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Endoscopic Sleeve Gastroplasty

Fear of surgical risks keeps many people who qualify for weight loss surgery, also called bariatric surgery, from receiving it. Endoscopic sleeve gastroplasty (ESG) is a new nonsurgical weight loss option to help adults with obesity lose weight and keep it off.

ESG is a minimally invasive weight loss procedure that’s effective, durable, and safe.

What Is Endoscopic Sleeve Gastroplasty?

Endoscopic sleeve gastroplasty (ESG) is a nonsurgical weight loss procedure that makes your stomach 60% to 65% smaller, so it can hold less food. This type of bariatric surgery is known as a restrictive procedure — you eat less food, so your system absorbs fewer calories.

ESG also changes the shape of your stomach, so it empties into your intestines more slowly. With ESG, food stays in your stomach longer, so you feel full longer.

Why Would I Need Endoscopic Sleeve Gastroplasty?

Obesity can impact your health and quality of life. People who have obesity face a higher risk of several chronic, or long-term, health conditions, including:

  • Diabetes.
  • Hypertension, or high blood pressure.
  • Nonalcoholic fatty liver disease.
  • Sleep apnea.

Losing weight with ESG can reduce your risk of these chronic diseases, and you may also need to take fewer medications to treat them.

People who've had ESG report feeling healthier. They also say they're able to walk and exercise easier than before the procedure.

Surgical alternatives to ESG

UPMC offers surgical options for weight loss, including:

  • Gastric bypass surgery, also called the Roux-en-Y gastric bypass procedure, creates a small pouch that bypasses the stomach and attaches to the intestine. It is the most common form of weight loss surgery performed in the U.S. today.
  • Laparoscopic sleeve gastrectomy (LSG), also called gastric sleeve surgery. With LSG, part of the stomach is removed and then stitched closed to form the gastric sleeve.
  • Malabsorptive surgery, like single anastomosis duodenal switch (SADI-S) or classical duodenal switch (BPD with DS).

What are the benefits of ESG?

Benefits of ESG include:

  • No incisions into the abdomen or stomach, so less postsurgical pain. Incisions can also create scarring that could complicate future abdominal procedures.
  • No overnight stay. ESG is an outpatient procedure.
  • Rapid recovery. Most people recover in two or three days.
  • Reduced risk of vitamin deficiencies compared to other bariatric weight loss procedures.
  • Reduced risk of gastroesophageal reflux disease (GERD) compared to gastric sleeve surgery.

For most people, ESG is also a potentially reversible and repeatable procedure. The surgeon can go in and remove or add the sutures or reverse the ESG procedure if you decide to try another bariatric surgery.

Surgeons can repeat ESG every few years if your stomach stretches out or the stitches loosen.

Surgeons also can use endoscopic sleeve gastroplasty to fix a previous LSG procedure that has stretched in size.

Who is a candidate for endoscopic sleeve gastroplasty?

ESG is a Medicare-approved procedure for weight loss in adults. Please call your insurance provider to see if it is a covered procedure.

You may benefit from ESG if you:

  • Have a body mass index (BMI) of 30 or higher. Other bariatric surgical options require people to have a BMI of at least 35 to receive insurance approval.
  • Haven't achieved lasting weight loss results with lifestyle changes, like diet and exercise.
  • Have had previous gastric sleeve surgery that needs revision.
  • Want an alternative to surgical treatment options.
  • Will commit to a healthy lifestyle after the procedure.

Who can’t get endoscopic sleeve gastroplasty?

Not everyone is a candidate for ESG. You may not be suitable for this procedure if you:

  • Have a large hiatal hernia.
  • Have stomach ulcers, at least until the ulceration heals.
  • Are pregnant.

How much weight can you expect to lose with ESG?

On average, people who have this procedure:

  • Lose 50% of excess weight.
  • Lose between 15% and 20% of their total body weight. By comparison, people who have LSG lose 25% of their total body weight, on average.

Most people begin noticing weight loss within three to four weeks. About 90% of weight loss occurs in the first six months, but it may take a full year to see the complete effects of the procedure.

To help boost weight loss, your doctor may prescribe appetite suppressants several months after the procedure. These older drugs are often less expensive and more widely available than the newer weight loss injectable medications. Often, when two or more weight loss modalities are combined, people experience greater weight loss benefits and can keep it off.

What’s the success rate of endoscopic sleeve gastroplasty?

Endoscopic sleeve gastroplasty can have a lasting effect on weight loss. Studies have shown that 80% of the weight loss people experience with ESG stays off for up to five years.

Like other bariatric procedures, 10% of people either won’t lose much weight or may put some weight back on over time. That's why UPMC makes ESG part of a complete weight loss program.

What Are the Risks and Complications of Endoscopic Sleeve Gastroplasty?

Every weight loss procedure has risks and complications. Risks of ESG include:

  • Loosening of stitches.
  • Stomach leaks, though this is rare.

A common concern is that the stomach will stretch over time, or stitches will fall apart. ESG creates folds with full-thickness bites along the outer wall of the stomach that fuse together. This makes it less likely for the stomach to stretch or for the stitches to come apart.

What Should I Expect From ESG?

Your care team will provide instructions on how to prepare for ESG, including:

  • Dietary restrictions. In general, you should stop eating at midnight the day before the procedure. You should stop drinking three hours before the procedure.
  • Temporary medication changes before and after the procedure.
  • Whether you need any laboratory tests beforehand.
  • When to arrive for the procedure.

You're given general anesthesia for ESG. So, a family member or friend will need to drive you to and from the procedure. It can’t take place unless you have someone to help you get home.

Where does the ESG procedure take place?

Endoscopic sleeve gastroplasty takes place at the Minimally Invasive Bariatric and General Surgery at UPMC Magee-Womens Hospital.

How long does ESG take?

ESG is an outpatient procedure. Most people go home the same day. In rare cases, such as if you have severe nausea, you may need to stay overnight in the hospital.

The procedure itself takes an hour to 90 minutes.

From the time you check in to the time you go home may be several hours. Your surgeon may ask you to arrive up to an hour beforehand to get you ready for the IV drip. You can also expect to stay an hour or two in outpatient recovery to make sure you're well enough to go home.

What can you expect during the procedure?

You'll first receive general anesthesia through an IV drip, so you won't feel any pain during endoscopic sleeve gastroplasty. You'll also get medication to prevent nausea and cramping.

Your care team will monitor your vital signs throughout the procedure. Even though endoscopic sleeve gastroplasty is not surgery, a surgeon will perform the procedure.

  • They'll first insert a thin flexible tube, called an endoscope, down your throat and into your stomach. The endoscope is fitted with an optical lens to see into the stomach and a suturing or stitching device.
  • Using the endoscopic suturing device, they'll place six stitches that create U-shaped folds along the outer wall of your stomach. This creates what's called a gastric sleeve or weight loss surgery sleeve. You can think of it as your stomach stitched into the shape and volume of a banana.

Recovery after endoscopic sleeve gastroplasty

You may feel some abdominal pressure or cramping right after the procedure. ESG has a quick recovery time — most people feel better within two to three days.

Common side effects of ESG include:

  • Burping. About 5% of people experience frequent burping, typically for one to two months following the procedure. Your doctor can prescribe medications to control it. 
  • Nausea. About 10% of people experience nausea or an upset stomach. You'll get antinausea drugs before your procedure to prevent this, and a prescription to treat nausea in case it continues after.

What should you do and avoid during recovery?

You'll receive discharge instructions, including how to manage side effects and things to do and avoid during recovery.

In general, you:

  • Can return to normal activity, including office work, within a week or two.
  • Can and should get up and walk the day of your procedure, and then continue walking daily as part of your weight loss program.
  • Shouldn't drive on the day of the procedure. You can start driving the next day if you feel well enough.
  • Should avoid strenuous physical activity, like heavy exercising or lifting weights, for four weeks. This gives the stitches time to fuse the folds properly.

Diet after an ESG procedure

Recovery includes a stepwise progression for what you can eat. How long you stay in each phase is geared toward your personal needs and includes:

  • Phase 1: Liquid-only diet.
  • Phase 2: Pureed foods, like mashed potatoes.
  • Phase 3: Normal diet.

How often will I need to come back for follow-ups?

You'll see your surgeon and care team five or six times in the first year after endoscopic sleeve gastroplasty. After that, you'll need to go for annual checkups.

Do I need to make any lifestyle changes after ESG?

Endoscopic sleeve gastroplasty is part of UPMC’s Comprehensive Weight Loss program. Your weight loss care team will include nutritionists who can help you make healthy lifestyle choices that support and maintain weight loss with ESG.

To adjust to a smaller stomach, you'll also need to change how and what you eat. Take smaller bites, eat more slowly, chew thoroughly, and stop eating after you feel satisfied. Overeating can lead to nausea and vomiting.

Your nutritionist can help you with a healthy eating plan that focuses on eating less carbohydrates, like bread and pasta, and more protein, like lean fish and poultry. Doctors also encourage people who have ESG to take a daily multivitamin.

When to call your doctor

Your discharge instructions will include who to call and when for follow-up care or any concerns. Call your doctor if you experience a fever or severe abdominal pain. While rare, it may be a sign of an infection or serious complication.

If you notice you aren’t losing weight or if it takes longer to feel full, talk to your doctor. While rare, your stitches may have come loose. If that happens, the surgeon can strengthen the stitches endoscopically.

Last reviewed by Bestoun Ahmed, MD on 2024-04-10.