ENDOSCOPIC SLEEVE GASTROPLASTY

Anyone who’s obese and has not achieved their desired weight loss through diet and exercise is a candidate for ESG.

There’s no specific weight or body mass index (BMI) required for the procedure, though most patients will have a BMI somewhere between 30 and 40.

However, this procedure has been performed in people with higher BMIs who aren’t interested in pursuing surgical treatments. “Of all patients eligible to undergo bariatric [weight-loss] surgery, only 1% take advantage,” says Dr. Batash. “The universal reasons they give are that they’re terrified of surgery, don’t want to be cut open, and want all of their parts to stay in place. The ESG procedure, they say, ‘I will do.’”

Pros 

• By reducing the size of the stomach by 70% to 80%, the procedure can help people achieve significant weight loss without surgery. On average, people lose 18% to 20% of their total body weight after one year.
• Though it’s intended to be permanent, endoscopic sleeve gastroplasty is reversible. Unlike gastric sleeve surgery, no portion of your stomach is removed. 
• ESG is performed on an outpatient basis, so there’s no need to stay overnight
• The procedure is performed via endoscopy, so there are no incisions or scars. The lack of incisions significantly reduces the risk of post-op complications like infection.  
• ESG is safer than gastric sleeve surgery and results in fewer complications.
• Unlike bariatric surgery, which is typically limited to those with a BMI of at least 35 who have specific significant health problems (such as type 2 diabetes, high blood pressure, or sleep apnea), ESG can be performed at an earlier stage and at a lower BMI. This means more patients can get the treatment they need before their weight increases and comorbidities develop or progress.
• The recovery is quick. “Within 48 hours, you can expect to feel like your old self,” says Dr. Batash, who offers ESG under the name Suture Sculpt Endoscopic Sleeve. 

Cons

• Weight loss with ESG isn’t as significant as with sleeve gastrectomy. On average, sleeve gastrectomy helps people lose about 60% to 70% of their excess weight over the first year after surgery. On the other hand, compared to gastric balloons, ESG resulted in greater weight loss—21% vs. 14%. 
• It’s not a magic bullet: Like other weight-loss procedures, ESG requires commitment to a healthier lifestyle to ensure long-term success. Your provider may recommend that you participate in a lifestyle intervention program that often includes psychologists and nutritionists.
• The procedure is expensive, and it isn’t covered by insurance. 
• If a patient overeats on a constant basis, the stomach can stretch out. “In our experience, the success rate with ESG is 85% to 90%,” says Dr. Batash. “It’s essential for a person who does this procedure to have discipline.” That means eating a healthy diet with portion control. “Portion control is king and queen,” says Dr. Batash. “If you do portion control, you’ll succeed. If you cannot, you will not.”
• Due to the procedure being so new, data on the longevity of weight loss past 24 months isn’t yet available.

RealSelf Tip: The procedure doesn’t change how your body absorbs nutrients from the food that you eat, but because you’ll be eating a smaller amount of food, talk to your provider about taking a multivitamin to supplement your diet.

The procedure is done with the aid of an endoscope, a long flexible tube with a camera that allows the doctor to see and operate inside your stomach without making incisions in your abdomen. 

Here’s what to expect:

• First, you’ll be given general anesthesia, so you’ll be completely asleep during the procedure.
• Then the endoscope is inserted through the mouth into the stomach.
• The front and back walls of the stomach are marked to help guide placement of the sutures. 
• A miniscule suturing device creates full-thickness stitches, to bind together the two sides of the stomach. The sutures are made of polypropylene, a very durable material. 5-year data shows that they stay intact and continue restricting the stomach volume. 
• The sutures are tightened, bringing the walls of the stomach together like an accordion.
• This pattern is repeated along the stomach to reduce both its volume and length. The stomach will decrease from about 12” long and 6” wide at its widest point to about the size of a banana.
• The new stomach will be tube-shaped, similar to the stomach left intact after gastric sleeve surgery.

The entire procedure typically takes 60–90 minutes, depending on various factors, such as how large your stomach is to start. If your case is complex, it can take longer. 

Once the surgery is over, you’ll be monitored for a couple of hours before being discharged. The effects of anesthesia can be felt for about 24 hours, so be sure to arrange for someone you trust to drive you home.

The endoscopic sleeve gastroplasty photos in our gallery have been shared by the provider who performed the procedure, with the patient's consent.

There’s almost no recovery time required after ESG.

You’ll be encouraged to get up and walk around after the procedure, to increase blood flow in the legs and prevent blood clots; however, vigorous exercise isn’t advised for the first few weeks.  

You will need to change the way that you eat for the first month:

• Week one: Four hours after your treatment, you can start consuming a low-sugar clear-liquid diet. You’ll be asked to adhere to this diet for the first week. 
• Week two:  You’ll switch to a soft diet, which includes anything you can mash up with a fork. Opt for foods that are low-fat, low-sugar, and high protein (aim for 12–20 grams of protein at each meal), such as eggs, beans and lentils, and baked fish. 
• Week four: You can start eating a solid diet again. 

Abdominal pain or nausea are common in the days following the procedure. In a 2018 study of 1,000 patients, 92.4% complained of such side effects during the post-op period. Both are managed with medication and the vast majority resolve within the first week, according to the Mayo Clinic.

The recovery for RealSelf member minnesotajen was very manageable. She says the pain after surgery was not unbearable, just a burning sensation in her stomach. By day four, she says, the pain had resolved and she was back to her usual routine, taking care of her kids.

The first month after ESG is when the most dramatic weight loss occurs: between 11 and 24 pounds, likely due to being on a no-solid-food diet. 

People who have ESG typically lose 15% to 20% of their starting total body weight within the first year. If you commit to portion control and routine exercise, you’ll likely experience continued weight loss. 

For those who desire more weight loss, combination therapy using ESG and obesity medications has demonstrated weight-loss outcomes nearing those of bariatric surgery. In one double-blind study, ESG patients who received the diabetes drug semaglutide lost on average 28% of their total bod weight compared to the control group, which lost on average 20% of their total body weight.

Endoscopic procedures are considered very safe and less risky than surgery. Compared to surgical sleeve gastrectomy, the complication rate for ESG is quite low: 9% to 17% for sleeve gastrectomy, compared to 2% to 3% for ESG in one systematic review. 

Most complications, such as pain and nausea, are mild to moderate. Serious risks like bleeding, infection, or tears in the stomach are very unlikely, occurring in less than 1% in one review of 11 studies. 

“Weight loss with surgical bariatric procedures is very fast, and with the surgical sleeve, you can lose 25% to 35% of your total body weight,” says Dr. Batash. “The price is complications, including severe acid reflux in up to 35% of patients.”

Gastric leak, which can be life-threatening, occurs up to 16% of the time after bariatric surgery; with ESG, the rate is .5%. “The procedures are like night and day,” says Dr. Batash.