ESG, or endoscopic sleeve gastroplasty, is a weight loss procedure that reduces the size of your stomach by about 70% using internal sutures, all without a single surgical incision. A flexible tube with a camera and suturing device is passed through your mouth and into your stomach, where a doctor stitches the stomach wall inward to create a narrow, tube-like shape. The result looks similar to a surgical gastric sleeve, but the procedure is less invasive, has a better safety profile, and typically allows you to go home the same day.
How the Procedure Works
During ESG, a gastroenterologist or bariatric surgeon uses a specialized endoscopic suturing system threaded through your mouth and esophagus. You’re under general anesthesia, so you won’t feel anything. The device places a series of stitches through the full thickness of the stomach wall along the greater curvature, which is the outer, curved side of the stomach. As these stitches are tightened, the stomach folds inward on itself.
Several suturing patterns exist. Some surgeons use a Z-shaped triangulated pattern, others a U-pattern that enhances the shortening effect, and others place parallel rows to distribute tension more evenly. Regardless of the pattern, the goal is the same: reduce the stomach’s functional volume by roughly 70% and shorten its length by about 30%. The smaller, tube-shaped stomach holds less food, which helps you feel full faster and eat smaller portions. The FDA has cleared the Apollo ESG system specifically for this purpose in adults with a BMI between 30 and 50.
Who Qualifies for ESG
ESG is designed for adults with obesity (a BMI of 30 or higher) who haven’t achieved lasting weight loss through diet, exercise, and other non-surgical approaches. Most guidelines require at least six months of unsuccessful conservative therapy before the procedure is considered. International consensus statements from the 2023 IFSO conference position ESG combined with lifestyle changes as preferable to lifestyle changes alone for adults with Class I obesity (BMI 30 to 34.9), Class II obesity (BMI 35 to 39.9), and even adolescents with Class II obesity.
For people with Class III obesity (BMI 40 or higher), ESG is considered an acceptable option when traditional bariatric surgery carries too high a risk due to medical or psychological conditions, or when the patient simply doesn’t want a more invasive operation. The UK’s NICE guidelines specifically highlight ESG as a potential fit for people who decline bariatric surgery because of its associated risks, or for those with Class I or II obesity where the procedure could prevent the condition from worsening.
Certain conditions can disqualify you. A hiatal hernia larger than 3 to 5 centimeters (the exact cutoff varies by center), previous stomach surgery, active stomach ulcers, bleeding disorders, esophageal or stomach motility disorders, pregnancy, and certain psychiatric conditions are all common exclusion criteria.
What to Expect for Weight Loss
Most patients lose between 14% and 15% of their total body weight within the first six months. At one year, that number climbs to roughly 17% to 18%, and by two years, studies report losses of about 19% to 21% of total body weight. To put that in perspective, a person weighing 250 pounds could expect to lose roughly 35 to 38 pounds by six months and 47 to 52 pounds by two years.
One multicenter study found that at 24 months, average BMI dropped from 38.3 to 30.8, with patients losing about 60% of their excess weight. These results are meaningful, but they’re more modest than what traditional sleeve gastrectomy delivers. ESG tends to produce the best outcomes for people with mild to moderate obesity who combine the procedure with sustained changes to diet and activity.
Benefits Beyond Weight Loss
Weight loss from ESG can improve or even resolve obesity-related conditions, particularly type 2 diabetes. A systematic review found that about half of patients with type 2 diabetes (50.6%) saw measurable improvement in their blood sugar control after ESG, including reduced medication needs or lower blood sugar markers. Among studies that specifically tracked full remission, 57% of patients no longer met the criteria for type 2 diabetes within six to 36 months. That remission rate is comparable to the 60.8% seen after traditional surgical sleeve gastrectomy. In some studies, 30% to 50% of patients were able to stop all glucose-lowering medication entirely within 12 months.
Recovery and Diet Progression
Most people go home the same day or after an overnight stay. Nausea and abdominal discomfort are common in the first few days and typically managed with medication. The recovery diet follows a structured progression to give the internal sutures time to heal properly.
For the first six weeks, you’ll be on a liquid-only diet. Weeks seven and eight introduce soft foods. By week nine, you can begin eating a regular diet, though portion sizes will be significantly smaller than before. This gradual reintroduction is essential. Eating solid foods too early risks disrupting the sutures before they’ve fully anchored into the stomach tissue. Most people return to work and normal activities within a few days of the procedure, though the dietary restrictions require planning.
How ESG Compares to Gastric Sleeve Surgery
The most common comparison is between ESG and laparoscopic sleeve gastrectomy (LSG), the traditional surgical version. LSG is more effective for pure weight loss. At six months, LSG patients typically lose 23% to 24% of their total body weight compared to 14% to 15% for ESG. At one year, LSG reaches about 29%, while ESG sits around 17% to 18%. For people with severe obesity whose primary goal is maximum long-term weight loss, surgical sleeve gastrectomy remains the stronger option.
Where ESG consistently wins is safety. One comparative study found that LSG was associated with a 16.9% rate of adverse events, while ESG’s rate was 5.2%. ESG also causes fewer cases of new-onset acid reflux, which is a well-known downside of surgical sleeve gastrectomy. Hospital stays are shorter, procedure times are faster, and when complications do occur with ESG, they tend to be milder. In one study, the surgical group had mild-to-severe adverse events at a 27% rate, while the ESG group had only mild-to-moderate events at 25%.
ESG also has an important structural advantage: it’s reversible. Because the stomach is sutured rather than permanently cut and stapled, the procedure can potentially be undone. It can also serve as a bridge to surgical bariatric procedures later if more aggressive weight loss becomes necessary.
Risks and Complications
ESG has a favorable safety profile, but it’s not risk-free. The most commonly reported serious complication is gastrointestinal bleeding. In a study of 222 consecutive patients at a single center, four experienced perioperative bleeding, a rate of 1.8%. Of those, one required intensive care. That same study recorded no other types of serious adverse events, such as gastric leaks or perforations, which are more commonly associated with surgical approaches. Perigastric fluid collections (small pockets of fluid near the stomach) are occasionally reported in the broader literature but weren’t observed in that cohort.
Common, non-serious side effects include nausea, vomiting, and abdominal pain in the first few days. These are expected and generally resolve quickly with standard medications. The overall picture across multiple studies is that serious complications are uncommon, occurring in roughly 2% to 5% of cases depending on the center and the surgeon’s experience level.