Obesity, defined as having a body mass index (BMI) of 30 kg/m2 or higher, is recognized as a global public health challenge by the World Health Organization (WHO). The development of obesity is influenced by a combination of genetic predisposition, prolonged unhealthy dietary patterns, and a lack of physical activity. The primary approach to treating obesity involves implementing dietary plans and adopting lifestyle changes to encourage increased physical activity. However, achieving meaningful results requires consistent patient adherence, as the process is often lengthy and demanding. For individuals seeking a less invasive alternative to traditional bariatric surgery, endoscopic sleeve gastroplasty (ESG) has emerged as a promising option.
Understanding Endoscopic Sleeve Gastroplasty (ESG)
Endoscopic sleeve gastroplasty (ESG) is a minimally invasive transoral procedure that replicates the restrictive effects of bariatric surgery. ESG has demonstrated effectiveness in achieving weight loss and improving obesity-related comorbidities while maintaining a favorable safety profile. ESG may offer a viable alternative for elderly patients who are not candidates for traditional bariatric surgery. ESG involves placing full-thickness sutures along the stomach’s greater curvature, reshaping it into a sleeve-like structure, and reducing its volume by approximately 80%. This procedure effectively reduces the stomach’s capacity, limiting food intake and promoting weight loss. ESG is a non-surgical procedure that involves placing sutures in your stomach to reduce the amount of food it can hold during one meal. These sutures are placed from the inside of your stomach using a special tool called an endoscope that is lowered down your throat, allowing the doctor to gain access to your stomach. Endoscopic sleeve gastroplasty reduces the patient’s stomach by placing stitches in strategic locations in their stomach, and no portion of the stomach is cut or removed. Patients do not have any activity restrictions after ESG and can participate in any activities they feel able to.
ESG vs. Bariatric Surgery
Bariatric surgery has proven to induce a long-term and durable effect in terms of weight loss, which can be up to 25-30% of initial weight. ESG offers significantly fewer risks with a 2.9% risk profile vs. There are many advantages of endoscopic sleeve gastroplasty when comparing it to bariatric surgery and very few downsides. Interestingly, only 1 in 100 people who qualify for bariatric surgery actually choose to undergo the operation. This may be due to their health, and they may not be able to safely have surgery, or it may be that they are scared or their responsibilities do not allow them the time needed for the recovery. However, ESG provides a promising alternative to traditional bariatric surgery, particularly for patients who are looking for a less invasive reversible option. In addition, the method may be appropriate as an alternative less invasive procedure for patients who, due to their limited health condition, are at a higher risk of negative side effects from anesthesia and surgery and are not candidates for bariatric surgery.
ESG Procedure and Recovery
The ESG procedure itself is straightforward and often described by patients as surprisingly easy. Patients are placed under general anesthesia, meaning they’re completely asleep and don’t feel a thing during the procedure. The doctor uses a flexible endoscope to place a series of internal stitches, which reduce the size of the stomach by about 75%. Afterward, most patients spend a few hours in recovery. Medical teams closely monitor hydration, pain levels, and any signs of nausea before sending patients home. Recovery after ESG is typically short and manageable. Most patients are up and walking the same day, and many return to work or light daily activities within a few days. During the first few days, patients stick to clear liquids and focus heavily on hydration. Patients gradually transition from liquids to pureed foods, then soft foods, over several weeks. By week 5 or 6, most are eating regular healthy meals in smaller portions.
Weight Loss Outcomes
ESG helps you lose weight because the sutures reshape and resize your stomach to be much smaller, which only allows you to eat very small meals. The smaller stomach takes longer to empty, so you do not get hungry as often. Most patients lose about 20% of their total body weight after 12 months, but we have seen many patients surpass that amount. In terms of weight loss, ESG typically leads to a total body weight loss (TWL) of approximately 20-25% and excess weight loss (EWL) ranging from 40% to 60% within the first 12 to 24 months. These outcomes are similar to those achieved with more invasive bariatric procedures, such as laparoscopic sleeve gastrectomy, but with the added benefit of being minimally invasive.
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A study of 612 patients (69.3% female) with a mean age of 40.70 ± 12.66 years and mean body mass index of 34.30 ± 5.05 kg/m2 underwent ESG. Out of 612 patients, follow-up rates for a 1-2-3 and 4 years were 93.1%, 90.2%, 81.7% and 81.9%, respectively. The mean percentage total body weight loss was 18.19% (95% confidence interval [CI]: 17.72-18.57) and %EWL was 49.30% (95% CI: 48.91-49.68) with 90% of participants-maintaining a percentage of total weight loss of ≥5% and 70% of patients maintaining an EWL of ≥25% at 4 years, respectively.
Another study by Abu Dayyeh et al is the first randomized trial to demonstrate efficacy outcomes with ESG and life-style modifications compared to lifestyle changes alone for patients with obesity. The mean %EWL was 49.2% (SD 32.0) in the ESG group and lower at 3.2% (SD 18.6) in the control group (P<0.001). The ESG group also had improvement in their metabolic comorbidities.
Improvements in Comorbidities
In addition to weight reduction, ESG has shown considerable success in improving obesity-related comorbidities. One of the most notable benefits is the improvement in type 2 diabetes, with several studies reporting remission or significant reduction in blood sugar levels post procedure. Hypertension and dyslipidemia have also been shown to improve, contributing to better cardiovascular health and a reduced risk of complications associated with these conditions. Adult populations have reported remission or significant improvement in conditions such as type 2 diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea following ESG.
A study showed Resolution/improvement of comorbidities was 51.2% cases of T2DM, 65.8% cases of hypertension, 73.6% cases of dyslipidaemia and 89.9% remission were in obstructive sleep apnoea.
Patient Reviews and Testimonials
Across public forums like Reddit and RealSelf, many ESG patients report positive early results, supportive care, and a surprisingly easy recovery. These reviews reflect a common experience: ESG patients often see results quickly, feel well-supported during recovery, and appreciate the non-surgical, low-downtime nature of the procedure. Bariendo’s ESG patients consistently highlight how the procedure helped them reclaim their energy, improve their health, and build lasting confidence. The ESG procedure has truly transformed my life. From reduced hunger and better portion control to renewed confidence and energy, Bariendo’s ESG patients often describe the experience as life-changing.
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Potential Side Effects
Most patients describe side effects after ESG as mild and short-lived. The most common are nausea, gas bloating, and fatigue in the first few days. Serious complications are rare. According to large studies, fewer than 2% of patients experience significant issues like bleeding or infection. Overall, side effects from ESG are usually described as manageable. Most people say the hardest part isn’t pain, but getting used to small sips and changes in energy while healing.
Long-Term Maintenance
When combined with lifestyle changes that promote maintaining a healthy weight, ESG offers significant weight loss potential. One largeresearch studyshowed that most patients lost around 60-65% of their excess body weight and were successful in maintaining these results even after 2 years. Clinical studies suggest that ESG results can last well beyond the first year. Patients typically maintain at least 60-70% of their total weight loss at the two-year mark, and many continue to lose weight gradually into the third year. Those who stay engaged with their aftercare plan-particularly around diet, movement, and mindset-tend to see the best outcomes. Regular monitoring by a multidisciplinary team is a key measure to success, we think that renewed weight gain can be partially prevented by close clinical follow-up. Another key advantage of ESG is that the procedure can easily be repeated if weight regain occurs.
Eligibility and Considerations
If you have a BMI of 30 or higher and have struggled getting your weight under control with diet and exercise, you may be a good candidate for ESG. You should be free from certain medical conditions involving the stomach or esophagus, hernias, or have a bleeding disorder. Potential candidates should undergo a thorough medical, psychological and lifestyle evaluation to ensure there are no other conditions that would interfere with their post procedure lifestyle and diet. Ideally these individuals have good functional status and can exercise. One of the most important keys to success is a motivated patient who is ready and willing to follow instructions and stay engaged with the team.
Cost and Insurance Coverage
The cost of ESG is currently not covered on medical insurance plans, and patients must self-pay. The good news is that ESG is less expensive than undergoing surgery, and because of the quick recovery time, ESG patients do not need to take much time off work, which helps them avoid losing wages.
The Future of ESG
Combination therapy using ESG and obesity medications has demonstrated augmented weight loss outcomes nearing those of bariatric surgery. The co-authors also explain that future widespread adoption of ESG could mean that gastroenterology and bariatric surgery societies will offer formal training in endobariatric procedures and provide preoperative, intraoperative and postoperative management algorithms to optimize outcomes. The popularity is expected to continue to grow as insurance companies recognize its value and provide reimbursement. Refining algorithms for a comprehensive approach to obesity care will require collaboration from all members of the healthcare team, the institution and payors, industry partners, and researchers.