March 10, 2026
Mayo Clinic uses endoscopic bariatric procedures for the management of metabolic dysfunction-associated steatotic liver disease (MASLD) whenever appropriate. A significant subset of patients with MASLD can benefit from these procedures, which are less invasive than traditional bariatric surgery.
"Endobariatrics is unique in that it's organ sparing," says Eric J. Vargas Valls, M.D., M.S., a gastroenterologist at the Metabolic and Bariatric Endoscopy Program at Mayo Clinic in Rochester, Minnesota, with advanced training in complex endoscopic procedures. "It can be a game changer for patients who are trying to lose weight and overall have a healthy liver."
Criteria for patient selection for endoscopic bariatric therapies include body mass index, liver disease severity and other comorbidities, including type 2 diabetes, along with patient preference and risk profile. Several endoscopic procedures have emerged to address MASLD, and Mayo Clinic has long been closely involved in refining each therapy. Each option offers distinct mechanisms of action, enabling physicians to tailor interventions according to individual patient profiles.
At Mayo Clinic, physicians and patients share decision-making to select the most appropriate therapy.
Endoscopic sleeve gastroplasty
Endoscopic sleeve gastroplasty (ESG) is a U.S. Food and Drug Administration (FDA)-approved, minimally invasive alternative to surgical sleeve gastrectomy. Using endoscopic suturing, ESG reduces stomach volume by approximately 80% without external incisions or visible scars.
Mayo Clinic has played a leading role in pioneering ESG, including participation in a multicenter randomized clinical trial published in The Lancet in August 2022, which established its safety and effectiveness.
Clinical studies demonstrate that patients achieve a mean total body weight loss (TBWL) of 17% at 12 months after the procedure. Beyond weight reduction, ESG has been associated with meaningful metabolic benefits, including improvements in liver health. In one study published in Biomedicines, patients experienced a reduction in hepatic steatosis index, and in some cases, regression of liver fibrosis over time.
"ESG is the most favorable of the endoscopic procedures because it's a one-time procedure and we see more weight loss sustained over a longer period," Dr. Vargas says.
Intragastric balloon
An intragastric balloon is an FDA-approved weight-loss device that is placed endoscopically and typically removed endoscopically after six months. The balloon acts through a restrictive mechanism and promotes satiety. It also delays gastric emptying and creates favorable hormonal changes that reduce hepatic fat storage and liver stiffness, particularly in people with advanced fibrosis. The Biomedicines study reviews the reported TBWL of 10% to 15% for patients over the six-month time span.
Because the balloon is a temporary therapy, some patients may experience weight regain 1 to 2 years after removal if additional strategies are not implemented. For this reason, it is often used as part of a broader treatment plan.
"We tend to see better long-term results with the endoscopic sleeve," Dr. Vargas says.
"At Mayo Clinic, we view the intragastric balloon as a useful tool for short-term weight loss — particularly as a bridge to surgery or transplant, or as a way to initiate momentum in a comprehensive weight management program," Dr. Vargas says.
"Endobariatrics is unique in that it's organ sparing. It can be a game changer for patients who are trying to lose weight and overall have a healthy liver."
Duodenal-jejunal bypass liner
The duodenal-jejunal bypass liner (DJBL) is a device available through clinical trials. The liner is placed endoscopically and remains in place for up to 12 months. The impermeable sleeve creates a physical barrier between chyme and the duodenal-jejunal mucosa, replicating aspects of the Roux-en-Y gastric bypass. By preventing direct contact between nutrients and the proximal small intestine, this approach alters gut-pancreatic signaling, leading to improvements in insulin sensitivity and glycemic control.
Clinical studies report an average total body weight loss of approximately 13% during the implantation period. Because the device is temporary, some weight regain may occur after removal. Nonetheless, the procedure has been associated with meaningful improvements in hemoglobin A1C, triglycerides, hepatic enzymes and markers of hepatic steatosis. To date, studies have not shown a clear improvement in hepatic fibrosis markers over the treatment period.
Dr. Vargas notes that these results demonstrate the potential role of DJBL for patients with both type 2 diabetes and MASLD.
Duodenal mucosal resurfacing
Duodenal mucosal resurfacing (DMR) is an investigational one-time endoscopic therapy that uses controlled hydrothermal ablation of the duodenum mucosa to modulate abnormal metabolic signaling. It is being studied primarily in patients with type 2 diabetes, including those with MASLD.
Clinical studies suggest that DMR can improve glycemic control, with hemoglobin A1C reduction of 1% in some populations. In the REVITA-2 trial, patients with elevated baseline liver fat reduced hepatic fat by 5.4% at 12 weeks after the procedure, interrupting the inflammatory cascade that leads to liver scarring and fibrosis.
"DMR is more investigational compared to other endoscopic procedures," Dr. Vargas says. He adds that DMR nonetheless improves glycemic control independent of weight loss, which can reduce fat storage in the liver.
Duodenal cellular regeneration using electroporation therapy
As a pioneer of endobariatric therapies, Mayo Clinic explores novel regenerative therapies.
Researchers and collaborators at Mayo Clinic's campus in Minnesota developed and continue to investigate recellularization via electroporation therapy (ReCET). According to an article in the journal Diabetes, ReCET is a nonthermal, endoscopic duodenal therapy to induce controlled cellular apoptosis followed with mucosal reepithelization. This therapy may offer even greater metabolic improvements with an enhanced safety profile compared with DMR, as it promotes mucosal regeneration while preserving tissue architecture.
"This is the first regenerative medicine procedure for type 2 diabetes we've had," Dr. Vargas says. "And it's likely to be a game changer."
For more information
Metabolic and Bariatric Endoscopy Program. Mayo Clinic.
Abu Dayyeh B, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): A prospective, multicentre, randomised trial. The Lancet. 2022;400:441.
Ghusn W, et al. Endoscopic bariatric therapies for metabolic dysfunction-associated steatotic liver disease: Mechanistic insights and metabolic implications. Biomedicines. 2025;13:2437.
O'Neal DN, et al. Duodenal mucosal recellularization via pulsed electric field–induced electroporation (ReCET) in type 2 diabetes: First in human experience. Diabetes. 2024;73(suppl 1):896 P.
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