Endoscopic Sleeve Gastroplasty (ESG)

At a Glance

• What it is: An incisionless procedure performed through the mouth that sutures the stomach into a narrower tube
• Who it is for: Adults with obesity, generally a BMI of about 30–40, who have not succeeded with diet and lifestyle alone
• Results: Meaningful weight loss and metabolic improvement in a randomized trial (see Landmark Evidence below)
• Hospital stay and recovery: Same day or overnight; most resume normal activity within a few days to a week
• Reversibility: No stomach is removed, and ESG can be converted to surgery later if needed

Endoscopic sleeve gastroplasty is an endoluminal (performed entirely from inside the stomach) procedure that reduces stomach volume by placing a series of full-thickness sutures in the gastric wall through a flexible endoscope — no incisions, no removal of stomach tissue, and no rerouting of the intestine (Apovian et al., Clinical Management of Obesity, The Obesity Society, 2025). The suture pattern folds the stomach inward to create a narrow, sleeve-like tube, decreasing gastric capacity by up to 70% (Apovian et al., 2025; Pelizzo et al., Obesity Surgery, 2025).

First performed in 2012 and now supported by data from more than 40,000 procedures worldwide, ESG has matured into an established endoscopic bariatric therapy (McCarty & Thompson, Yamada's Textbook of Gastroenterology, 2022; Dayyeh et al., Obesity Surgery, 2024). It occupies a middle ground between anti-obesity medications and traditional surgery: less powerful than a surgical sleeve gastrectomy, but less invasive, organ-preserving, reversible, and repeatable (Abuawwad et al., Diabetes Obes Metab, 2024). Like all obesity treatment, it works best within a multidisciplinary program providing long-term dietary, behavioral, and medical support (Docimo et al., ASMBS Systematic Review, 2023).

ESG produces weight loss primarily through gastric restriction. The suturing physically narrows the stomach lumen so patients feel full with much smaller portions, and it delays gastric emptying — in one study, solid-food emptying was delayed by about 90 minutes at 3 months, and patients retained 32% of a test meal at 4 hours versus 5% before the procedure (Pelizzo et al., Obesity Surgery, 2025). In a nutrient-drink test, caloric intake at maximum fullness dropped by 59% after ESG (Pelizzo et al., 2025).

Importantly, because the gastric fundus is deliberately left intact and no intestine is bypassed, ESG has minimal effect on gut hormones such as ghrelin, GLP-1, and PYY — its mechanism is mostly mechanical rather than hormonal (Pelizzo et al., 2025). Some older descriptions note modest hormonal and insulin-sensitivity improvements that are likely secondary to the weight loss itself (Apovian et al., 2025).

• Completely incisionless — no abdominal scars, performed entirely through the mouth (Docimo et al., ASMBS, 2023).
• Organ-preserving — no portion of the stomach is removed, and natural anatomy is maintained (Abuawwad et al., Diabetes Obes Metab, 2024).
• Reversible and repeatable — sutures can be cut to reverse the procedure, or additional sutures added later ("redo ESG") if the stomach stretches over time (Pelizzo et al., 2025).
• Very low complication rate and markedly lower risk of new-onset reflux than surgical sleeve (Beran et al., Obesity Surgery, 2022).
• Outpatient or short-stay with faster recovery than laparoscopic surgery.
• An option for those who can't or won't have surgery — high surgical risk, prior abdominal operations, or fear of surgery (Docimo et al., ASMBS, 2023).

ESG is best supported for adults with class I–II obesity (BMI 30–40 kg/m²), which is the range covered by the great majority of published studies (Docimo et al., ASMBS, 2023). The ASGE suggests consideration for a BMI of 30–45 kg/m² in patients who have not succeeded with diet and lifestyle alone (Abuawwad et al., 2024). Weight-loss results tend to be proportionally greater in class I obesity (BMI <35) (Apovian et al., 2025).

ESG is also an attractive option for people who:

• Are poor candidates for or at high risk from surgery due to age, prior abdominal operations, or comorbidities (Docimo et al., ASMBS, 2023).
• Wish to avoid surgical scars or have anxiety/fear of surgery (Docimo et al., ASMBS, 2023).
• Have had a suboptimal response to anti-obesity medications or want an alternative to lifelong medication (Abuawwad et al., 2024).

Data in class III obesity (BMI >40) and in BMI 27–30 are sparser and warrant individualized counseling (Docimo et al., ASMBS, 2023).

ESG is performed under general anesthesia, typically by an advanced endoscopist or bariatric surgeon, and usually takes about 1–1.5 hours (Pelizzo et al., 2025; Abuawwad et al., 2024). A flexible endoscope fitted with an endoscopic suturing device — most commonly the Apollo OverStitch system — is passed through the mouth into the stomach. Starting near the distal stomach (body-antrum transition), the endoscopist places a series of full-thickness sutures along the greater curvature up toward the fundus, cinching the stomach inward in a purse-string fashion (Pelizzo et al., 2025; McCarty & Thompson, 2022). Typically four to seven sutures reduce gastric volume by approximately 70–80%, creating a narrow tubular lumen (Pelizzo et al., 2025). The fundus is deliberately preserved to maintain a food reservoir, support early satiety, and reduce the risk of leaks and abscess (McCarty & Thompson, 2022).

ESG has a favorable safety profile. Mild, self-limited symptoms — nausea, vomiting, and abdominal pain — are common (affecting about two-thirds of patients) and typically resolve within 7 days (Abuawwad et al., 2024). Serious adverse events are uncommon, reported in roughly 1–3% of patients across large series and meta-analyses (Docimo et al., ASMBS, 2023; Abuawwad et al., 2024). In a meta-analysis of 1,772 patients, the severe adverse-event rate was about 2.2%, including pain/nausea requiring hospitalization (1.08%), upper GI bleeding (0.56%), perigastric leak or collection (0.48%), and rare pulmonary embolism or pneumoperitoneum (Kassem, Diabetes Obes Metab, 2026). In the MERIT randomized trial, ESG-related serious adverse events occurred in 2% of participants, with no deaths, ICU admissions, or need for surgery (Abu Dayyeh et al., Lancet, 2022).

Because the technique uses full-thickness bites, rare but serious complications can include bleeding (spleen, liver, or gastric vessels), gastric or esophageal perforation, organ injury, and abscess; avoiding suturing at the fundus reduces abscess risk (Docimo et al., ASMBS, 2023). ESG is technically demanding and outcomes are best in experienced, high-volume hands (Abuawwad et al., 2024). Notably, one national registry analysis found ESG had higher 30-day and 6-month readmission (3.8% vs 1.6%) and reoperation (1.0% vs 0.3%) rates than surgical sleeve, which should be part of candidate counseling (Leslie et al., J Am Coll Surg, 2026).

Recovery is faster than after laparoscopic surgery. Most patients go home the same day or after a single overnight stay (Pelizzo et al., 2025). Expect several days of nausea, cramping, or reflux-type discomfort that usually settles within a week (Abuawwad et al., 2024). Patients follow a staged diet — clear liquids, then full liquids, then pureed and soft foods, before returning to regular textures over several weeks — with an emphasis on hydration and protein. Normal activity typically resumes within a few days.

ESG produces durable, clinically meaningful weight loss, generally in the range of 13–20% total body weight loss (TBWL) at 12 months (Docimo et al., ASMBS, 2023; Apovian et al., 2025). In the MERIT randomized trial, mean TBWL was 13.6% at 52 weeks, and 68% of patients maintained ≥25% excess weight loss at 104 weeks (Abu Dayyeh et al., Lancet, 2022). A 5-year prospective cohort reported 11.8% TBWL at 60 months, demonstrating that most of the early loss is maintained (Lahooti et al., Gastrointest Endosc, 2025). If the stomach dilates over time, a repeat ("redo") ESG or conversion to surgery remains possible (Pelizzo et al., 2025; Docimo et al., ASMBS, 2023).

The honest comparison: surgical sleeve gastrectomy produces more weight loss than ESG — meta-analyses show roughly 7–10% greater TBWL with LSG at 12 months — but ESG offers fewer complications and far less new-onset reflux (Beran et al., Obesity Surgery, 2022; LaPlante et al., Surg Endosc, 2026).

Landmark Evidence

• MERIT randomized trial (209 adults, BMI 30–40): ESG produced 49.2% excess weight loss and 13.6% total body weight loss at one year, versus 3.2% and 0.8% with lifestyle therapy alone. Eighty percent of ESG patients improved at least one metabolic condition (versus 45% of controls), and 68% of those who reached 25% excess weight loss maintained it at two years (Abu Dayyeh et al., The Lancet, 2022).
• Society review: the ASMBS has published a systematic review supporting ESG as an option for selected patients (Docimo et al., ASMBS, 2023).

How It Compares

• Versus sleeve gastrectomy: no incisions and no stomach removed, but less weight loss. Surgery remains the stronger option at higher BMIs.
• Versus gastric balloons: ESG is longer-lasting and does not need to be removed.
• Versus medication alone: ESG can be combined with anti-obesity medication for greater effect.

More in Endoscopic Weight-Loss Procedures

Related procedures: Gastric Balloon, Orbera Intragastric Balloon, Allurion Balloon, Endoscopic Balloon Removal, Transoral Outlet Reduction, Medical Weight Loss Program. Related primary operations: Sleeve Gastrectomy.

Conditions treated: Obesity, Overweight, Weight Regain, Metabolic Adaptation.

Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, has been performing bariatric endoscopy since 2007 with the early ROSE procedures, the precursor to the ESG. His clinical experience is buoyed by his research experience, which has had him serve as a Principal Investigator for 6 different bariatric endoscopic FDA pivotal trials.

Dr. de la Cruz-Muñoz is a board-certified metabolic and bariatric surgeon who offers the full spectrum of weight-loss options, from endoscopic therapies like TORe and ESG through primary and revision surgery, which means candidates receive an unbiased, individualized recommendation and, critically, a seamless pathway to redo ESG or surgical conversion should their needs change over time.

ESG patients are treated by a surgeon who also offers every surgical alternative. Dr. de la Cruz-Muñoz has been performing bariatric surgery for over 25 years and has completed more than 9,000 bariatric operations, a volume few surgeons reach.

Authored by Nestor de la Cruz-Muñoz, MD, FACS, DABOM. Last updated November 2026.

Expect approximately 13–20% TBWL at 12 months, with results generally maintained at 2–5 years (Docimo et al., ASMBS, 2023; Lahooti et al., 2025). In a large propensity-matched comparison, excess weight loss after ESG was 77% at 1 year and 60% at 3 years, versus 95% and 74% for surgical sleeve — meeting non-inferiority criteria while being less invasive (Alqahtani et al., Gastrointest Endosc, 2022). Weight loss tends to be proportionally greater for patients with class I obesity (BMI <35) (Apovian et al., 2025). Individual results depend on starting BMI, adherence to nutrition and activity, and suture integrity over time (Pelizzo et al., 2025).

Despite its mechanical mechanism, ESG improves obesity-related metabolic disease through weight loss. At 5 years, patients showed significant reductions in HbA1c (−0.42%), systolic blood pressure (−4.1 mm Hg), and ALT (a liver-function marker, −7.4 U/L), reflecting benefits for diabetes, hypertension, and fatty liver disease (Lahooti et al., Gastrointest Endosc, 2025). In the MERIT trial, 80% of ESG patients had improvement in one or more metabolic comorbidities at 52 weeks (Abu Dayyeh et al., Lancet, 2022). In matched comparisons, comorbidity remission after ESG versus surgical sleeve was 64% vs 82% for diabetes, 66% vs 64% for dyslipidemia, and 51% vs 46% for hypertension (Alqahtani et al., 2022).

Durable results require ongoing support: protein-prioritized nutrition, portion control, regular physical activity, and multidisciplinary behavioral follow-up (Docimo et al., ASMBS, 2023). Suture integrity matters — intact gastroplasty correlates with greater weight loss, and a redo ESG can re-tighten a stretched stomach (Pelizzo et al., 2025). Anti-obesity medications (including GLP-1 therapy) can be layered on to augment or protect weight loss, and conversion to surgery remains an option if needed (Abuawwad et al., 2024).

A major advantage of ESG is its low risk of reflux. Because the fundus and gastroesophageal junction are preserved and the stomach is not resected, de novo GERD after ESG is reported in under 3% of patients, dramatically lower than after surgical sleeve gastrectomy (new-onset GERD ~18%) (Docimo et al., ASMBS, 2023; Beran et al., Obesity Surgery, 2022). A systematic review found ESG carried a significantly lower risk of de novo GERD than LSG (RR 0.33) (LaPlante et al., Surg Endosc, 2026). This makes ESG particularly appealing for patients concerned about reflux. A large para-esophageal hernia is a contraindication (Abuawwad et al., 2024).

ESG is uniquely flexible. If weight loss is inadequate or the stomach dilates, options include a redo ESG (additional sutures) or conversion to surgical sleeve gastrectomy or Roux-en-Y gastric bypass (Pelizzo et al., 2025; Docimo et al., ASMBS, 2023). In a large series, 2.7% of ESG patients underwent revision to surgical sleeve and 0.9% had resuturing (Alqahtani et al., 2022). For conversions, experts recommend a preoperative swallow study followed by endoscopic removal of T-fasteners, either beforehand or as the first step of a one-stage conversion (Docimo et al., ASMBS, 2023).

As with any weight-loss intervention, a portion of weight lost is lean mass, so preserving muscle is important. A high daily protein intake (generally ≥60–80 g/day), resistance training, and body-composition monitoring help ensure the weight lost is predominantly fat, protecting metabolic rate and supporting durable results.

ESG is frequently not covered by insurance and is often offered as a self-pay procedure, as coverage policies are still evolving and formal society/payer guidelines are limited (Abuawwad et al., 2024). Candidacy is determined by a full multidisciplinary evaluation rather than the strict BMI thresholds applied to covered surgery; the commonly used range is BMI 30–40 (up to 45) kg/m² after a suboptimal response to diet and lifestyle (Docimo et al., ASMBS, 2023; Abuawwad et al., 2024). Our team verifies any available benefits and reviews self-pay options.

Preparation mirrors a multidisciplinary bariatric work-up: medical, nutritional, and psychological evaluation within an accredited program (Docimo et al., ASMBS, 2023). A pre-procedure upper endoscopy assesses the stomach and rules out contraindications — large para-esophageal hernia, gastric ulcers in the body or fundus, congestive gastropathy, gastric polyposis, varices, or uncontrolled psychological disease (Abuawwad et al., 2024). Mild-to-moderate gastritis, prior non-bariatric gastric surgery, benign polyps, and H. pylori infection are not contraindications (Abuawwad et al., 2024). Patients follow pre-procedure fasting and any prescribed pre-procedure diet.

Patients follow a staged diet — clear liquids, full liquids, pureed, soft, then regular textures — progressing over several weeks, with emphasis on adequate protein, hydration, and small portions. Because no intestine is bypassed, the malabsorptive nutritional risks of gastric bypass or duodenal switch do not apply, though a general bariatric multivitamin and dietitian follow-up are recommended to support healthy weight loss.

Light activity and walking resume within a day or two. Patients gradually build to a combined aerobic and resistance-training program over the first several weeks to preserve lean muscle mass and support durable weight loss, avoiding strenuous exertion only briefly during initial recovery.

ESG involves no incisions, and most patients go home the same or the next day. International patients should plan on three to five days in Miami to cover the first days of the liquid diet. Coaching and follow-up continue virtually.