Endoscopic Sleeve Gastroplasty (ESG)

Introduction

Endoscopic sleeve gastroplasty — usually shortened to ESG — is a weight loss procedure that reshapes the stomach from the inside, using stitches placed through a thin flexible tube passed down the throat. There are no cuts on the abdomen, no part of the stomach is removed, and there is no rerouting of the intestines. For many patients living with obesity, ESG sits in an important middle space between medication and lifestyle programmes on one side, and bariatric surgery such as gastric sleeve or gastric bypass on the other.

If you are reading this, you have likely already discussed your weight, your health, and your treatment options with a doctor, and ESG is one of the choices on the table. This guide explains what the procedure involves, who tends to be considered a good candidate, how recovery typically unfolds, what kind of results published studies have shown, and what life looks like in the months and years afterwards. It is not a substitute for the personal evaluation your doctor will do, but it should help you ask better questions and feel more prepared.

What Is Endoscopic Sleeve Gastroplasty?

Endoscopic sleeve gastroplasty is a procedure in which a doctor uses an endoscope — a long, flexible tube with a camera at the tip — to place a series of stitches inside the stomach. These stitches gather and fold the stomach wall inward, narrowing the stomach into a tube or sleeve shape. The overall stomach volume is reduced by roughly two-thirds, although the exact amount depends on the suturing pattern used.

Stomach anatomy before and after ESG: ① normal stomach capacity, ② endoscopic sutures folding the stomach wall inward, ③ resulting sleeve-shaped stomach with reduced volume.

*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.

Because the endoscope is passed through the mouth and down the oesophagus, the entire procedure takes place inside the body. There are no external incisions, no staples, and no tissue is cut away. The stomach is reshaped rather than reduced by removal.

How ESG Differs from Bariatric Surgery

Anatomical comparison of three weight loss approaches: ① ESG — stomach folded and sutured, no tissue removed; ② sleeve gastrectomy — majority of stomach surgically removed; ③ Roux-en-Y gastric bypass — small stomach pouch with rerouted small intestine.

*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.

• No cuts on the abdomen and no external scars
• The stomach remains anatomically whole — nothing is removed
• Hospital stay is usually a few hours to one night, rather than several days
• Recovery is generally faster
• The procedure can, in principle, be revised or in some cases reversed, because the sutures eventually dissolve or can be cut

ESG is sometimes called the “non-surgical sleeve” or “accordion procedure” in patient-facing material, because the folded stomach resembles the bellows of an accordion. The formal medical name remains endoscopic sleeve gastroplasty.

How ESG Works to Support Weight Loss

ESG helps with weight loss through several mechanisms that work together.

Smaller Stomach Capacity

By folding the stomach into a narrow tube, ESG reduces the volume of food the stomach can hold at one time. This means you feel full sooner during a meal and naturally eat smaller portions.

Slower Stomach Emptying

Studies have shown that ESG slows the rate at which food leaves the stomach. Food stays in contact with the stomach lining longer, which prolongs the feeling of fullness between meals and can reduce snacking.

Some Hormonal Changes

Unlike sleeve gastrectomy, ESG does not remove the part of the stomach that produces ghrelin (the “hunger hormone”), so its hormonal effects are smaller. However, the changes in how the stomach handles food appear to influence appetite signalling in ways that researchers are still mapping out. The result is weight loss that tends to be more gradual than after surgery but can still be clinically meaningful.

A Tool, Not a Cure

Doctors and major societies, including the American Society for Gastrointestinal Endoscopy (ASGE) and the American Gastroenterological Association (AGA), emphasise that ESG is one component of a broader weight management programme. Lasting results depend on dietary changes, physical activity, behavioural support, and ongoing follow-up. The procedure makes those changes easier to sustain, but it does not replace them.

Why ESG Is Performed

ESG is performed to help people with obesity achieve clinically meaningful weight loss, with the aim of improving health, reducing obesity-related conditions, and improving quality of life. It is generally considered when:

• Diet, exercise, and behavioural programmes have not produced enough weight loss to improve health
• Weight loss medications have been tried, not tolerated, or not enough on their own
• Bariatric surgery is not desired, not advisable, or the person does not meet surgical criteria
• There are obesity-related health problems that would benefit from weight reduction, such as type 2 diabetes, high blood pressure, fatty liver disease, sleep apnoea, joint pain, or high cholesterol

The decision to offer ESG is always individual. Doctors look at body mass index (BMI), other health conditions, previous weight loss attempts, and the patient’s willingness and ability to engage with the long-term lifestyle changes the procedure requires.

Who Is a Candidate for ESG?

Candidate selection matters. ESG is most studied and most often offered in the following situations.

Typical Candidates

• Adults with a BMI between approximately 30 and 40
• Adults with a BMI of 27–30 who also have obesity-related conditions such as type 2 diabetes, hypertension, or sleep apnoea
• Patients who do not qualify for, or do not want, traditional bariatric surgery
• Patients who have tried medical weight management and not reached their goals
• People able and willing to commit to dietary changes, follow-up visits, and behavioural support

ESG has also been studied in patients with higher BMIs (over 40) when surgery is not an option, although the absolute weight loss may not match what bariatric surgery achieves in this group.

When ESG May Not Be Suitable

ESG is generally not offered to patients who have:

• A large hiatal hernia (a hernia where part of the stomach pushes up through the diaphragm)
• Severe gastro-oesophageal reflux disease (GERD) not controlled by medication
• Active stomach ulcers or significant gastritis
• A history of certain previous stomach surgeries that have altered the stomach’s anatomy
• Bleeding disorders that cannot be managed
• Pregnancy, or active plans to conceive in the very near term
• Untreated eating disorders
• Conditions that make general anaesthesia unsafe

The pre-procedure work-up usually includes an upper endoscopy to look at the stomach and oesophagus, along with blood tests, a review of medications, and a discussion with a dietitian and sometimes a mental health professional. This evaluation helps confirm that ESG is appropriate and identifies anything that should be treated first.

Alternatives to ESG

ESG is one of several approaches to weight management. Understanding the alternatives helps put the choice in context. The right approach is a clinical decision that depends on your BMI, health conditions, prior attempts, and preferences.

Lifestyle and Behavioural Programmes

Structured programmes that combine dietary counselling, physical activity, behavioural change techniques, and regular follow-up remain the foundation of weight management. For some people they produce enough weight loss to meaningfully improve health, particularly when supported by a dietitian and a multidisciplinary team. Even when a procedure is planned, these programmes are part of preparation and long-term care.

Weight Loss Medications

A new generation of medications, particularly the GLP-1 receptor agonists such as semaglutide and dual-agonist drugs such as tirzepatide, has changed the landscape of medical weight management. In clinical trials these medications have produced average weight losses that overlap with what ESG achieves. They require ongoing use; weight tends to return when the medication is stopped. Doctors increasingly discuss medication and ESG together, sometimes in combination, when planning treatment.

Intragastric Balloons

An intragastric balloon is a soft balloon placed in the stomach endoscopically and filled with fluid or air. It takes up space, helping you feel full sooner. Balloons are usually removed after about six months. Weight loss tends to be smaller than with ESG, and weight regain after balloon removal is common.

Sleeve Gastrectomy (Gastric Sleeve Surgery)

Sleeve gastrectomy is a surgical procedure in which about 75–80% of the stomach is removed, leaving a narrow tube. It is one of the most commonly performed bariatric surgeries worldwide. It produces greater average weight loss than ESG — typically around 25–30% of total body weight in the first year or two — and has stronger effects on conditions like type 2 diabetes. However, it is permanent, involves abdominal incisions, and carries surgical risks that are higher than ESG’s.

Roux-en-Y Gastric Bypass

Gastric bypass creates a small stomach pouch and reroutes part of the small intestine. It produces substantial weight loss and strong improvements in diabetes and other metabolic conditions. It is a more complex operation with a different risk profile and nutritional considerations.

Choosing Between Options

In general, current guidance from bodies such as the American Society for Metabolic and Bariatric Surgery (ASMBS) and ASGE describes ESG as suitable for people with class I or II obesity who want a less invasive approach, while bariatric surgery remains the standard for higher BMIs and for patients with significant metabolic disease who can tolerate surgery. The choice is individual and is best made after a full evaluation.

Preparing for ESG

Preparation for ESG starts weeks before the procedure itself. The aim is to make sure ESG is appropriate, to optimise your health, and to begin the dietary and behavioural changes that will continue afterwards.

Medical Evaluation

Your team will typically arrange:

• A complete medical history and physical examination
• Blood tests, including measures of blood sugar, liver function, kidney function, lipids, and nutritional markers
• An upper endoscopy to check the stomach and oesophagus
• Screening for sleep apnoea, fatty liver disease, and other obesity-related conditions where relevant
• A review of all current medications, including supplements and over-the-counter drugs

Dietitian and Behavioural Support

Meeting with a dietitian before ESG helps you understand the post-procedure eating phases and start practising portion control and slower eating. Behavioural sessions, where available, address eating triggers, emotional eating, and goal setting. These services often continue after the procedure.

The Pre-Procedure Diet

In the days leading up to ESG, you will usually be asked to follow a low-calorie liquid or soft diet. This reduces the size of the liver and the contents of the stomach, making the procedure safer and easier. You will also fast (no food or drink) for several hours before the procedure, following the team’s specific instructions.

Medications to Adjust

The ESG procedure in four stages: ① endoscope passed through the mouth and oesophagus, ② suturing device positioned inside the stomach, ③ full-thickness stitches placed to fold the stomach wall, ④ completed sleeve shape confirmed before endoscope removal.

*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.

ESG is performed under general anaesthesia, which means you are fully asleep and feel nothing. The procedure typically takes between 60 and 90 minutes, although this can vary.

Step by Step

1. You arrive at the hospital or endoscopy unit, change, and meet the anaesthetist and the endoscopy team.
2. An intravenous line is placed and general anaesthesia is given.
3. Once you are asleep, the doctor passes a flexible endoscope through your mouth, down the oesophagus, and into the stomach.
4. An endoscopic suturing device, attached to the tip of the endoscope, is used to place a series of full-thickness stitches in a specific pattern. These stitches gather and fold the stomach wall.
5. The doctor checks the new stomach shape, makes sure there is no bleeding, and removes the endoscope.
6. You are moved to a recovery area where the anaesthesia wears off.

There are no incisions on the abdomen and no external stitches. The internal stitches are made of materials that hold the folds in place; some are designed to stay long-term, while the fibrous tissue that forms around them helps maintain the shape.

Going Home

Most patients go home the same day or after one night of observation. You will not be able to drive after general anaesthesia and will need someone to take you home.

Recovery and Healing

Recovery from ESG is generally faster than recovery from bariatric surgery, but it still requires patience and careful adherence to the dietary plan.

The First Few Days

It is common to feel some nausea, mild abdominal cramping, and a sense of fullness in the upper abdomen for two to three days. Some patients experience shoulder discomfort from the air used during the endoscopy. These symptoms usually settle with medications your team provides for nausea and pain.

During this period you will be on clear liquids only — water, clear broth, sugar-free electrolyte drinks, and similar fluids. Sips at a time, frequently through the day, are easier to tolerate than large amounts at once.

The First Two Weeks

Post-ESG dietary progression: ① days 1–3 clear liquids, ② days 4–14 full liquids and protein shakes, ③ weeks 3–4 pureed and soft foods, ④ week 5 onwards soft solids, ⑤ week 6–8 return to regular textured diet.

*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.

• Clear liquids in the first few days
• Full liquids (including protein shakes, thin yoghurt, strained soups) for roughly the next one to two weeks
• Pureed or very soft foods next
• Soft solids before returning to a regular textured diet

The exact timing varies by programme; your dietitian will give you a specific schedule. Many patients return to non-physical work within about a week, and to most normal activities within two weeks.

Resuming Activity

Light walking is encouraged from the day of the procedure. Strenuous exercise and heavy lifting are usually avoided for about two weeks. Once you have been cleared, gradually increasing physical activity is an important part of long-term success.

Follow-Up Visits

Follow-up after ESG is intensive in the first year, with visits to the doctor, dietitian, and sometimes a behavioural specialist. These visits adjust your nutrition plan, monitor progress, and provide accountability. Skipping follow-up is one of the strongest predictors of disappointing long-term results.

Results and What to Expect Over Time

Published studies, including the MERIT randomised controlled trial reported in The Lancet in 2022 and several large case series, give a reasonable picture of what ESG typically achieves.

Average Weight Loss

In published studies, patients lose, on average, around 13–20% of their total body weight in the first 12 to 18 months after ESG. This is generally expressed as “total body weight loss” (TBWL). For example, someone weighing 100 kg might lose roughly 13–20 kg in the first year, although individual results vary considerably.

Average total body weight loss comparison across four procedures: ① intragastric balloon, ② ESG, ③ sleeve gastrectomy, ④ Roux-en-Y gastric bypass.

*AI-generated image - for illustration only. Clinical accuracy is not guaranteed.

The picture for any individual depends on starting weight, adherence to dietary changes, physical activity, sleep, other medications, and the support around them. Some patients lose more than the average; some lose less.

Health Improvements

Beyond weight on the scale, ESG has been associated in clinical studies with improvements in:

• Blood sugar control in people with type 2 diabetes or prediabetes
• Blood pressure
• Triglycerides and other lipid markers
• Liver enzymes in fatty liver disease
• Symptoms of sleep apnoea
• Joint pain and physical mobility

These improvements are not guaranteed but are common when meaningful weight loss is achieved.

Durability

Follow-up studies have shown that much of the weight loss from ESG is maintained at three to five years in people who continue with the dietary and behavioural changes. Some regain is common, particularly after the second year. The stitches may loosen or partially release over time, and the stomach can stretch with consistent overeating.

When Results Are Disappointing

If weight loss stalls or significant regain occurs, options that doctors may discuss include intensifying behavioural and dietary support, adding weight loss medication, performing a repeat ESG (re-suturing), or considering conversion to bariatric surgery. None of these is a failure of effort — obesity is a complex chronic condition, and most patients need ongoing support across years.

Risks and Complications

ESG has a strong safety record in published studies and is associated with a lower rate of serious complications than bariatric surgery. However, it is a real medical procedure, and risks exist. Your doctor will explain these in the context of your individual health.

Common, Short-Term Effects

• Nausea and vomiting in the first few days
• Abdominal pain or cramping
• Mild sore throat from the endoscope
• Fatigue during the early recovery
• Reflux or heartburn, which often improves with time

Less Common Complications

• Bleeding from the suture sites
• Infection
• A collection of fluid around the stomach (peri-gastric collection)
• Suture loosening or partial release
• Dehydration if fluid intake during the liquid phase is inadequate
• Anaesthesia-related risks

Rare but Serious Complications

• A full-thickness injury to the stomach wall (perforation)
• A significant bleed requiring intervention
• Blood clots in the legs or lungs

In large series, the rate of serious adverse events has been around 1–2%, with most managed without further surgery. The team performing the procedure plays an important role in safety; ESG is best performed by gastroenterologists or bariatric endoscopists with specific training and experience in endoscopic suturing.

When to Seek Medical Attention After ESG

Contact your team or seek urgent care if you experience any of the following after going home:

• Severe or worsening abdominal pain
• Persistent vomiting that prevents you from keeping fluids down
• Vomiting blood or passing black, tarry stools
• Fever or chills
• Shortness of breath or chest pain
• Swelling, pain, or redness in one leg

Life After ESG

The procedure is one day. The change that produces lasting results takes years.

Eating Habits

After ESG, eating patterns shift in several lasting ways:

• Smaller portions, taken at each meal
• Slower eating, with proper chewing
• Eating protein first to support fullness and lean tissue
• Stopping when full, rather than when the plate is finished
• Avoiding drinking large volumes of liquid with meals
• Limiting high-calorie liquids, including sweetened drinks and alcohol

Many patients describe that the procedure makes these behaviours easier to maintain — fullness comes sooner and lasts longer — but the behaviours themselves still need to be practised.

Physical Activity

Regular physical activity is important for maintaining weight loss, preserving muscle, improving metabolic health, and supporting mental well-being. The activity does not have to be intense; consistent walking, strength training a few times a week, and avoiding long stretches of sitting all help.

Mental and Emotional Health

Weight loss can bring positive changes in mood, energy, and self-image, but it can also surface difficult feelings. Changes in body shape, in social interactions around food, and in identity can be unexpectedly hard. Many programmes include access to a psychologist or counsellor experienced in weight management, and using this support is associated with better outcomes.

Nutritional Considerations

Because ESG does not bypass the intestines, it has a lower risk of nutritional deficiencies than bypass surgery. However, eating less means it is easier to fall short on protein, iron, calcium, vitamin D, and B vitamins. Your dietitian will guide you on protein targets and whether supplements are needed. Periodic blood tests check your levels.

Pregnancy and Fertility

Weight loss can improve fertility, sometimes quickly. If pregnancy is possible, contraception is usually advised in the first year after ESG, both to allow weight to stabilise and to avoid pregnancy during the period of rapid change. If pregnancy is planned, discuss timing with your doctor.

Long-Term Follow-Up

Long-term follow-up — at least yearly — is part of good ESG care. These visits track weight, health markers, nutritional status, and behavioural goals. They also catch problems early and adjust the plan when needed.

Frequently Asked Questions

Is ESG painful?

The procedure itself is done under general anaesthesia and is not felt. Afterwards, most patients experience mild to moderate abdominal discomfort, nausea, and a feeling of fullness for two to three days. These symptoms are usually well controlled with medication.

How long does the effect of ESG last?

Studies have shown that meaningful weight loss is generally maintained at three to five years in people who continue with dietary and behavioural changes. Some weight regain over time is common. The stitches and the fibrous tissue around them hold the stomach shape, but the stomach can stretch with consistent overeating.

Is ESG reversible?

ESG is considered potentially reversible because no part of the stomach is removed. In practice, reversal is rarely needed; if required, the sutures can be cut endoscopically or will eventually loosen over time. The stomach generally returns close to its previous shape, though there may be some residual change.

Can ESG be repeated if I regain weight?

Yes. Repeat ESG — where new sutures are placed to restore the sleeve shape — is performed in some patients who experience significant regain. Whether this is the right step is a clinical decision that depends on the situation and the alternatives.

How does ESG compare with weight loss medications?

Newer weight loss medications, particularly GLP-1 receptor agonists, can produce average weight losses that overlap with ESG. Medications need to be continued indefinitely; stopping them is usually followed by weight regain. ESG is a one-time procedure with effects that depend on long-term lifestyle changes. Doctors increasingly discuss both options, sometimes in combination, and the choice depends on individual circumstances, side effect profiles, and patient preference.

Will I have loose skin after ESG?

Loose skin is more common after large amounts of weight loss. Because ESG generally produces moderate rather than dramatic weight loss, significant loose skin is less common than after bariatric surgery, but it can occur. Skin changes also depend on age, skin elasticity, the speed of weight loss, and genetics.

Can I drink alcohol after ESG?

Alcohol is generally avoided in the early recovery weeks. In the longer term, alcohol is high in calories, often consumed in liquid form (which is easy to over-consume), and can irritate the stomach. Many programmes advise limiting alcohol significantly to support weight loss and gastric health.

Is ESG done in adolescents?

ESG is primarily performed in adults. There is growing research in adolescents with severe obesity, but it is performed only in specialised paediatric programmes after thorough multidisciplinary evaluation. If you are considering ESG for a young person, this requires a specific paediatric assessment.

What happens if I do not follow the diet?

Not following the dietary phases in the early weeks can cause vomiting, abdominal pain, suture stress, and rarely more serious complications. In the longer term, eating consistently large portions or high-calorie liquid foods will limit weight loss and can stretch the stomach over time, reducing the durability of results.

How is success measured?

Success after ESG is usually measured by total body weight loss, improvements in obesity-related health conditions, and changes in quality of life. Most programmes consider 10% or more of total body weight loss as a clinically meaningful result, although individual goals vary.

Conclusion

Endoscopic sleeve gastroplasty is one of several options available to people living with obesity who are looking for meaningful, durable weight loss. It sits between intensive lifestyle and medication approaches on one hand and bariatric surgery on the other, offering a procedure that is minimally invasive, performed without external incisions, and associated with relatively rapid recovery in published studies.

It is not a quick fix and not a stand-alone solution. The results published in clinical studies have been achieved by patients who combined the procedure with structured dietary changes, behavioural support, physical activity, and consistent follow-up. For the right candidate, ESG can be a useful tool that makes long-term change easier to maintain. Whether it is the right choice for you is a decision to make with a doctor who has reviewed your full picture — your health, your previous attempts, your goals, and the alternatives available.