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Background and Aims EUS remains a primary diagnostic tool for the evaluation of pancreaticobiliary disease. Although EUS combined with FNA or biopsy sampling is highly sensitive for the diagnosis of neoplasia within the pancreaticobiliary tract, limitations exist in specific clinical settings such as chronic pancreatitis. Enhanced EUS imaging technologies aim to aid in the detection and diagnosis of lesions that are commonly evaluated with EUS. Methods We reviewed technologies and methods for enhanced imaging during EUS and applications of these methods. Available data regarding efficacy, safety, and financial considerations are summarized. Results Enhanced EUS imaging methods include elastography and contrast-enhanced EUS (CE-EUS). Both technologies have been best studied in the setting of pancreatic mass lesions. Robust data indicate that neither technology has adequate specificity to serve as a stand-alone test for pancreatic malignancy. However, there may be a role for improving the targeting of sampling and in the evaluation of peritumoral lymph nodes, inflammatory pancreatic masses, and masses with nondiagnostic FNA or fine-needle biopsy sampling. Further, novel applications of these technologies have been reported in the evaluation of liver fibrosis, pancreatic cysts, and angiogenesis within neoplastic lesions. Conclusions Elastography and CE-EUS may improve the real-time evaluation of intra- and extraluminal lesions as an adjunct to standard B-mode and Doppler imaging. They are not a replacement for EUS-guided tissue sampling but provide adjunctive diagnostic information in specific clinical situations. The optimal clinical use of these technologies continues to be a focus of ongoing research.

Background and Aims Artificial intelligence (AI)-based applications have transformed several industries and are widely used in various consumer products and services. In medicine, AI is primarily being used for image classification and natural language processing and has great potential to affect image-based specialties such as radiology, pathology, and gastroenterology (GE). This document reviews the reported applications of AI in GE, focusing on endoscopic image analysis. Methods The MEDLINE database was searched through May 2020 for relevant articles by using key words such as machine learning, deep learning, artificial intelligence, computer-aided diagnosis, convolutional neural networks, GI endoscopy, and endoscopic image analysis. References and citations of the retrieved articles were also evaluated to identify pertinent studies. The manuscript was drafted by 2 authors and reviewed in person by members of the American Society for Gastrointestinal Endoscopy Technology Committee and subsequently by the American Society for Gastrointestinal Endoscopy Governing Board. Results Deep learning techniques such as convolutional neural networks have been used in several areas of GI endoscopy, including colorectal polyp detection and classification, analysis of endoscopic images for diagnosis of Helicobacter pylori infection, detection and depth assessment of early gastric cancer, dysplasia in Barrett’s esophagus, and detection of various abnormalities in wireless capsule endoscopy images. Conclusions The implementation of AI technologies across multiple GI endoscopic applications has the potential to transform clinical practice favorably and improve the efficiency and accuracy of current diagnostic methods.

Obesity affects 39.6 of adults in the United States and is a risk factor for many diseases including but not limited to diabetes, cardiovascular disease, and nonalcoholic fatty liver disease. Weight loss can reduce the risk of these diseases, but weight loss of ≥10% total body weight are likely needed to see reduction in endpoints including myocardial infarction, stroke, and liver fibrosis. This magnitude of weight loss is difficult to achieve with lifestyle intervention alone. In clinical practice treatment with endoscopic bariatric therapies in conjunction with lifestyle intervention have demonstrated weight loss ≥10% total body weight. Several lines of evidence indicate that the intensity of lifestyle intervention affects overall weight loss seen with endoscopic bariatric therapies. Moreover, tailoring the lifestyle intervention to compliment the mechanism of action of the endoscopic bariatric therapy may enhance weight loss further.

The gas-filled intragastric balloon (IGB) system (Obalon) and the fluid-filled IGB system (Orbera) are the current FDA-approved IGB systems to treat obesity; however, they have not been previously compared in clinical practice. The aims of this study were to compare their efficacy, tolerance, and safety in a clinical setting.This is a retrospective cohort study of consecutive patients treated with the gas-filled IGB or fluid-filled IGB between October 2015 and May 2020 at 2 academic centers. The primary endpoints included percent total body weight loss at balloon removal in patients who completed at least 20 weeks of therapy, the difference in adverse events that required urgent evaluation or hospitalization, and early removal in the 2 groups.A total of 87 patients underwent successful IGB placement (gas-filled IGB n=57, age 48.9±8.8, body mass index 35.5±5 kg/m2; fluid-filled IGB n=30, age 49.2±14.3, body mass index 38.8±6 kg/m2). Eleven patients underwent early device removal. There were no differences in percent total body weight loss at balloon removal and 12 months between the balloon systems (P=0.39). Patients who received the fluid-filled IGB were more likely to require urgent evaluation or treatment, require hospital stay24 hours, and need early balloon system removal compared with patients treated with the gas-filled IGB.In this 2-center cohort, both FDA-approved gastric balloon systems had the same effectiveness, but the gas-filled IGB had fewer serious adverse events and better tolerability than the fluid-filled IGB.

With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.

Background Obesity is the most common chronic disease in the United States today. Additional therapies are needed to improve obesity treatment. Objective A swallowable, gas-filled intragastric balloon system was approved for the treatment of obesity by Food and Drug Administration in September 2016 and commercialization started January 2017. A registry was made available to physicians to capture evidence of safety and effectiveness with use. Setting United States private clinics, surgery centers, and hospitals. Methods This study is a retrospective analysis of a prospective registry of patients with body mass index (BMI) ≥25 kg/m2 that initiated therapy in the first year. Data on demographics, procedural timing, weight loss, adverse events, and device deficiencies were captured. Results The final analysis comprised 1343 patients across 108 treating physicians (mean age 45.7 ± 10.8 yr, 78.6% female, baseline BMI of 35.4 ± 5.4 kg/m2). Nonserious and serious adverse events were reported in 14.2% and .15% of patients, respectively. There were 7 balloon deflations, none caused obstruction. Weight loss in the indicated use (BMI 30–40 kg/m2) was 9.7 ± 6.1 kg and 10.0 ± 6.1% total body weight loss (TBWL). Weight loss in other BMI categories was 8.2 ± 5.6 kg or 10.3 ± 7.0% total body weight loss for BMI 25 to 29.9 kg/m2 and 11.6 ± 7.8 kg or percent total body weight loss 9.3 ± 6.0 for BMI >40 kg/m2. Conclusions This swallowable gas-filled intragastric balloon system is safe and effective at inducing weight loss and offers physicians another tool for patients whose obesity has been resistant to noninvasive treatments.

Background Obesity is a significant health problem and additional therapies are needed to improve obesity treatment. Objective Determine the efficacy and safety of a 6-month swallowable gas-filled intragastric balloon system for weight loss. Setting Fifteen academic and private practice centers in the United States. Methods This was a double-blind, randomized sham-controlled trial of the swallowable gas-filled intragastric balloon system plus lifestyle therapy compared with lifestyle therapy alone for weight loss at 6 months in participants aged 22 to 60 years with body mass index 30 to 40 kg/m2, across 15 sites in the United States. The following endpoints were included: difference in percent total weight loss in treatment group versus control group was >2.1%, and a responder rate of >35% in the treatment group. Results Three hundred eighty-seven patients swallowed at least 1 capsule. Of participants, 93.3% completed all 24 weeks of blinded study testing. Nonserious adverse events occurred in 91.1% of patients, but only .4% were severe. One bleeding ulcer and 1 balloon deflation occurred. In analysis of patients who completed treatment, the treatment and control groups achieved 7.1 ± 5.0% and 3.6 ± 5.1% total weight loss, respectively, and a mean difference of 3.5% (P = .0085). Total weight loss in treatment and control groups were 7.1 ± 5.3 and 3.6 ± 5.1 kg (P Conclusions Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.

Background and Aims Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). Methods In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. Results Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. Conclusions Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Classically, Non-Alcoholic Fatty Liver Disease (NAFLD) has been thought to be driven by excessive weight gain and obesity. The overall greater awareness of this disorder has led to its recognition in patients with normal body mass index (BMI). Ongoing research has helped to better understand potential causes of Lean NAFLD, the risks for more advanced disease, and potential therapies. Here we review the recent literature on prevalence, risk factors, severity of disease, and potential therapeutic interventions.

The Obalon Balloon System (Obalon Therapeutics, Carlsbad, CA) is the only swallowable gas-filled intragastric balloon system with approval for use in the United States, Brazil, the EU, Saudi Arabia, and Kuwait. The balloon system includes three balloons that are swallowed and inflated in the stomach over the course of 6–12 weeks without the need for sedation, endoscopy, or radiation exposure. All balloons are removed endoscopically 6 months after the first balloon administration. The swallowable gas-filled balloon system has demonstrated effectiveness with twice as much weight loss in a US multicenter randomized sham-controlled trial and a very low rate of serious adverse events. A large prospective registry from the United States confirmed clinical practice weight loss is higher than in the randomized sham-controlled trial with a continued very low rate of serious adverse events. In conclusion, the swallowable gas-filled balloon system has level I evidence demonstrating safety and effectiveness for weight loss in patients with obesity.

GOALS The aim of this study was to evaluate the efficacy of tilt-down (TD) versus left lateral (LL) positioning in speed and ease of colonoscope insertion in women with risk factors for difficult colonoscopy. BACKGROUND Risk factors for difficult colonoscopy in women include pelvic surgery, diverticulosis, and thin body habitus. STUDY Female patients with body mass index (BMI) under 25, diverticulosis and history of pelvic surgery were randomized to TD or LL positioning. Five colonoscopists performed all studies at a single center. Time to splenic flexure and cecum, type and amount of medication administered, Boston Bowel Prep Score (BBPS), adverse events, and findings were recorded. The Mann-Whitney U test was used to evaluate the primary endpoint. RESULTS A total of 150 women were enrolled (81 TD, 69 LL). The mean age was 60.1 (SD 10.5) and the mean BMI was 23.9 (SD 3.5). In total 98 (65.3%) women had prior pelvic surgery, 94 (62.7%) had BMI

The disease obesity continues to be a major health issue in the United States and abroad due to its prevalence and associated comorbidities. Treatment has consisted of lifestyle intervention, pharmacotherapy, and surgery; however, this treatment paradigm has not resulted in a decrease in the prevalence of obesity in the United States. The Food and Drug Administration (FDA) has recently approved four gastric endoscopic bariatric therapies (EBTs) for the primary treatment of obesity. These include three intragastric balloons (IGBs) (the ReShape Dual Balloon, the Orbera Balloon System, and the Obalon Balloon System) and the ASpireAssist System. These therapies provide additional options for treatment of obesity. They provide more weight loss than lifestyle intervention and pharmacotherapy, but less weight loss than bariatric surgery. However, they are also less invasive and carry less risk than bariatric surgery, which may make EBTs a more acceptable treatment to many patients.

Background Myeloproliferative neoplasms (MPNs), a group of rare hematologic malignancies comprised of myelofibrosis, polycythemia vera and essential thrombocythemia, significantly impact the lives of patients with historically few effective treatment options. In this quality improvement (QI) initiative we assessed barriers to patient-centered MPN care in 2 large U.S. hospital systems. Methods Between 3/2021 and 5/2021, 24 hematology/oncology healthcare professionals (HCPs) from 2 large hospital systems completed surveys designed to characterize self-reported practice patterns, challenges, and barriers to collaborative MPN care. Additionally, 26 Black patients and 25 non-Black patients with MPNs completed surveys regarding their goals for treatment, barriers to care, and communication with providers. Findings from all surveys paired with patient chart data was presented to 18 HCPs from the systems in AF sessions to reflect on their own practice patterns and prioritize areas for improvement in MPN care. Participants developed team-based action plans to overcome identified challenges, including barriers in risk stratification, care coordination, and shared decision-making (SDM) for patients with MPNs. Surveys conducted before and after the small-group AF sessions evaluated changes in participants' knowledge and confidence in delivering collaborative, patient-centered MPN care. Results Team-Based Surveys: HCPs identified difficulty managing their symptoms (35%) and difficulty choosing therapy that best meets their treatment preferences and goals (25%) as the most pressing challenges their patient's face in their MPN care. The most challenging issue encountered by HCPs in selecting therapies for patients with MPNs is identifying when patients are undergoing disease progression/transformation (48%). HCPs reported effects on quality of life (75%) and treatment effectiveness (65%) as the most important factors for treatment decision-making among patients with MPNs. Teams were underutilizing SDM to provide patient-centered care, citing not enough time to engage in SDM (55%) and patients' low health literacy (50%) as the largest barriers. Patient Surveys: In contrast to HCP responses, the biggest challenge faced in their MPN care reported by Black patients was lack of reliable transportation or long distance to and from my care center (46%) difficulty managing my symptoms (36%) for non-Black patients. Furthermore, Black patients with MPN identified cost of treatment (56%) and advice from loved ones (40%) as the top factors for treatment decision-making, whereas, non-Black patients cited how the treatment is taken (52%) and how well the treatment will control my symptoms (50%). All patients identified they wish they had more time to discuss goals and preferences for treatment (62% Black, 64% non-Black ) with their provider. Black patients reported their MPN care team could improve most in education about MPNs and treatment options (73%), while non-Black patients felt improvements in empathy throughout the emotional journey of managing my MPN (68%) would be most beneficial. Small-Group AF Sessions: Across the 2 oncology centers, teams participating in the AF sessions (Table 1) shared a self-reported caseload of 219 patients with MPNs per month. HCPs reported meaningful shifts in confidence in their ability to provide optimal, patient-centered care (Figure 1) and knowledge of treatment options for MPNs (Figure 2). The aspects of patient-centered care HCPs will routinely discuss in more detail with patients are patients' goal and preferences (81%), results of genetic testing (63%), and risks and benefits of treatment options (56%). To achieve these goals, 63% of HCPs committed to improve team skills in appropriate risk stratification and differentiation of therapy based on patient-centered factors followed by sharing action plans with additional clinical team members (56%). Conclusions Participation in this QI initiative resulted in increased confidence in hematology/oncology HCPs ability to deliver patient-centered MPN care and improve commitment to team-based collaboration. Remaining practice gaps and challenges can inform future QI programs. Study Sponsor Statement The study reported in this abstract was funded by an independent educational grant from Incyte Corporation. The grantors had no role in the study design, execution, analysis, or reporting. Figure 1 Figure 1. Disclosures Verstovsek: CTI BioPharma: Research Funding; NS Pharma: Research Funding; Ital Pharma: Research Funding; Celgene: Consultancy, Research Funding; Roche: Research Funding; Protagonist Therapeutics: Research Funding; Promedior: Research Funding; PharmaEssentia: Research Funding; Gilead: Research Funding; Incyte Corporation: Consultancy, Research Funding; Genentech: Research Funding; Blueprint Medicines Corp: Research Funding; AstraZeneca: Research Funding; Novartis: Consultancy, Research Funding; Sierra Oncology: Consultancy, Research Funding; Constellation: Consultancy; Pragmatist: Consultancy. Mesa: Sierra Oncology: Consultancy, Research Funding; Gilead: Research Funding; Novartis: Consultancy; Celgene: Research Funding; Genentech: Research Funding; CTI: Research Funding; Abbvie: Research Funding; CTI: Research Funding; Incyte Corporation: Consultancy, Research Funding; Promedior: Research Funding; Samus: Research Funding; Constellation Pharmaceuticals: Consultancy, Research Funding; Pharma: Consultancy; AOP: Consultancy; La Jolla Pharma: Consultancy.

IN BRIEF Several new endoscopic bariatric therapies have been approved by the U.S. Food and Drug Administration for the treatment of obesity, with many more devices and procedures undergoing investigational studies. This article describes these devices and procedures and special considerations for their use in patients with diabetes.

The use of RFA as a treatment modality in gastrointestinal endoscopy is expanding. RFA is frequently used in combination with focal EMR for the treatment of dysplastic BE and as standalone therapy for flat BE. Its efficacy in the treatment of esophageal squamous dysplasia appears promising. RFA appears to be successful and safe in the management of refractory GAVE and RP, and it may also be beneficial in treatment-naive patients. Biliary RFA and EUS-RFA are emerging technologies.

Weight management is increasingly incorporating endoscopic bariatric therapy (EBT). As the global burden of obesity and its comorbidities has increased, it is evident that novel therapeutic approaches will be necessary to address the obesity epidemic. EBTs offer greater efficacy than diet and lifestyle modification and lower invasiveness than bariatric surgery. The US Food and Drug Administration has approved two intragastric balloons and aspiration therapy for the treatment of obesity: Apollo Orbera is indicated for the treatment of Class I and Class II obesity, Re Shape Integrated Dual Balloon system is indicated for the same range with a comorbidity, and Aspire Bariatrics AspireAssist is approved for patients with a body mass index of 35–55 kg/m2. These devices have proven safe and effective in clinical trials and are gaining commercial acceptance in the USA; the Orbera has been used extensively outside the USA for over 20 years. These devices will need to be delivered in the context of a multidisciplinary weight loss program, integrating comprehensive care of obesity. Patient selection is important, and ensuring appropriate patient expectations and understanding of alternatives such as pharmacologic therapy and surgery is essential. With several EBTs on the horizon, patients with obesity will have an even broader array of safe and effective options for weight management in the future.

Endoscopic bariatric and metabolic therapies (EBMT) are a new addition to the treatment arsenal for obesity. These include devices that are placed or removed via flexible endoscopy, and procedures that utilize instruments that require flexible endoscopy for the indications of weight loss or treatment of glucose intolerance (from pre-diabetes to diabetes). The EBMTs are generally divided into gastric and small bowel categories, and although individual EBMTs may have unique mechanisms of action, similar themes in proposed mechanism of action are seen in the gastric and small bowel EBMTs, respectively. In this review we will describe the therapies approved for use in the United States or currently in the process of obtaining approval for use in the United States. We will discuss potential mechanisms of action and examine safety and efficacy data.

Aspiration therapy is a weight loss therapy in the United States for patients with a body mass index between 35 kg/m2 and 55 kg/m2. Aspiration therapy allows patients to remove up to one-third of calories consumed at a meal and causes patients to eat fewer calories than prior to starting treatment. Studies demonstrate 14.2% to 21.5% total body weight loss in participants who complete 1 year of treatment and maintenance of weight loss in patients treated for 2 years. Aspiration therapy is a safe and effective new treatment of obesity.

The AspireAssist System (AspireAssist) is an endoscopic weight loss device that is comprised of an endoscopically placed percutaneous gastrostomy tube and an external device to facilitate drainage of about 30% of the calories consumed in a meal, in conjunction with lifestyle (diet and exercise) counseling.In this 52-week clinical trial, 207 participants with a body-mass index (BMI) of 35.0-55.0 kg/mAt 52 weeks, participants in the AspireAssist group, on a modified intent-to-treat basis, had lost a mean (±s.d.) of 31.5±26.7% of their excess body weight (12.1±9.6% total body weight), whereas those in the Lifestyle Counseling group had lost a mean of 9.8±15.5% of their excess body weight (3.5±6.0% total body weight) (P0.001). A total of 58.6% of participants in the AspireAssist group and 15.3% of participants in the Lifestyle Counseling group lost at least 25% of their excess body weight (P0.001). The most frequently reported adverse events were abdominal pain and discomfort in the perioperative period and peristomal granulation tissue and peristomal irritation in the postoperative period. Serious adverse events were reported in 3.6% of participants in the AspireAssist group.The AspireAssist System was associated with greater weight loss than Lifestyle Counseling alone.

Endoscopic bariatric therapy consists of devices or procedures for primary weight loss or weight regain after Roux-en-Y gastric bypass that are placed or done endoscopically. In most cases, they result in less weight loss, but fewer complications than bariatric surgery; and more weight loss than lifestyle therapy or weight loss medications. These therapies are important advances to treat patients with obesity. This article focuses on therapies or devices with US Food and Drug Administration approval or those with current or planned US pivotal trials.

Nonalcoholic fatty liver disease (NAFLD) is quickly emerging as a global epidemic in parallel with the rise in obesity and the Metabolic Syndrome. NAFLD, once seen simply as a passive consequence of the Metabolic Syndrome (MetS), has been found to interact with other features of MetS to exacerbate insulin resistance, diabetes, and cardiovascular disease. NAFLD is also becoming the top indication for liver transplant and an important risk factor for hepatocellular carcinoma. Treatment of this disorder is limited mainly to lifestyle modifications to promote weight loss along with consideration for off-label use of certain medications, but recent progression in clinical trials means more effective treatments are on the horizon. Therefore, the primary care provider must be prepared to recognize and determine the severity of this disorder in order to optimize management. In this review, we will discuss risk factors for NAFLD, workup and differential, and finally, offer recommendations on screening.

BackgroundThe AspireAssist is the first Food and Drug Administration-approved endoluminal device indicated for treatment of class II and III obesity.ObjectivesWe earlier reported 1-year results of the PATHWAY study. Here, we report 4-year outcomes.SettingUnited States-based, 10-center, randomized controlled trial involving 171 participants with the treatment arm receiving Aspiration Therapy (AT) plus Lifestyle Therapy and the control arm receiving Lifestyle Therapy (2:1 randomization).MethodsAT participants were permitted to continue in the study for an additional year up to a maximum of 5 years providing they maintained at least 10% total weight loss (TWL) from baseline at each year end. For AT participants who continued the study, 5 medical monitoring visits were provided at weeks 60, 68, 76, 90, and 104 and thereafter once every 13 weeks up to week 260. Exclusion criteria were a history of eating disorder or evidence of eating disorder on a validated questionnaire. Follow-up weight, quality of life, and co-morbidities were compared with the baseline levels. In addition, rates of serious adverse event, persistent fistula, withdrawal, and A-tube replacement were reported. All analyses were performed using a per-protocol analysis.ResultsOf the 82 AT participants who completed 1 year, 58 continued to this phase of the trial. Mean baseline body mass index of these 58 patients was 41.6 ± 4.5 kg/m2. At the end of first year (at the beginning of the follow-up study), these 58 patients had a body mass index of 34.1 ± 5.4 kg/m2 and had achieved an 18.3 ± 8.0% TWL. On a per protocol basis, patients experienced 14.2%, 15.3%, 16.6%, and 18.7% TWL at 1, 2, 3, and 4 years, respectively (P < .01 for all). Forty of 58 patients (69%) achieved at least 10% TWL at 4 years or at time of study withdrawal. Improvements in quality of life scores and select cardiometabolic parameters were also maintained through 4 years. There were 2 serious adverse events reported in the second through fourth years, both of which resolved with removal or replacement of the A tube. Two persistent fistulas required surgical repair, representing approximately 2% of all tube removals. There were no clinically significant metabolic or electrolytes disorders observed, nor any evidence for development of any eating disorders.ConclusionsThe results of this midterm study have shown that AT is a safe, effective, and durable weight loss alternative for people with class II and III obesity and who are willing to commit to using the therapy and adhere to adjustments in eating behavior.

A subcommittee of the Association for Bariatric Endoscopy, a division of the American Society for Gastrointestinal Endoscopy (ASGE) comprising experts in the subject area, performed this systematic review and meta-analysis. The systematic review and meta-analysis was reviewed by the ASGE Technology Committee and was ultimately submitted to the ASGE Governing Board for approval. The systematic review and meta-analysis underwent peer review by outside experts in statistics and meta-analysis before receiving final ASGE Governing Board approval. The Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) initiative is an ASGE program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice, presuming the appropriate training in that endoscopic technology has been achieved. ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds.

The American Society for Gastrointestinal Endoscopy (ASGE), as well as a number of federal agencies and medical societies, recognizes obesity as a disease requiring primary therapy. In 2011, the ASGE and the American Society for Metabolic and Bariatric Surgery (ASMBS) jointly published a white paper with the intent of providing a pathway for bringing endoscopic bariatric therapy (EBT) to clinical practice and Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for safety and efficacy. As multiple EBTs are on the verge of being approved for clinical use, this position statement addresses the ASGE position on the role of the endoscopist in the primary treatment and bridge treatment of obesity with EBT. The prevalence of obesity (body mass index [BMI] of 30 kg/m) in adults in the United States remains high at 35%. Although the total number of U.S. adults with a BMI of 30 kg/m has remained stable since 2003, the prevalence of adults with a BMI >40 kg/m increased 70% between 2000 and 2010. This is of particular concern due to the positive correlation between increasing BMI above >30 kg/m with rates of obesityrelated comorbidities and mortality. The estimated cost associated with treating obesity and directly attributable

IN BRIEF Several new endoscopic bariatric therapies have been approved by the U.S. Food and Drug Administration for the treatment of obesity, with many more devices and procedures undergoing investigational studies. This article describes these devices and procedures and special considerations for their use in patients with diabetes.