Dear Editor, Metabolic syndrome is a global health problem and a major public health priority1. A recent burden of disease study estimated a prevalence of metabolic syndrome of 2.8% (∼25.8 million) and 4.8% (∼35.5 million) in children and adolescents, respectively. This prevalence was higher in low-income and middle-income countries in both groups, representing a serious problem for the medium-term and long-term cardiovascular health of future generations1. In adults, another burden of disease study published in 2021 found that a population of 685,616 individuals globally had a prevalence of overweight, obesity, and diabetes mellitus of 27.2%, 21%, and 9.2%, respectively2. Taking into account that diabetes and obesity are directly related to the development and complication of other cardiovascular risk factors, such as arterial hypertension and dyslipidemia, it can be deduced that the current prevalence of metabolic syndrome in adults is close to the percentage of its criteria and cardiovascular risk factors2. Considering the advances in medical technologies and research in low-income and middle-income countries, and based on emerging evidence3,4, the use of bariatric surgery has been proposed as an option to resolve this condition5,6. However, questions remain as to which technique offers the most benefit and is the safest, and specifically, in which subgroups? Very recently, Abu Dayyeh et al.5 carried out a prospective multicenter controlled trial (MERIT trial), where they evaluated the efficacy and safety of endoscopic sleeve gastroplasty for class 1 and 2 obesity, having as outcomes the percentage of excess weight loss (defined as the extra weight, above the necessary to have a body mass index of 25 kg/m2) at week 52 postintervention. As secondary outcomes, the change in metabolic comorbidities was evaluated. Of 209 individuals studied [85 in the intervention group versus 124 in the control group (lifestyle modifications only)], an excess weight loss percentage of 49% versus 3.5% in the control group was evidenced (P<0.0001), and an average total weight loss of 13.6% in the intervention group versus 0.8% in the control group (P<0.0001). On the secondary outcome, it was found that 80% of the intervention group demonstrated an improvement in one or more of the metabolic risk factors versus 45% in the control group. At week 104, 68% of individuals in the intervention group maintained at least 25% of the excess weight loss. There were no deaths, no need for intervention, and only 3 patients presented adverse events. Thus, the authors concluded that endoscopic sleeve gastroplasty proved to be a safe and effective intervention for the resolution or control of obesity and metabolic syndrome components5. Supporting this hypothesis, in previous years, Khan et al.6 performed a meta-analysis of 12 studies with a total of 1149 individuals, where they compared the efficacy of endoscopic sleeve gastroplasty, primary obesity surgery endolumenal, and AspireAssist. As outcomes, the percentage of excess weight loss and the percentage of total body weight loss were determined. It was found that at 6 and 12 months, the use of endoscopic sleeve gastroplasty reduced to a greater extent both the percentage of excess weight loss (49.6 and 52.7%, respectively) and total body weight loss (16 and 17.4%, respectively), compared to primary obesity surgery endolumenal, where the excess weight loss at 6 and 12 months was 43.7 and 44.9%, respectively. However, the AspireAssist reduced 50.8% of excess weight at 12 months, being the intervention with the best performance at that cut-off point. This allowed the authors to conclude that both endoscopic sleeve gastroplasty and AspireAssist have excellent performance at 6 and 12 months in terms of weight loss and weight maintenance6. Thus, it can be seen that endoscopic sleeve gastroplasty is effective and safe in the control of weight and risk factors for metabolic syndrome. Carr et al.7 conducted a study where they evaluated efficacy, safety and quality of life related to weight loss in endoscopic sleeve gastroplasty (n=16) versus laparoscopic sleeve gastroplasty (n=45), observing that at 12 months postintervention, laparoscopic gastroplasty was superior in the reduction of excess body weight (79 versus 57%, P<0.001) and in quality of life (48.1 versus 19.8%, P<0.05). Both techniques significantly reduced some laboratory parameters, with endoscopic surgery having a greater impact on HbA1c (−0.5%, P<0.05) and triglycerides (−0.6 mmol/l, P<0.05). But between the two, laparoscopic surgery reduced fat-free mass more at 6 and 12 months (P<0.05). It should be noted that the difference in the frequency of adverse events between the two techniques was not significant (25% in endoscopic surgery versus 27% in laparoscopic surgery). Thus, it was concluded that both surgeries had excellent performance7. Endoscopic surgery has even been evaluated in high-risk patients, contraindications for abdominal surgery and body mass index greater than50 kg/m2, showing an effective performance in terms of BMI reduction, weight reduction, percentage of excessive and total weight loss, with a null rate of intraoperative complications and a very low frequency of moderate adverse events8. Therefore, considering that it is increasingly feasible to replicate these techniques in countries with limited resources, a more resolutive vision should be considered in terms of metabolic syndrome and cardiovascular risk, and surgery could be the first option, with complementary pharmacological therapy. In this way, it would be possible to reproduce endoscopic sleeve gastroplasty, to achieve definitive results effectively, safely, and with a significant impact on the quality of life of patients. In order to achieve this, it is necessary to develop specialized surgical centers and a surgical research system that facilitates the follow-up and evaluation of outcomes in each social, clinical, and demographic context9. Similarly, the training of surgeons and aspiring surgeons in these techniques should be encouraged10 to help control the obesity pandemic, which generates a greater burden of disease in third-world countries and is unsustainable for health systems today. Ethical approval Not applicable. Sources of funding None. Author contribution All authors equally contributed to the analysis and writing of the manuscript. Conflicts of interest disclosure All authors declare that there exist no commercial or financial relationships that could, in any way, lead to a potential conflict of interest. Research registration unique identifying number (UIN) 1. Name of the registry: not applicable. 2. Unique Identifying number or registration ID: Not applicable. 3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable. Guarantor A.R. Narvaez-Rojas, International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua. E-mail: [email protected] Provenance and peer review Commentary, internally reviewed. Data statement Data sharing is not applicable to this article as no new data were created or analyzed in this study.