ESG, or endoscopic sleeve gastroplasty, is a weight loss procedure that shrinks your stomach without surgery. A doctor uses a flexible tube inserted through your mouth to place stitches inside your stomach, reshaping it from its natural pouch into a narrow tube. This smaller stomach holds less food, so you feel full faster and eat less. The procedure takes 1 to 2.5 hours, requires no incisions, and most people recover within a few days.
How the Procedure Works
During ESG, a gastroenterologist passes an endoscope (a long, flexible tube with a camera and suturing device) down your throat and into your stomach while you’re under general anesthesia. Using a specialized stitching tool, the doctor places a series of full-thickness sutures that pull the front and back walls of your stomach together along its larger curve. This transforms the stomach from its wide, bean-like shape into a tight, tubular sleeve. The stitches stay in place permanently, though the procedure is technically reversible if needed later.
Because everything happens through your mouth, there are no cuts to your abdomen, no staples removing part of your stomach, and no rerouting of your digestive tract. Your stomach remains intact, just significantly smaller in volume.
How Much Weight People Lose
On average, people lose about 15 to 17% of their total body weight in the first one to two years after ESG. At 12 months, roughly 83% of patients lose at least 10% of their body weight, and about 61% lose 15% or more. For someone starting at 250 pounds, that translates to a loss of roughly 38 to 43 pounds.
Results vary by how much weight you carry going in. People with the highest BMIs (class III obesity, or a BMI of 40 and above) tend to see larger absolute losses, averaging around 20% of total body weight at two years. Those with class I or class II obesity typically settle closer to 13 to 14% at the same time point. These numbers reflect real-world U.S. clinical data, not just controlled trial results.
ESG vs. Surgical Sleeve Gastrectomy
The most common comparison is between ESG and laparoscopic sleeve gastrectomy (LSG), which is the traditional surgical version. Surgery produces more weight loss: at six months, one comparative study found LSG patients lost 23.6% of body weight versus 17.1% for ESG. That gap persists over time.
The tradeoff is safety. ESG’s complication rate sits around 5%, while surgical sleeve gastrectomy carries a rate closer to 17%. Surgery can lead to serious problems like stomach leaks, fistulas, and bleeding, along with chronic acid reflux. ESG largely avoids these risks. For people who want meaningful weight loss but aren’t comfortable with or don’t qualify for surgery, ESG fills a middle ground between lifestyle changes alone and a full operation.
Who Qualifies for ESG
ESG is designed primarily for people with class I obesity (BMI of 30 to 34.9) and class II obesity (BMI of 35 to 39.9). It’s also an option for people with class III obesity (BMI 40 or higher) who either don’t want traditional bariatric surgery or aren’t good candidates for it due to other health conditions. The average starting BMI in large studies is around 37.5.
This is one of ESG’s key advantages over surgical options, which have historically required a BMI of 35 or higher (or 30 with obesity-related health problems). ESG opens a path for people in that lower BMI range who still struggle significantly with their weight but wouldn’t be offered surgery.
Recovery and the Post-Procedure Diet
Most people return to normal daily activities within a few days. The recovery is far shorter than surgical alternatives, which can require weeks off work. That said, your stomach needs time to heal around the new sutures, so your diet follows a strict progression.
For the first two days, you’ll stick to clear liquids only: broth, water, sugar-free drinks, clear protein supplements, and sugar-free popsicles. Nothing carbonated, caffeinated, or with added sugar. From day 3 through day 14, you move to full liquids, adding protein shakes, fat-free pureed soups (no chunks), and plain low-fat yogurt. Starting in week 3, you can begin introducing soft foods as tolerated. This two-week liquid phase is essential for letting the sutures set properly.
Long-term success depends heavily on what comes after. ESG is a tool that restricts how much your stomach can hold, but it works best alongside ongoing dietary changes and regular physical activity. Without those, weight regain is possible over time.
Risks and Side Effects
ESG has a favorable safety profile compared to surgery. The most common side effects in the days after the procedure are nausea, abdominal pain, and vomiting, which are typically temporary and manageable. Serious complications like bleeding or infection occur in a small percentage of cases, with overall adverse event rates around 5% in large studies.
Cost and Insurance Coverage
ESG is not routinely covered by insurance in the United States. Most people pay out of pocket, with estimates averaging around $16,360. Some patients gain access through clinical trials where costs are covered by research funding, but this is uncommon. Insurance coverage for obesity treatments has been expanding slowly, particularly for nutritional counseling and, more recently, weight loss medications. Coverage for procedures like ESG and bariatric surgery has lagged behind, despite the growing demand.
Reversibility and Conversion Options
One of ESG’s practical advantages is that it’s reversible. If the sutures need to be removed, an endoscopist can do so. And if you don’t achieve enough weight loss with ESG alone, conversion to a surgical sleeve gastrectomy or gastric bypass is feasible. Case studies show that this conversion can be performed safely using a combined endoscopic and laparoscopic approach. This makes ESG a reasonable first step for people who want to start with the least invasive option while keeping surgical alternatives available down the road.