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

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive approach that makes your stomach smaller and limits the amount of food you can eat, which is why it falls into a category of bariatric surgery procedures known as restrictive procedures.

Unlike conventional bariatric surgeries, ESG is performed with an endoscope — a thin tube that holds a camera that allows doctors to look inside your body. Specifically, 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.

This article tells you the benefits and downsides of ESG, including its effectiveness, safety, and recovery process.

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 and is also known as the Apollo method or the accordion procedure.

ESG is performed under general anesthesia, which allows a doctor to insert an endoscope with a camera through your mouth and into your 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 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 incisionless approach, which has fewer risks than LSG and other weight loss surgeries.

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

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

Qualifying conditions include:

On the other hand, you may not be eligible for ESG if you are 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.


Studies suggest that people at 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 identity, 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 to the 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 and that the procedure 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 isn’t the only factor that influences 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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How much weight can you lose?

Because ESG is a relatively new medical procedure, evidence on its effectiveness for long-term weight loss is lacking. Still, available research shows promising results.

One research review including data on 1,542 people found that people had lost 31%, 44%, 53%, and 59% of their excess weight at 1, 3, 6, and 12 months after the procedure, respectively.

A small study among 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, and waist circumference dropped significantly, from 120 cm to 93 cm, during the same time.

(But keep in mind that the BMI has serious limitations, especially for People of Color, and isn’t a clear metric of health.)

Nevertheless, a small study in 25 people found that among the 8 people 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 modifications 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 meta-analysis found that the rate of severe adverse effects for ESG was only 1%.

Furthermore, research has determined that, compared to 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 your stomach to your bowels after a meal, leading to diarrhea and abdominal pain
  • reduced rate of vitamin deficiencies

However, this doesn’t mean that 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, research describes:

  • Narrowing of the gastroesophageal junction: This means that 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: One study reported one case of pulmonary embolism — a condition in which 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, and pneumothorax is a collapsed lung caused by a penetrating chest injury. One study reported 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 are 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 of gastroesophageal reflux disease.
  • It may improve insulin sensitivity and reduce levels of ghrelin, a hunger-promoting hormone.
  • The procedure takes less than 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 is possible to regain lost weight.
  • The procedure comes with the risk of stitch reopening.
  • It’s expensive and may not be covered by insurance.
  • 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 agree to pay out of pocket. On average, ESG costs $12,000, but costs can range from $7,000 to $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 will decide whether a Medicare beneficiary can receive coverage for the procedure, as long as the person:

  • has a BMI of 35 or more
  • has at least one “obesity-related” complication
  • has been previously unsuccessful with 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 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 that you can easily mash with a fork, such as yogurt, eggs, cottage cheese, gelatin snacks, some fruits and vegetables, and 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 will be 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 reproductive function, metabolic health and weight management, blood pressure regulation, blood sugar regulation, vision, thinking ability and memory, and more.

Endoscopic sleeve gastroplasty (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 is a lower risk and more cost-effective alternative to the surgical version of the procedure, laparoscopic sleeve gastroplasty (LSG).

Unlike LSG, ESG is a reversible procedure, does not require an incision, and leaves no scars. However, there is 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, promotes a shorter hospital stay, is linked to fewer nutritional deficiencies, and significantly improves obesity-related complications compared with other bariatric surgeries.

Additionally, you could lose up to 59% of excess weight within 12 months after the procedure if you follow a healthy lifestyle.

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 at high 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 is developing a directory that will launch in 2022.

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