Struggling with weight loss can be a daunting challenge, and for some, traditional methods like diet and exercise may not suffice. Endoscopic Sleeve Gastroplasty (ESG) has emerged as a promising, minimally invasive option for individuals seeking to lose weight and improve their overall health. This article delves into the advantages and potential drawbacks of ESG, providing a comprehensive overview to help you make an informed decision.
What is Endoscopic Sleeve Gastroplasty (ESG)?
ESG is a minimally invasive bariatric procedure designed to reduce the size of the stomach, thereby limiting the amount of food a person can comfortably consume. Some scientists believe that bariatric surgery is the most effective weight loss strategy for people with severe obesity. Unlike traditional bariatric surgeries that involve incisions, ESG is performed endoscopically. This means a thin, flexible tube with a camera, called an endoscope, is inserted through the mouth and into the stomach. The doctor then uses another device to double-stitch the wider part of your stomach, creating a tube-like sleeve that reduces your stomach’s capacity by 70-80%, leaving a small gastric pouch. The procedure was first described in 2013 and is also known as the Apollo method or accordion procedure.
The change in the stomach’s shape actually mimics another popular surgical procedure called laparoscopic sleeve gastrectomy (LSG). However, because ESG is an endoscopic method, it’s an incision-less approach. It has fewer risks than LSG and other weight loss surgeries.
How ESG Aids Weight Loss
ESG aids weight loss through several mechanisms:
- Reduced Stomach Capacity: By reducing the size of the stomach, ESG limits the amount of food you can eat, making you feel full sooner.
- Delayed Gastric Emptying: ESG significantly changes the rate at which your stomach empties its contents (a process called gastric emptying). According to a 2022 review, 4 hours after a person consumes solid foods, 32% of the meal still remains in the small gastric pouch, compared with 5% observed before the procedure. This prolongs the feeling of fullness and reduces food intake.
- Increased Feelings of Fullness: Studies have determined that because of the delayed gastric emptying, a person can reach maximum fullness after eating 59% fewer calories. The procedure also prevents the related increase in the hunger-promoting hormone ghrelin, thus preventing rebound hunger.
- Increase in Satiety Hormones: ESG weight loss stands out for its lower risk of complications than traditional weight loss surgeries. This non-invasive approach significantly reduces the likelihood of complications such as infections, bleeding, and hernias, which are more common with surgery.
Advantages of ESG
- Minimally Invasive: One of the standout advantages of Endoscopic Sleeve Gastroplasty (ESG) is that it’s a non-invasive outpatient procedure. This non-invasive approach offers several advantages. First, it significantly reduces the risk of complications typically associated with surgery, such as infections and wound healing issues. Since ESG does not involve incisions, there is less trauma to surrounding tissues and organs.
- Reversible Procedure: Another notable advantage of ESG weight loss is that it’s a reversible procedure. The sutures used in ESG can be removed or adjusted, offering peace of mind for patients who may be concerned about making a permanent change to their digestive system. It also provides flexibility if you’re not seeing the expected results or encounter unforeseen complications. Unlike LSG, ESG is a reversible procedure, does not require an incision, and leaves no scars. However, there’s a risk that the stitches will reopen, which would reverse the procedure.
- Shorter Recovery Time: A major pro of ESG is the reduced recovery time compared to traditional weight loss surgeries. Patients typically experience less pain and discomfort, allowing them to resume their normal activities and return to work in about three days. Additionally, the shorter recovery time often means patients can start seeing and enjoying the benefits of their weight loss sooner.
- Earlier Exercise: Another key advantage of Endoscopic Sleeve Gastroplasty (ESG) is the ability for patients to start exercising almost immediately, reducing muscle loss often associated with major surgeries. In contrast, traditional weight loss surgeries like gastric sleeve and gastric bypass require patients to avoid exercising for about four weeks, leading to muscle loss and difficulty restarting routines.
- Lower Risk of Complications: ESG weight loss stands out for its lower risk of complications than traditional weight loss surgeries. This non-invasive approach significantly reduces the likelihood of complications such as infections, bleeding, and hernias, which are more common with surgery. In formal studies, the complication rate for ESG is around 1-2%, but in real life, it’s been estimated to be below 1%.
- Reduced risk of dumping syndrome: Research has determined that compared with other surgical techniques, ESG has reduced concern of dumping syndrome, a condition in which food moves too quickly from the stomach to the bowels after a meal, leading to diarrhea and abdominal pain.
- Reduced rate of vitamin deficiencies: ESG is safer and promotes a shorter hospital stay. It’s linked to fewer nutritional deficiencies and significantly improves obesity-related complications than other bariatric surgeries.
Potential Drawbacks of ESG
- Requires Specialized Expertise: One significant drawback is that ESG requires advanced endoscopists with specialized skills and dexterity. Currently, there are only two formal advanced fellowship programs in the United States, including one at Brigham and Women’s Hospital at Harvard Medical School led by Dr. Pichamol Jirapinyo. There are fewer than 30 doctors who have undergone formal advanced fellowship programs with ESG in the United States. Many doctors offer ESG without formal training, and some use fewer sutures than optimal to save costs. This can impact the effectiveness and durability of the procedure. It’s not uncommon for doctors not trained in a formal program to achieve only 12-13% weight loss, despite advertising higher success rates.
- Limited Insurance Coverage: One significant drawback of ESG is that most health insurance plans do not cover it. This can result in higher out-of-pocket costs, making it less accessible for some patients.
- General Anesthesia: Even though the ESG procedure is performed endoscopically, it requires the use of general anesthesia.
- Variable Results: Like any weight loss surgery or procedure, the results of ESG can vary from person to person. It’s important to recognize that achieving and maintaining long-term weight loss, even with ESG, requires a commitment to healthy diet and lifestyle changes.
- Potential Side Effects and Complications:
- Common minor side effects include mild abdominal pain, nausea, vomiting, and heartburn. These typically resolve within a few days.
- As for moderate complications, some research describes: Narrowing of the gastroesophageal junction: This means the place where your esophagus meets your stomach narrows, which can hinder the passage of food and lead to vomiting. Loosening of stitches: This could reduce the procedure’s effectiveness and require a second procedure.
- Possible severe complications include: Stomach leaks: Stomach contents can leak, leading to abdominal infection. Pulmonary embolism: A 2017 study reports one case of pulmonary embolism, when a blood clot blocks a pulmonary artery, restricting blood flow. However, it was resolved within 72 hours. Pneumoperitoneum and pneumothorax: Pneumoperitoneum is the presence of air in the abdominal cavity caused by a perforated stomach. Pneumothorax is a collapsed lung caused by a penetrating chest injury. The same 2017 study reports one instance of these conditions.
- Risk of Eating Disorders: Studies also suggest that eating disorders may develop after bariatric surgery. Eating disorder recovery advocates mention that disordered eating behaviors are also common after weight loss surgeries. These behaviors mimic those of eating disorders. Although they’re not severe enough to warrant a formal diagnosis, disordered eating behaviors can be distressing and harmful. Pressure to maintain lost weight and avoid weight regain can contribute, as can the restrictive nature of many prescribed postsurgery diets. Gastrointestinal symptoms and other eating problems also frequently develop.
Eligibility for ESG
As with any bariatric surgery, you must meet the eligibility criteria to become a candidate for ESG. Qualifying conditions include having a:
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- body mass index (BMI) of 30-40
- stable weight for 3 months before the procedure
On the other hand, you may not be eligible for ESG if you’re undergoing anticoagulation therapy, are pregnant, or have gastric ulcers or hiatal hernias larger than 5 centimeters (cm). Bariatric surgeries are also not recommended for people with untreated eating disorders.
To qualify for ESG weight loss, you typically need to have a BMI over 30 and have struggled to lose weight through diet and exercise alone. While there is no upper BMI limit for ESG, those with a higher BMI (such as over 60) might want to consider gastric bypass surgery. Factors such as existing health conditions or anatomical considerations may influence whether ESG is a suitable option for you.
Cost of ESG
Because medical insurance companies do not cover the procedure due to the lack of evidence of long-term weight loss after ESG, people typically have to pay out of pocket. On average, ESG costs $12,000. However, costs can range from $7,000-$16,000 or more. Some medical centers offer medical loans or flexible financing options.
Preparing for ESG
Before an ESG procedure, your doctor may request some lab tests and temporarily modify your medication. For example, during one 2017 study, participants received antibiotics and anti-vomiting medications before the procedure. Your doctor will likely also ask you to avoid consuming foods and drinks the night before the procedure.
Recovery After ESG
As for the recovery, research shows that most people are back in action within 3 days of an ESG procedure. The most critical aspect of recovery is the dietary changes during the first month. For the first 2 weeks after ESG, your doctor will likely prescribe a liquid diet supplemented with protein powder, followed by 2 weeks of a pureed or semisolid diet, before you transition to a regular diet.
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Examples of foods to consume during the pureed/semisolid phase:
- yogurt
- eggs
- cottage cheese
- gelatin snacks
- some fruits and vegetables
- soft fish
To avoid damaging your stitches, it’s best not to consume carbonated drinks or solid foods during the first month after the procedure. You can also follow these dietary tips:
- Eat smaller portion sizes.
- Stop eating when you feel full.
- Chew your food thoroughly.
- Stay hydrated.
- Seek care if you experience disordered eating, symptoms consistent with eating disorders, or trouble reading your hunger and fullness cues.
Lastly, because your stomach’s capacity is reduced, it’s essential to focus on eating nutrient-dense foods - those that provide lots of nutrients per serving - to keep nutritional deficiencies to a minimum. Nutritional deficiencies can negatively affect many areas of health, such as:
- reproductive function
- metabolic health
- weight management
- blood pressure regulation
- blood sugar regulation
- vision
- thinking ability
- memory
Expected Weight Loss with ESG
One 2020 research review with data on 1,542 people found they had lost the following percentages of excess weight after the procedure:
- 31% at 1 month
- 44% at 3 months
- 53% at 6 months
- 59% at 12 months
A small 2017 study including 91 people found that the percentage of total body weight loss increased from 14% at 6 months to 18% at 12 months and 21% at 24 months. Additionally, BMI scores decreased from 41 to 32 at 12 months. Waist circumference dropped significantly, from 120 cm to 93 cm, during the same time.
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Nevertheless, another small 2017 study with 25 people found that among the 8 participants available for the 20-month follow-up, 3 (38%) had regained all the weight they had lost.
All of this suggests that, as with other bariatric surgeries, lifestyle strategies like diet and exercise are essential for long-term success after ESG.
ESG Compared to Other Weight Loss Procedures
Endoscopic Sleeve and Surgical Gastric Sleeve are two popular weight loss options that have helped many people achieve their weight loss goals. Endoscopic Sleeve is an out patient, non-surgical procedure in which the size of the stomach is reduced by approximately 70% by way of an endoscope. Both surgeries have their pros and cons, and the choice between the two ultimately depends on the individual's specific needs and goals. Endoscopic Sleeve is less invasive and has a shorter recovery time, but it may not be as effective for those with a higher BMI or those who have previously undergone weight loss surgery.
Surgical gastric sleeve, also known as vertical sleeve gastrectomy, is a weight loss treatment in which a portion of the stomach is extracted to make it smaller. This procedure is usually carried out laparoscopically, meaning that small incisions are made in the midsection, and a camera and surgical tools are inserted through them.
Long-Term Effectiveness of ESG
Because ESG is a relatively new medical procedure, evidence of its effectiveness for long-term weight loss is lacking. Still, available research shows promising results.
Most previous studies have reported clinical outcomes of ESG for up to 2 years after the procedure. Long-term studies on its effectiveness are lacking. Recently, Sharaiha et al. conducted a 5-year analysis of a prospectively maintained cohort [16]. At 1, 3, and 5 years, the mean %TBWL values were 15.6%, 14.9%, and 15.9%, respectively. Further, 5% and 10% TBWL was maintained by 89% and 77% of the patients at 1 year, 85% and 63%, at 3 years, and 90% and 61%, at 5 years, respectively.