Endoscopic sleeve gastroplasty (ESG) is a weight loss procedure that shrinks the stomach without surgery. Instead of cutting or removing tissue, a doctor uses a flexible tube passed through the mouth to stitch the stomach into a smaller, tube-like shape from the inside. The result is a stomach that holds less food, helping you feel full faster. It’s FDA-cleared for adults with a BMI between 30 and 50 who haven’t been able to lose weight through diet and exercise alone.
How the Procedure Works
ESG is performed entirely through the mouth, so there are no external incisions. While you’re under general anesthesia, a gastroenterologist or bariatric surgeon passes an endoscope (a thin, flexible tube with a camera and suturing device attached) down your throat and into your stomach. The device places a series of stitches through the stomach wall, drawing the tissue inward like an accordion. This reshapes the stomach from a wide pouch into a narrow sleeve, reducing its volume by roughly 70 to 80 percent.
The FDA-cleared system used for this is the Apollo ESG platform, classified as a Class II medical device. The entire procedure typically takes 60 to 90 minutes, and most people go home the same day or after one night of observation.
How Much Weight People Lose
In the MERIT trial, the largest randomized study of ESG, patients lost an average of 13.6% of their total body weight at one year, compared to 0.8% in a control group that received lifestyle counseling alone. To put that in perspective, someone starting at 250 pounds could expect to lose about 34 pounds in the first year.
Longer-term data is encouraging. A five-year follow-up study found that average total body weight loss reached 15.9%, with 90% of patients maintaining at least 5% weight loss and 61% maintaining at least 10%. Those numbers suggest the procedure’s effects hold up over time for the majority of people, though outcomes depend heavily on continued lifestyle changes, including diet modifications and regular physical activity.
Who Qualifies
ESG is designed for people who fall into a specific gap: heavy enough that lifestyle changes alone aren’t working, but who either don’t qualify for traditional bariatric surgery or prefer to avoid it. The general eligibility criteria include:
- BMI of 30 or above (up to 50 per FDA clearance)
- Failed prior attempts at sustained weight loss through diet and exercise
- Willingness to commit to behavioral therapy, nutritional counseling, and regular follow-up appointments
Certain conditions rule out ESG. If you have a large hiatal hernia, active gastritis, or peptic ulcer disease, the procedure isn’t safe because of the bleeding risk associated with suturing inflamed or structurally compromised tissue.
How ESG Compares to Surgical Sleeve Gastrectomy
Traditional laparoscopic sleeve gastrectomy (LSG) permanently removes about 80% of the stomach through small abdominal incisions. It produces more weight loss than ESG at the one-year mark, with greater BMI reduction overall. If maximum weight loss is the primary goal, surgical sleeve gastrectomy remains the more effective option.
The tradeoff is risk. ESG has a notably better safety profile. One comparative review found adverse event rates of 5.2% for ESG versus 16.9% for surgical sleeve gastrectomy. New-onset acid reflux, a common complaint after stomach surgery, occurred in just 1.3% of ESG patients compared to 17.9% of surgical patients. ESG also involves a shorter recovery period and no hospital stay for most people, whereas surgical sleeve gastrectomy typically requires one to three nights in the hospital and several weeks of restricted activity.
Because ESG doesn’t remove any tissue and is potentially reversible, some people view it as a less permanent commitment. That said, the stitches are durable and the procedure is intended to be long-lasting.
Safety and Side Effects
A large systematic review pooling data from ESG procedures worldwide found a serious adverse event rate of 2.26%. No deaths were reported. The most common serious complications were gastrointestinal bleeding and perigastric fluid collection (a small pocket of fluid forming near the stomach wall), but each of these occurred in fewer than 1% of patients.
More common, less serious side effects in the days after the procedure include nausea, abdominal pain, and a sore throat. These typically resolve within a week. You’ll be on a liquid diet for about two weeks after ESG, gradually transitioning to soft foods and then regular meals over the following weeks.
Cost and Insurance Coverage
This is where ESG gets complicated. Despite FDA clearance, most insurance companies still classify the procedure as investigational. Excellus BlueCross BlueShield, for example, explicitly lists ESG under procedures it considers investigational and will not cover. This is a common stance across major insurers.
A new billing code for ESG takes effect in January 2026, which could open the door to broader coverage decisions. Until then, most people pay out of pocket. The typical cost ranges from $10,000 to $18,000 depending on the facility and geographic location, though prices vary widely. Some centers offer financing plans.
What Recovery Looks Like
Most people return to normal daily activities within a few days, though strenuous exercise is usually off-limits for about two weeks. The dietary progression is strict: clear liquids for the first few days, full liquids for one to two weeks, pureed foods for another week or two, then a gradual return to solid foods. Eating too much too soon can cause significant nausea or vomiting and may stress the new suture lines.
The ongoing commitment matters as much as the procedure itself. ESG works by physically restricting how much your stomach can hold, but it doesn’t change hunger hormones or food preferences the way some surgical procedures do. Behavioral therapy, nutritional guidance, and regular check-ins with a care team are part of why the five-year outcomes look as strong as they do. People who treat ESG as a tool within a broader lifestyle plan tend to see the most durable results.