Endoscopic Sleeve Gastroplasty (ESG)

Overview

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive weight loss procedure performed entirely through the mouth, requiring no surgical incisions. This approach offers an effective option for patients seeking weight reduction with fewer risks and a faster recovery compared to traditional bariatric surgery.  

Candidates

ESG may be right for you if you: 

Have a BMI more than 30  

Have a BMI lower than that with: 

• Weight-related conditions like type 2 diabetes or high blood pressure.  
• Failed weight loss after supervised diet treatment and exercise. 1Eisenberg, D., Shikora, S. A., Aarts, E., Aminian, A., Angrisani, L., Cohen, R. V., Luca, M. D., Faria, S. L., Goodpaster, K. P. S., Haddad, A., Himpens, J. M., Kow, L., Kurian, M., Loi, K., Mahawar, K., Nimeri, A., O’Kane, M., Papasavas, P. K., Ponce, J., … Kothari, S. N. (2022). 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surgery for Obesity and Related Diseases, 18(12), 1345–1356. https://doi.org/10.1016/j.soard.2022.08.013

Prefer to avoid invasive surgeries.  

How does it work?

Unlike sleeve gastrectomy, ESG doesn't remove any part of your stomach. Instead, your doctor uses stitches to fold it into a smaller, tube-like shape, reducing its size by 60–80%. 

This slows how quickly food leaves your stomach, and you feel full after eating a small amount of food. After ESG, food stays in your stomach about 90 minutes longer, keeping you full for nearly an hour more than before.

Benefits

ESG was proved to be more effective for weight loss compared to lifestyle changes alone and less invasive than other bariatric surgeries. 

Weight Loss Results: 

• Patients can lose up to 60 % of their excess weight. 
• Weight loss can be maintained for an average 3-5 years. 3Dayyeh, B. K. A., Stier, C., Alqahtani, A., Sharaiha, R., Bandhari, M., Perretta, S., Jirapinyo, S. P., Prager, G., & Cohen, R. V. (2024). IFSO Bariatric Endoscopy Committee Evidence-Based Review and Position Statement on Endoscopic Sleeve Gastroplasty for Obesity Management. Obesity Surgery, 34(12), 4318–4348. https://doi.org/10.1007/s11695-024-07510-z 4Vargas, V. P. S., Thaher, O., Elshafei, M., Pouwels, S., & Pape-Köhler, C. (2025). Outcomes of Endoscopic Sleeve Gastroplasty: A Systematic Review. Medicina, 61(10), 1821. https://doi.org/10.3390/medicina61101821

Improving Obesity-related Conditions  

ESG works as well as sleeve gastrectomy at improving conditions linked to excess weight. 5Baratte, C., Sebbag, H., Arnalsteen, L., Auguste, T., Blanchet, M.-C., Benchetrit, S., Abou-Mrad, A., Reche, F., Genser, L., Caiazzo, R., Lazzati, A., Catheline, J.-M., Pourcher, G., Leyre, P., Kamoun-Zana, S., Stenard, F., Coste, T., Sterkers, A., Blanchard, C., … Robert, M. (2025). Position statement and guidelines about Endoscopic Sleeve Gastroplasty (ESG) also known as “Endo-sleeve.” Journal of Visceral Surgery, 162(1), 71–78. https://doi.org/10.1016/j.jviscsurg.2024.12.003

After 4 years, patients see significant improvements: 

• 90% resolve sleep apnea 
• 74% improve cholesterol levels 
• 66% reduce high blood pressure  
• 51% control or reverse type 2 diabetes 6Bhandari, Mahak, Kosta, S., Reddy, M., Mathur, W., Neto, M. G., & Bhandari, Mohit. (2023). Four-year outcomes for endoscopic sleeve gastroplasty from a single centre in India. Journal of Minimal Access Surgery, 19(1), 101–106. https://doi.org/10.4103/jmas.jmas_3_22

Common Misconceptions

ESG is the same as sleeve gastrectomy. 

They produce similar weight loss results, but ESG is far less invasive. Your stomach stays intact and nothing is removed. 

ESG is fully reversible. 

In theory, yes. Your doctor can remove the stitches endoscopically since no tissue is removed. However, over time your stomach tissue heals around the stitches, so it may not return to its original shape. There isn't enough evidence yet to confirm full reversibility. 

It replaces healthy habits.

ESG is not enough alone. Long‑term success still depends on diet, exercise and behavioral therapy. 

Risks

Sleeve gastrectomy is a relatively safe weight reduction operation. 3Dayyeh, B. K. A., Stier, C., Alqahtani, A., Sharaiha, R., Bandhari, M., Perretta, S., Jirapinyo, S. P., Prager, G., & Cohen, R. V. (2024). IFSO Bariatric Endoscopy Committee Evidence-Based Review and Position Statement on Endoscopic Sleeve Gastroplasty for Obesity Management. Obesity Surgery, 34(12), 4318–4348. https://doi.org/10.1007/s11695-024-07510-z 7Li, P., Ma, B., Gong, S., Zhang, X., & Li, W. (2020). Efficacy and safety of endoscopic sleeve gastroplasty for obesity patients: A meta-analysis. Surgical Endoscopy, 34(3), 1253–1260. https://doi.org/10.1007/s00464-019-06889-6 While complications are possible, the possibility is low, and they are typically manageable. 

Mild complications (60%)  

These include pain, nausea, and vomiting. They typically resolve within the first week. 8Abu Dayyeh, B. K., Bazerbachi, F., Vargas, E. J., Sharaiha, R. Z., Thompson, C. C., Thaemert, B. C., Teixeira, A. F., Chapman, C. G., Kumbhari, V., Ujiki, M. B., Ahrens, J., Day, C., MERIT Study Group, Galvao Neto, M., Zundel, N., & Wilson, E. B. (2022). Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): A prospective, multicentre, randomised trial. Lancet, 400(10350), 441–451. https://doi.org/10.1016/S0140-6736(22)01280-6

Serious complications (1-2%)  3Dayyeh, B. K. A., Stier, C., Alqahtani, A., Sharaiha, R., Bandhari, M., Perretta, S., Jirapinyo, S. P., Prager, G., & Cohen, R. V. (2024). IFSO Bariatric Endoscopy Committee Evidence-Based Review and Position Statement on Endoscopic Sleeve Gastroplasty for Obesity Management. Obesity Surgery, 34(12), 4318–4348. https://doi.org/10.1007/s11695-024-07510-z 7Li, P., Ma, B., Gong, S., Zhang, X., & Li, W. (2020). Efficacy and safety of endoscopic sleeve gastroplasty for obesity patients: A meta-analysis. Surgical Endoscopy, 34(3), 1253–1260. https://doi.org/10.1007/s00464-019-06889-6

These may include gastrointestinal bleeding or fluid buildup near the stomach. Both happen in less than 1% of cases and are treatable. 9Hedjoudje, A., Abu Dayyeh, B. K., Cheskin, L. J., Adam, A., Neto, M. G., Badurdeen, D., Morales, J. G., Sartoretto, A., Nava, G. L., Vargas, E., Sui, Z., Fayad, L., Farha, J., Khashab, M. A., Kalloo, A. N., Alqahtani, A. R., Thompson, C. C., & Kumbhari, V. (2020). Efficacy and Safety of Endoscopic Sleeve Gastroplasty: A Systematic Review and Meta-Analysis. Clinical Gastroenterology and Hepatology: The Official Clinical Practice Journal of the American Gastroenterological Association, 18(5), 1043-1053.e4. https://doi.org/10.1016/j.cgh.2019.08.022 10Singh, S., Hourneaux de Moura, D. T., Khan, A., Bilal, M., Ryan, M. B., & Thompson, C. C. (2020). Safety and efficacy of endoscopic sleeve gastroplasty worldwide for treatment of obesity: A systematic review and meta-analysis. Surgery for Obesity and Related Diseases: Official Journal of the American Society for Bariatric Surgery, 16(2), 340–351. https://doi.org/10.1016/j.soard.2019.11.012

Results

Your weight loss timeline will look like this: