ESG is a minimally invasive procedure that makes your stomach smaller and limits the amount of food you can eat. It’s a type of bariatric surgery known as a restrictive procedure.

Some scientists believe that bariatric surgery is the most effective weight loss strategy for people with severe obesity.

Unlike conventional bariatric surgeries, ESG is performed with an endoscope, a thin tube with a camera at its end. It allows doctors to look inside your body. In this case, the endoscope lets the surgeon see inside your digestive tract.

This type of procedure leaves no scars, which is why it has become increasingly popular.

ESG is a reversible procedure that changes the shape of your stomach from a bean-like shape to a tube-like one. The procedure was first described in 2013. It’s also known as the Apollo method or accordion procedure.

ESG is performed under general anesthesia. This allows a doctor to insert an endoscope through your mouth and into your stomach without you feeling any pain or discomfort.

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 80%, leaving a small gastric pouch.

By reducing your stomach’s capacity, ESG limits the amount of food you can eat so you feel full sooner. This may help facilitate weight loss.

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.

Furthermore, ESG has evolved into an outpatient procedure, meaning you can usually return home the same day.

As with any bariatric surgery, you must meet the eligibility criteria to become a candidate for ESG.

Qualifying conditions include having a:

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.

Heads-up

Studies suggest that people with higher body weights are disproportionately likely to experience disordered eating and eating disorder symptoms. A significant number of people who explore and undergo bariatric surgery have eating disorders.

If you are preoccupied with food or your weight, feel guilt surrounding your food choices, or routinely engage in restrictive diets, consider reaching out for support. These behaviors may indicate a disordered relationship with food or an eating disorder.

Disordered eating and eating disorders can affect anyone, regardless of gender, race, age, body size, socioeconomic status, or other identities.

They can be caused by any combination of biological, social, cultural, and environmental factors — not just by exposure to diet culture.

Feel empowered to talk with a qualified healthcare professional, such as a registered dietitian, if you’re struggling.

You can also chat, call, or text anonymously with trained volunteers at the National Eating Disorders Association helpline for free or explore the organization’s free and low cost resources.

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ESG can aid weight loss by reducing the amount you can eat, significantly changing the rate at which your stomach empties its contents (a process called gastric emptying), and increasing feelings of fullness.

In fact, evidence suggests that people who have undergone ESG experience fullness immediately after consuming a meal with significantly reduced portion sizes.

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.

Furthermore, 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.

What else affects your weight?

Weight loss surgeries generally focus on reducing your appetite and the amount you can eat.

There’s a common misconception that overeating is the sole cause of higher body weight — and, thus, that simply eating less will result in weight loss. However, food and calorie intake aren’t the only factors influencing weight.

Your weight, and your body’s ability to modify its weight, may also be influenced by genetics, sex, hormones, medications, health conditions, stress levels, sleep quality, physical activity, age, a history of dieting or weight cycling, and more.

Remember, not all of these factors are within a person’s control.

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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.

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.

Keep in mind that BMI has serious limitations, especially for people of color, and isn’t a clear metric of health.

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.

As an endoscopic procedure, ESG has a favorable safety profile with a low rate of serious adverse effects. In fact, one 2020 meta-analysis found that the rate of severe adverse effects for ESG was 1%.

Furthermore, research has determined that compared with other surgical techniques, ESG has:

  • significantly lower complication rates and hospitalization times
  • rapid recovery with minimal postprocedure symptoms
  • 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

However, this does not mean the procedure comes without risks.

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.

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.

Pros of endoscopic sleeve gastroplasty

  • It’s a reversible procedure with no incisions or scars.
  • There’s no risk of device complications because no external device is left inside the body.
  • It’s safer and promotes a shorter hospital stay than laparoscopic procedures.
  • It may lead to significant reductions in HbA1c, blood pressure, and cholesterol levels as well as a reduced need for diabetes medication use.
  • It’s linked to a 100% rate of improvement in gastroesophageal reflux disease (GERD).
  • It may improve insulin sensitivity and reduce ghrelin levels, a hunger-promoting hormone.
  • The procedure takes under 2 hours and has a short recovery period of 1–3 days.
  • It presents less risk of nutritional deficiencies than other bariatric procedures.

Cons of endoscopic sleeve gastroplasty

  • It’s possible to regain lost weight.
  • The procedure comes with the risk of stitch reopening.
  • It’s expensive and insurance may not cover it.
  • Some people may experience worsened mental health after bariatric surgery, including a significant number who may develop eating disorders or harmful disordered eating behaviors.
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ESG is a less invasive and more cost-effective alternative to LSG.

However, medical insurance companies do not cover the procedure due to the lack of evidence of long-term weight loss after ESG.

Therefore, 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.

According to the Centers for Medicare and Medicaid Services, when a bariatric procedure is not identified as covered or noncovered — as is the case for ESG — local Medicare Administrative Contractors decide whether a Medicare beneficiary can receive coverage for the procedure, as long as the person has:

  • a BMI of 35 or more
  • at least one “obesity-related” complication
  • not had success with previous medical treatment for obesity

Some medical centers offer medical loans or flexible financing options.

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.

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.

Pureed or semisolid foods are those you can easily mash with a fork, such as:

  • 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

ESG is a minimally invasive procedure that involves stitching the walls of your stomach to reduce its size. This limits your food intake and can lead to weight loss.

It’s a lower risk and more cost-effective alternative to LSG.

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.

Bariatric surgeries also come with some mental health risks, including a risk of eating disorders or disordered eating.

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.

Additionally, you could lose up to 59% of excess weight within 12 months after the procedure if you follow your doctor’s recommendations.

Still, ESG is not a risk-free technique, and medical insurance companies currently do not cover its costs.

A note on weight discrimination

Although studies often suggest that obesity is a risk factor for certain health conditions, they rarely account for the role weight stigma and discrimination play in health.

Discrimination is one of the social determinants of health — the conditions in daily life that affect our health — and it can and does contribute to health inequities.

Weight discrimination in healthcare can prevent people with higher body weights from seeking medical care — and those who do may not receive accurate diagnoses or treatment because doctors may attribute their health concerns solely to their weight.

As a result, any health condition a person may have may be more advanced by the time they receive a diagnosis.

Meanwhile, experiences of weight stigma in daily life, even outside of medical settings, are associated with negative mental and physical health outcomes.

Everyone deserves appropriate and compassionate medical care. If you’re interested in finding weight-inclusive healthcare professionals, you may want to follow the work of the Association for Size Diversity and Health, which launched a provider directory in 2022.

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