There’s a certain set of sisters we’ve all been keeping up with whose ever-changing faces and bodies have been sources of plastic surgery speculation for decades. They’ve long claimed that achieving their look is possible for anyone willing to put in the work, though we’d argue that’s only the case for those with resources like personal trainers, in-home chefs, and, yes, plastic surgeons.
Lately, two of these sisters seem to have experienced rapid weight loss, with websites sharing before-and-afters that show a dramatic transformation over the course of just a few months. While it’s easy to assume that these results came courtesy of intense dieting, some speculate the method may actually have been a form of bariatric surgery known as endoscopic sleeve gastroplasty. Never heard of it? Neither have most people. This minimally invasive procedure is pretty new to the landscape of weight-loss surgery; the technique used today has been in practice for only about seven or eight years. And—unlike pretty much any form of bariatric surgery you’ve ever heard of—it’s often performed on perfectly healthy patients with “normal” BMIs, not just those who are overweight.
If you’re someone who’s always struggled with fluctuating weight or have put on a few stubborn pounds after kids, menopause, or just the pandemic (no judgment), endoscopic sleeve gastroplasty might sound like a dream come true. For many patients, it can be—with a few caveats.
Ahead, we break down what you need to know about this up-and-coming procedure, including who it’s best for, if it’s safe (even if you’re not overweight), and if it really works.
What is endoscopic sleeve gastroplasty, and how does it work?
The goal of all bariatric surgery is the same: limit the patient’s ability to consume high volumes of food and cause them to feel fuller faster, stimulating weight loss. To accomplish this, most procedures start and end the same way—with abdominal incisions and the permanent removal of some of your stomach. Not endoscopic sleeve gastroplasty though—no one’s cutting you open or removing anything. Though performed under general anesthesia, the procedure is “a less invasive option that is performed entirely through the patient’s mouth via a specialized camera for the GI tract,” explains Dr. Harvey Rainville, a board-certified bariatric surgeon at New York Bariatric Group.
During the procedure, your stomach is reduced in size “essentially by folding it up like an accordion,” says Dr. Steven Batash, a board-certified gastroenterologist in Rego Park, New York, and then sutured to keep it compact. This makes the organ shorter and narrower, accelerating satiety during and after meals. “A successful patient will say, ‘Before, I needed 20 to 25 bites to have a sensation of fullness,’” he says. “‘Now I get this sensation of fullness after four or five bites, and then I’m not hungry for six or seven hours.’” If, for any reason, you should decide that you no longer want a smaller stomach, the procedure can easily be reversed—your provider would just remove the sutures.
Who is a good candidate for endoscopic sleeve gastroplasty?
What makes this procedure particularly unique is that there are no limitations to qualifying. Generally speaking, candidates must have a certain BMI—typically 30 to 35 at the very minimum—to be cleared for weight-loss surgery. (As an example, someone who is 5’2” with a BMI of 30 puts them at about 165 pounds; someone 5’10” with the same BMI would weigh around 210 pounds.) “The requirement of a certain BMI for specific procedures is generally related to insurance requirements for [coverage],” says Dr. Rainville. But because endoscopic sleeve gastroplasty is such a new treatment, it’s not yet covered, so there is no BMI requirement unless your surgeon has set one.
That opens up the world of weight-loss surgery to a whole new subset of patients—people who have never had a problem with their weight previously but now can’t lose it or who have always experienced fluctuation but are hoping to stabilize. Dr. Batash gave the example of a perimenopausal patient with a BMI of 25 who perhaps had always had a BMI closer to 20. “Though her BMI is not terrible, it represents a differential of 40 or 50 pounds,” he explains. “She’s horrified and saying, ‘I’ve lived all my life being skinny, and now I’m fat,’ even though that doesn’t seem fat to the rest of the world.” The goal of treatment on this patient is not only the health benefits of weight loss but also restoring her self-image. (To level-set again, a BMI of 25 translates to around 135 pounds if a person is 5’2” and 175 pounds if they’re 5’10”.)
In addition to performing endoscopic sleeve gastroplasty on traditionally overweight patients, Dr. Batash operates on patients who are frustrated with their normal (yet high for them) BMI. “This segment of the population has been ignored, and to our detriment, because these people need help too,” he says. “Mental health is still health.”
And as Dr. Rainsville points out, there are rarely medical indications for cosmetic procedures, and everyone has their own aesthetic goals. “It’s easy to argue that, medically, no one needs to massively enlarge their breasts, lift their buttocks, or squeeze into a size 2 pair of jeans,” he says. “As a healthcare provider, it is not our place to judge these patients but to ensure their safety.”
What kind of results can you expect from endoscopic sleeve gastroplasty?
Dr. Batash notes that after experiencing weight loss from this procedure, the health of successful patients will improve. “Multiple studies have shown that if a person loses about 10% or more of their total body weight, it confers significant health benefits in terms of either preventing or ameliorating things like high blood pressure, diabetes, heart disease, and sleep apnea,” he says, adding that those with lower BMIs will largely benefit cosmetically.
Now, for the numbers you are looking for. Drum roll, please: According to Dr. Batash, the majority of studies show that patients tend to lose somewhere between 15% and 21% of their total body weight over the course of 6 to 24 months. (If those hypothetical patients with BMIs of 25 were to undergo this procedure and lose 20% of their body weight, that would result in the 5’2” individual weighing 108 pounds and the 5’10” person weighing 140.) “Having said that, I have lots of patients who do way better than that—20%, 25%, 30%, 35%,” he says. “It’s really a function of how disciplined you are.”
It’s only disciplined patients who make the cut at Dr. Batash’s practice; undisciplined patients are less likely to be successful and therefore waste these resources. “This is not a miracle,” he adds. For successful and lasting weight loss, you should have a regular fitness routine, eat well, and above all, be careful with your portion size. Nutritional counseling is key to the success of any weight-loss procedure—and if you’ve had issues with portion control, your counselor can help you learn to understand when your body is full.
However, many people who are disciplined yet struggle with overeating have problems with the feedback loop between their stomachs and brains. Ever eat a full dinner but still feel ravenous? You could be one of those people. “The stomach tries to send a message of satiety to the brain, but the brain is not processing this message in a timely manner,” explains Dr. Batash. “This is a very common problem, and if we ignore it, we won’t be as successful.” That’s why, in addition to nutritional counseling, Dr. Batash recommends supplementing endoscopic sleeve gastroplasty with weight-loss medications.
Generally speaking, this procedure offers a 10% to 15% nonresponse rate. That may sound high, but keep in mind that it’s like any weight-loss surgery: you need to do hard work on your own to get results, and those medications can help. “Studies show that the amount of weight that can be lost is about 27%—those are surgical numbers without the surgical risk—and the nonresponse rate shrinks from about 15 to 5%,” says Dr. Batash. There are a few medications that can be prescribed—including the old school phentermine, a stimulant that works but can give people anxiety, heart palpitations and insomnia—but the newest and most popular picks are weekly injectables, like semaglutide.
Semaglutide is the generic name for the medications Ozempic and Wegovy; Ozempic is indicated for treatment of diabetes, and after patients experienced weight loss from the treatment, the FDA approved the same medication for weight loss, under a new name (Wegovy). “Semaglutide has been very successful for my patients who have stalled on their weight-loss journeys,” says Dr. Jessie Cheung, a board-certified dermatologist in Chicago who specializes in aesthetics, regenerative medicine, and hormone replacement therapy. “I do have patients who are not overweight taking semaglutide, as it also helps with PCOS and insulin resistance.” She notes that these medications can offer serious side effects. Common ones include nausea, diarrhea, and fatigue, but rarer and more dangerous risks include gallbladder disease, kidney damage, and even thyroid tumors.
Are there risks to losing weight with endoscopic sleeve gastroplasty?
When you permanently remove part of the stomach, it can cause a whole host of issues, ranging from nutritional deficiencies to the regrettably named dumping syndrome, which happens when a surgically shrunken stomach empties food into the small intestine before it’s been digested. This causes nausea, cramping, and diarrhea. Because none of the stomach is removed with endoscopic sleeve gastroplasty, that risk is dramatically reduced, as is the risk of a perforation in the stomach. “With surgery, the chance of that happening is about 16%, and with our procedure, it’s about a half a percent,” says Dr. Batash.
Though it might be frustrating in the short term, you won’t lose weight as rapidly with this procedure as you would with a permanent surgery. But that’s a good thing—slow weight loss is easier on your body, skin included. “It is distinctly unusual for our patients to have loose skin with our procedure,” notes Dr. Batash; many patients who lose a lot of weight from traditional bariatric surgery have so much excess skin that they opt for body lifts.
While a body lift won’t be necessary, that’s not to say that you won’t see the effects of that lost volume, depending on how much weight you lose and how old you are. Fat makes a face look more youthful. As a result, weight loss can cause a face to look gaunt and leave some hanging skin behind. But you have a host of treatment options: “We inject dermal fillers, to replace lost volume in the face and body and can inject biostimulatory fillers such as Radiesse, Sculptra, and Bellafill to stimulate collagen production for skin tightening,” says Dr. Cheung. “Thread lifts can be performed, to lift and tighten skin anywhere on the body, not just the face but even the breasts, butt, arms, and thighs. Lasers and radiofrequency devices can be used for skin tightening, and high-intensity electromagnetic devices can tone muscles and lift the butt.”
Dr. Rainville also reminds his patients that exercising as you lose the weight post-procedure can help. “Resistance exercise will result not only in more overall weight loss but improved cosmetic results, with less saggy skin.”
How much does it cost?
Endoscopic sleeve gastroplasty is not covered by insurance, so you’ll be expected to foot the whole bill. The total will depend on where you live, your provider’s expertise, and the facility used, but if you’re in a major American city, expect to pay upwards of $10,000. Beyond price, “the limiting factor for patients right now in getting the procedure is finding surgeons trained in the technique with access to the appropriate facilities and resources,” says Dr. Rainville.
Truly, this procedure is so new that it can be a challenge to track down someone to perform it. But if despite a normal BMI, you’ve been watching the number on the scale slowly increase with no drop even when maintaining a healthy diet and regular exercise, endoscopic sleeve gastroplasty could be worth the hunt. “Obesity is a chronic, lifelong disease,” says Dr. Batash. “I’m a firm believer that the earlier you intervene, the better off you are, because you don’t give the disease a chance to ravage.”
