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Endoscopic Sleeve Gastroplasty
At The Center for Bariatrics, in Tijuana, Mexico, A procedure to address obesity, endoscopic sleeve gastroplasty can reduce the size of the stomach without the need for an incision through the skin.
According to Ismael Bailon MD, FACS, endoscopic sleeve gastroplasty is a minimally invasive weight loss procedure that uses an endoscopic suturing (stitching) device to reduce the stomach’s size and volume by about 70%.
What is endoscopic sleeve gastroplasty?
Endoscopic sleeve gastroplasty is a newer type of minimally invasive weight-loss procedure. There are no cuts with endoscopic sleeve gastroplasty. Instead, a suturing device is inserted into the throat and down to the stomach. The endoscopist then sutures the stomach to make it smaller.
When your stomach holds less volume, you can feel full with less food, absorb fewer calories and lose weight over time. ESG also shortens and re-shapes the stomach, which helps it empty into the intestines slower. This helps you feel fuller longer.
For the right candidate, ESG may be a less invasive alternative to laparoscopic sleeve gastrectomy. Both procedures reduce the stomach size, but the surgical approach does so by removing part of the stomach, while ESG uses stitches to bring folds of the stomach together like an accordion (similar to sewing a dart to tailor clothing). Endoscopic sleeve gastroplasty is reversible for most patients.
Who might be a candidate for endoscopic sleeve gastroplasty?
The endoscopic sleeve gastroplasty procedure may be an option for adults who:
- Have a body mass index (BMI) of 40 or greater, or over 35 with one or more comorbidities (serious medical conditions caused by obesity, such as sleep apnea, heart disease, or Type 2 diabetes)
- Have a body mass index (BMI) of 30 or higher (a sign of obesity)
- Have not had success with lifestyle modifications such as diet and exercise
- Are looking for an alternative to more invasive bariatric surgery
- Are prepared to make a commitment to a healthier lifestyle
ESG can be part of a plan to reduce the risk of weight-related illness such as high blood pressure, diabetes, fatty liver disease, sleep apnea or heart disease. This procedure is especially effective when combined with a program that includes behavioral therapy, exercise and dietary changes.
ESG may not be suitable for people with conditions including stomach ulcers, large hiatal hernias and bleeding disorders.
ESG After Laparoscopic Sleeve Gastrectomy or a Previous ESG
In some cases, ESG can be used to help restart weight loss after laparoscopic sleeve gastrectomy – a procedure that removes part of the stomach, shaping it like a narrow sleeve. Over time, this sleeve can stretch, allowing a person to consume more food, which can lead to weight gain. ESG can further reduce the size of the stomach to help you stay on track with your weight loss plan.
ESG can also be repeated after a few years, once the stomach has stretched out after the previous ESG or the endoscopic sutures have loosened.
Endoscopic Sleeve Gastroplasty Versus Gastric Bypass
Other surgical procedures besides ESG that can help people lose weight by reducing the stomach’s volume include laparoscopic gastric sleeve and roux-en-Y gastric bypass. Unlike endoscopic sleeve gastroplasty, a gastric bypass requires incisions to be made through the skin, and it makes more drastic changes to the anatomy.
With gastric bypass, a part of the stomach is separated into a small pouch, which is then connected to the small intestine. Food travels through the small pouch and bypasses the rest of the stomach. With sleeve gastroplasty, the connection between the stomach and intestine does not change. This can result in a shorter recovery time, less pain and fewer complications.
Because gastric bypass involves more changes to anatomy than endoscopic sleeve gastroplasty, it can lead to greater weight loss but is associated with more risks and side effects. Common side effects after stomach-reducing procedures include anemia, vitamin deficiencies and dumping syndrome, which are more common after a bypass than after a gastroplasty.
Your doctor will help you compare risks and benefits of these and other procedures and help you choose the right weight loss approach.
Preparing for Endoscopic Sleeve Gastroplasty
Before the endoscopic sleeve gastroplasty, your doctor may ask you to have some laboratory tests.
The doctor will discuss specific instructions you will need to follow before the procedure. They can include:
- Fasting from midnight the day before the procedure
- Temporary changes in your medications before and after the procedure
What happens during endoscopic sleeve gastroplasty?
The ESG takes place in an endoscopy suite while you are asleep under general anesthesia. It lasts about 90 minutes.
The procedure is performed using an endoscope — a flexible tube with a light, camera and an endoscopic suturing device attached. The tiny camera allows the doctor to see and operate inside the stomach without making incisions in the abdomen.
To perform endoscopic sleeve gastroplasty:
- The doctor inserts the endoscope into your mouth, down the throat and into the stomach.
- Lines are drawn along the stomach’s front and back walls, where sutures will be placed.
- with a running stitch pattern, the doctor uses the endoscope to place approximately eight sutures (stitches) in the stomach.
- The doctor tightens the sutures, drawing the front and back walls of the stomach together to reduce its volume by about 70%.
The sutures change the structure of the stomach, leaving it shaped like a tube or sleeve (hence the name sleeve gastroplasty). The sutures do not dissolve — your stomach tissue will heal around them to form the new shape. It is safe for the sutures to remain in your body, and they can be removed later if the procedure needs to be reversed.
With less volume in your stomach, you will feel full after eating less food, absorb fewer calories and lose weight.
Recovery After ESG
Most people go home the same day of an ESG. Others need to spend a night or more in the hospital for observation. Someone must drive you home when you are released.
Endoscopic Sleeve Gastroplasty Diet
Your doctor will provide detailed instructions on what to eat and not to eat while you recover from ESG and get used to the smaller stomach volume. Dietary restrictions during the first few weeks may include the following.
- First eight hours: no food — only clear liquids
- First week: liquid diet with powdered protein, no caffeine or alcohol
- Second week: Add soft foods (those that can be mashed with a fork) that are low in sugar and fat
- After a month: You can usually start eating small portions of solid food
Although the types of food you can eat will not be restricted once you recover from ESG, following a diet that emphasizes healthy and nutritious foods will help you achieve better results. Your doctor or nutritionist will provide information on how to adopt healthy eating habits. Their recommendations may include:
- First eight hours: no food — only clear liquids
- First week: liquid diet with powdered protein, no caffeine or alcohol
- Second week: Add soft foods (those that can be mashed with a fork) that are low in sugar and fat
- After a month: You can usually start eating small portions of solid food
- Eat slowly so you don’t overfill your stomach, causing discomfort.
- Chew your food well.
- Stay hydrated.
- Stop eating when you feel full.
- Eat smaller portions (no more than a cup of food during each meal).
- Continue focusing on foods that are low in sugar, fat and calories.
Endoscopic Sleeve Gastroplasty Results
People who had endoscopic sleeve gastroplasty lose approximately 12% to 20% of their body weight within one year.
It is important to understand that although the procedure is effective, the best weight loss results are achieved by people who participate in an integrated support program. Endoscopic sleeve gastroplasty helps you control your appetite while you establish new eating habits, and it works best in conjunction with behavioral therapy, exercise and nutritional guidance.
Endoscopy is an internal examination performed with a camera by a specialist doctor, and in this case it refers to the examination of the stomach. All endoscopies must be performed in accredited hospitals and by accredited doctors. Before the endoscopy begins, the patient is deeply sedated by a specialist anaesthetist. The camera (or endoscope) is then inserted through the mouth and into the stomach where an examination is performed to ensure it is safe to proceed with the procedure.
In total, the endoscopy can generally be expected to take approximately 20 minutes for balloon procedures (including insertion, adjustment or removal of the balloon). Some procedures, such as an ESG (Endoscopic Sleeve Gastroplasty) may take up to an hour or sometimes even a little longer. Once the procedure is finished, the patient is allowed to wake up and returns home the same day.
The risks relating to endoscopy are very low: typically, the risk of any complication is much less than 1%, and the risk of major complication is less than 0.1%. Your doctor will discuss endoscopy and any relevant risks specific to your health in your consultation.
You should plan at least three days of inactivity to recover from the procedure and to allow symptoms to resolve. We advise patients to wait until they are able to tolerate suitable volumes of fluid before resuming exercise to minimise the risk of dehydration. We encourage low to moderate intensity exercise during weeks 1-2 post-ESG, with a return to higher intensity exercise possible after one month.
Most patients are able to return to work within the week (unless travelling from interstate, as you are required to remain in Sydney for the 7-10 days following your procedure). You may be able to resume normal activity sooner or later than this depending on how quickly your body adjusts to the ESG.
In order to allow the stitches to mature, it is important that the diet progresses slowly. Thankfully, appetite is strongly suppressed by this therapy and hunger is not an issue. Our patients are required to maintain a liquid only diet for approximately 3 weeks before progressing to a puree diet, then soft diet. Our patients are able to return to a normal diet approximately 5 weeks after the procedure, however portion sizes are much smaller than previous, and will remain so for many months and even years.