of adhesions,
or at the jejunojejunal anastomosis.
Gastrojejunal anastomotic strictures occur in 5.1–6.8% of
patients following RYGB and typically present within the
first year following surgery [8]. The incidence of anasto-
motic stenosis is technique-dependent, with stapled ana-
stomoses yielding a higher stricture rate than those which
are hand sewn [16]. The mainstay of treatment for gastro-
jejunal anastomotic strictures is endoscopic balloon
dilation, although the use of Savary-Gilliard dilators (Cook
Medical, Indiana, USA) has also been described [8].
Repeat dilation with progressively larger balloons may
be required to achieve durable results. Studies demon-
strate that 17–67% of patients respond to the first dilation,
whereas 3–8% of patients require three or more dilations
[16]. The selection of an appropriate initial balloon
depends on a number of factors including the caliber of
the stricture and the presence of suture or staple material
that may inhibit full balloon expansion [16,17]. Some
apprehension exists that excessive balloon dilation of
the anastomosis may lead to subsequent weight gain
due to loss of physiologic restriction at the anastomosis.
However, data suggest that initial gastrojejunal stricture
dilation to 15 mm can be done safely in the majority of
cases without resultant weight gain, thereby reducing the
need for repeat dilation [8,18]. When standard dilation is
unsuccessful, additional strategies may be required such as
removal of exposed sutures with endoscopic scissors,
injection of the anastomosis with saline or steroids after
dilation, or needle-knife electocautery of scar tissue
[8,15].
Luminal stenosis following LAGB may be due to fibrosis
of gastric tissue in the region of the band, band angulation
or slippage, or formation of adhesions. Whereas fibrotic-
related stenosis may be effectively treated with dilation,
stenosis due to band angulation or slippage is rarely able
to be managed endoscopically [15]. Surgical options in

this scenario include band replacement or conversion
to RYGB.
Gastrointestinal bleeding
Significant upper gastrointestinal bleeding occurs in
approximately 1–4% of patients after RYGB and may
be acute or chronic [7]. It commonly occurs at the staple
line of the gastrojejunal anastomosis and may be associated
with marginal ulceration. Hemorrhage may also occur at
staple lines of the gastric remnant, pouch, or jejunojejunal
anastomosis. Thorough examination of the Roux and
biliopancreatic limbs is technically challenging and may
require the use of an enteroscope, colonoscope, balloon
enteroscope, or shape-locking overtube [15]. The endo-
scopic management of early postoperative bleeding after
RYGB is complicated by the risk of perforation at imma-
ture surgical anastomotic sites. Some experts advocate
early operative intervention with or without laparoscopi-
cally assisted endoscopy in this setting [7]. If early post-
operative endoscopy is considered, it must be conducted in
the operating room setting under general anesthesia to
permit immediate operative intervention should perfor-
ation occur or endoscopic intervention fail [7,19].
Early postoperative gastrointestinal bleeding is less com-
mon following LAGB, and standard upper endoscopy is
usually sufficient for management of hemorrhage in
this situation.
Endoscopic management of complications
following Roux-en-Y gastric bypass
Gastrojejunal anastomotic dilation, staple-line disrup-
tion, and marginal ulceration may all complicate RYGB.
Dilation of the gastrojejunal anastomosis
Widening of the gastrojejunal anastomosis may present as
weight regain due to failure of the anastomosis to restrict
food intake. Multiple endoscopic techniques to address
this complication have been described. Endoscopic scler-
otherapy with circumferential injection of sodium morrh-
uate at the anastomosis has been used successfully for
stomal contraction and offers a nonsurgical treatment
modality [20]. Endoscopic suturing provides an alterna-
tive means for stomal reduction. The EndoCinch system
(C.R. Bard Inc., New Jersey, USA) has been used to
position sutures at the rim of dilated gastrojejunal ana-
stomoses [21]. When tightened, the sutures form tissue
plications that effectively reduce aperture diameter and
result in variable but significant weight loss. The Inci-
sionless Operating Platform (USGI Medical, Inc., Cali-
fornia, USA) is a modality that allows for endoluminal
cutting, sewing, tissue manipulation, and creation of
tissue plications. Multicenter experience with this plat-
form for gastrojejunal stomal dilation demonstrated a
50% mean reduction in stomal diameter with mild-to-
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Bariatric endoscopy Levitzky and Wassef 635
moderate weight loss observed over a 1-year follow-up
period [22]. Other promising techniques using clips,
endoscopic suturing devices, fibrin glue, and argon
plasma coagulation are evolving and may provide inno-
vative strategies for reduction of anastomotic aperture.
More confirmatory data are needed before these tech-
niques can be routinely recommended.
Staple-line disruption, fistulas, and leaks
Staple-line disruption may result in extraluminal leaks or
gastrogastric fistulas. Extraluminal leaks are particularly
dreaded complications that occur in up to 5.6% of patients
after RYGB and may result in peritonitis, abscess for-
mation, sepsis, and death [8]. One series of 63 patients
with leaks after RYGB reported a mortality rate of 10%
[23]. The management of early postoperative leaks
remains primarily surgical and there is little role for
endoscopy in this setting [7]. Endoscopic evaluation
of suspected leaks should only be considered in a stable
patient whose diagnosis remains uncertain or in the rare
case in which an endoscopic intervention is planned.
Endoscopic management of leaks has been described
in small series using partially covered self-expanding
metal stents, Polyflex stents, argon plasma coagulation,
endoscopic clips, and fibrin glue [24,25]. Such methods
remain investigational at this time and are solely to be
considered as an adjunct to surgical therapy.
Techniques for the endoscopic management of chronic
gastrogastric fistulas are being actively investigated [26].
In one series of 95 patients with small, symptomatic
gastrogastric fistulas, endoscopic repair was attempted
with the EndoCinch suturing system or endoscopic clips
using a mean of 2.2 sutures or 3 clips [27]. Whereas
fistula closure was achieved in 95% of patients, reopening
occurred 65% of the time at a mean of 177 days. Fistula
size predicted long-term outcomes, with the best results
observed in fistulas 10 mm or less in diameter. Other
investigators used the technique of endoscopic peristo-
mal mucosectomy followed by the use of an endoscopic
tissue opposition device to achieve temporary gastrogas-
tric fistula closure [28]. Whereas temporary fistula repair
may be feasible endoscopically, long-term durability
remains an ongoing challenge. Additional long-term data
will be needed before these methods can be routinely
recommended [7].
Marginal ulceration
Marginal ulcers develop in 0.6–16% of patients following
RYGB [15]. They occur most commonly in the first
several months following surgery with a progressively
decreased incidence thereafter. In one series, marginal
ulcers were found endoscopically at 1 month following
surgery in 4.1% of patients after open RYGB and 12.3%
after laparoscopic RYGB, with 28% of all ulcers occurring
in the absence of symptoms [29]. Contributing factors to
 636 Stomach and duodenum

ulcer formation include local tissue ischemia, use of Figure 3 Slippage of a laparoscopic adjustable gastric band
nonsteroidal anti-inflammatory drugs, foreign body reac-
tions to staples or sutures, gastrogastric fistula, H. pylori
infection, and surgical factors including pouch orientation
and size.

The role of endoscopy in the management of marginal

ulcers is primarily diagnostic; however, as ulcers may
represent foreign body reactions to sutures or staples,
judicious removal of foreign material with endoscopic
scissors may lead to ulcer resolution [8]. The endo-
scopic approach to marginal ulceration begins with a
careful inspection of the gastric pouch and gastrojejunal
anastomosis. Gastrogastric fistulas result in increased
exposure of the pouch and stoma to gastric acid, making
the mucosa more vulnerable to damage [15]. In the
absence of staple-line dehiscence, management of
stomal ulcers includes a test-and-treat approach to
H. pylori, smoking cessation, initiation of a proton pump
inhibitor, and avoidance of ulcerogenic medications [13].
If a marginal ulcer is exceptionally large and unrespon-
sive to conservative therapy, surgical revision may be
required.
(Reprinted with permission of the Royal College of Surgeons of England)
[30].

Endoscopic management of complications

following laparoscopic adjustable gastric Long-term management of patients following
band bariatric surgery
Complications that pertain solely to LAGB include gastric
Morbid obesity and rapid weight loss are independent
band erosion and band slippage. These complications may
risk factors for gallstone formation. The challenges pre-
present with a myriad of symptoms including gastroeso-
sented by postoperative choledocholithiasis are therefore
phageal reflux, peptic ulcer disease, and luminal stenosis
issues of long term relevance to the gastroenterologist.
[8].

Band erosion Choledocholithiasis after Roux-en-Y gastric bypass

Band erosion occurs in 1.6–3% of patients following
LAGB [8]. Diagnosis is best accomplished endoscopi-
cally with direct visualization of the band eroding through
gastric mucosa. Adjustable gastric band extraction cannot
be performed solely by means of endoscopy due to the
presence of tubing that connects the band to the subcu-
taneous port. Adjustable band removal is best handled
surgically with either band excision and replacement or
conversion to RYGB [15].
Band slippage
Band slippage, as shown radiographically in Fig. 3, is
another complication that may occur after LAGB
and is best diagnosed by upper gastrointestinal series
[30]. The endoscopic appearance of band slippage is
variable and dependent on the degree of slippage
encountered. Findings may include an enlarged pouch
size with or without associated gastritis or distal esopha-
gitis. Severe cases are potentially life-threatening and
may present endoscopically as mucosal ulceration or
tissue necrosis [8].
Bariatric surgical patients have a high rate of both pre-
operative and postoperative choledocholithiasis for which
stone extraction may be required [9]. A standard approach
to endoscopic retrograde cholangiopancreatography
(ERCP) is quite feasible after LAGB. In contrast, RYGB
anatomy poses a technical challenge for the endoscopist
when biliary access is required [31]. Successful biliary
cannulation after RYGB depends on a variety of factors
including operator skill and the lengths of the biliopan-
creatic and Roux limbs. The largest series to date in this
population reported successful papillary cannulation in
10 out of 15 patients [32].
In cases when biliary access following RYGB is unattain-
able, a variety of techniques may permit successful biliary
cannulation. ERCP using single or double balloon-assisted
enteroscopes can help the endoscopist more effectively
pleat the small bowel, thereby improving rates of advance-
ment of the endoscope to the papilla [33]. Pooled data from
centers with experience in balloon-assisted enteroscopy
demonstrate an 80% success rate in papillary cannulation

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 Bariatric endoscopy Levitzky and Wassef 637

in RYGB anatomy [31]. Another well described approach Figure 5 Vertical banded gastroplasty
is laparoscopic-assisted ERCP. In this technique, trans-
gastric ERCP is performed through a trocar placed surgic-
ally into the excluded portion of the stomach. Once the
trocar is in place, the endoscopist is able to advance a
duodenoscope to the papilla for biliary access [31]. Other
researchers have described the use of percutaneous gastro-
enterostomy tubes placed into the excluded stomach as
conduits for successful ERCP. All of these approaches are
reasonable means to address the difficult quandary of
ERCP after RYGB. Selection of an individual technique
is dependent on the resources available to the endoscopist
and the skill set of the operator.

Potential future applications of bariatric

endoscopy
There is considerable interest in the development of well
tolerated and effective endoscopic alternatives to surgery
for primary weight loss. To date, no such method has
been perfected. This section will discuss investigational
applications of endoscopy to achieve weight reduction.

Endoscopic gastroplasty
Endoscopic gastroplasty has been performed using both
endoscopic stapling and suturing devices. Initial studies
on a system for transoral gastroplasty (TOGa; Satiety Inc.,
California, USA) reported encouraging results for the
endoscopic creation of a stapled-restrictive pouch along
the lesser curvature of the stomach [34]. Figure 4 demon-
strates the steps used by TOGa for pouch creation. A
randomized, sham-controlled trial to assess the safety and
efficacy of TOGa is currently underway.
Endoluminal vertical gastroplasty using the EndoCinch
system utilizes endoscopic suturing to restrict the volume
Figure 4 Transoral gastroplasty (TOGa)
(Reprinted with permission of the American Society for Gastrointestinal
Endoscopy) [35].
of the gastric lumen (Fig. 5) [35]. In a trial of 64 patients,
endoluminal vertical gastroplasty resulted in a decrease
in the mean body mass index from 39.9 to 30.6 without
serious adverse events reported [35]. Similar short-term
efficacy of endoluminal vertical gastroplasty was reported
in 16 patients within the US and a randomized, multi-
center trial is ongoing at this time [36]. Well designed
trials with long-term follow-up will be necessary to

(a) Diagram depicting deployment of the TOGa over-the-scope, with the endoscope retroflexed for viewing the procedure. (b) Diagram illustrating
retroflexed endoscopic view of the TOGa device gathering anterior and posterior gastric mucosa into the suction chamber prior to stapling. (c) Diagram
depicting formation of a stapled restrictive pouch along the lesser curvature with overlapping staple lines using the TOGa system (Courtesy of Satiety
Inc; with permission).

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 638 Stomach and duodenum
determine the durability of weight loss, particularly since
long-term stability of the gastric plications remains
unproven [37].
Intragastric balloon
The BioEnterics Intragastric Balloon (Allergan Inc., Cali-
fornia, USA) (Fig. 6) is an endoscopically placed balloon
that occupies the gastric lumen, thereby limiting func-
tional intragastric volume [38]. Studies on the use of this
balloon over 3-month and 1-year intervals have resulted
in significant weight loss, although concern for potential
gastrointestinal obstruction has been raised [8,37]. It
may have value in specific patients by providing a bridge
to surgery in high-risk, severely obese individuals who
may otherwise be nonoperative candidates [8,39]. Firm
evidence of the long-term safety and efficacy of the
intragastric balloon is lacking, and it remains unapproved
by the Food and Drug Administration for use in the US.
Figure 6 The BioEnterics intragastric balloon
(Reprinted with permission of the American Society for Gastrointestinal
Endoscopy) [38].
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 7 The GI Dynamics duodenojejunal bypass sleeve
(Courtesy of GI Dynamics, with permission).
Duodenojejunal bypass sleeve
Endoluminal appliances used to induce gastrointestinal
malabsorption remain in an early stage of development
but may offer great potential for long-term weight loss
[37]. The EndoBarrier duodenojejunal bypass sleeve
(GI Dynamics, Massachusetts, USA) is an endoscopically
deployed prosthesis comprised of a self-expanding
implant which lodges in the duodenum and is attached
to a 60-cm plastic sleeve that extends to the proximal
jejunum (Fig. 7). In a trial of 25 patients, the sleeve
stayed in place over a 3-month period in 80% of patients
and achieved noninvasive duodenal exclusion and short-
term weight loss [40]. However, major adverse events
occurred in 20% of patients and included anchor
migration, stent obstruction, and upper gastrointestinal
bleeding. Further studies will be needed to clarify the
safety and efficacy of this device and it remains unap-
proved for use within the US.
Conclusion
As the prevalence of morbid obesity continues to rise,
gastroenterologists will care for bariatric surgical patients
with increasing frequency. It is imperative that gastro-
enterologists be knowledgeable about their role in the
management of bariatric patients preoperatively, intrao-
peratively, and postoperatively in the early recognition of
complications and their endoscopic management. As
technology continues to evolve, we can anticipate new
endoscopic platforms which will broaden the application
of endoscopy for the morbidly obese patient leading to
bariatric endoscopy. This is a term we are using here to
refer to primary endoluminal weight loss procedures that
provide a well tolerated and effective alternative to
surgery. These techniques are on the horizon and offer
the promise of less invasive weight loss strategies for the
morbidly obese patient. However, to date the use of such
techniques cannot be routinely recommended outside the
realm of a clinical trial. Until then, the role of endoscopy in

this burgeoning field, which was very limited in the recent
past and seems to be expanding at an exponential rate, is
curtailed only by our imagination.
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