Sleeve Gastrectomy

ESG vs. Gastric Bypass: Weighing Your Options

BY DR PATRICK NOEL

October 26, 2023

Introduction

In the evolving realm of medical interventions for obesity, three procedures have risen to prominence: Gastric Sleeve, Gastric Bypass and Endoscopic Sleeve Gastroplasty (ESG)[1]. As the obesity epidemic swells, with the World Health Organization reporting a near-tripling of global obesity rates since 1975, the urgency to find effective weight loss strategies has never been higher [2]. Gastric Bypass, a surgical intervention dating back decades, has showcased its ability to produce substantial weight loss and manage or even resolve many obesity-related conditions [3]. Conversely, ESG represents the newer generation of weight loss procedures, harnessing endoscopic techniques to offer a less invasive treatment avenue with unique advantages and challenges [4]. This article delves deep into the intricacies of both methods, ESG and Bypass, offering a comparative analysis to guide individuals in their quest for the most suitable weight loss intervention. We aim to elucidate the various facets of each procedure, from invasiveness and efficacy to recovery dynamics and cost implications, ensuring readers emerge well-equipped to make an informed decision congruent with their health trajectories [5].

Overview of Gastric Bypass Surgery

Definition and Procedure

Gastric Bypass, specifically the Roux-en-Y Gastric Bypass (RYGB), is one of the most commonly performed bariatric surgeries worldwide [6]. The procedure involves creating a small stomach pouch and rerouting the digestive tract to bypass a significant portion of the stomach and the upper part of the small intestine. This dual mechanism—restricting food intake and reducing nutrient absorption—facilitates weight loss and metabolic improvements [7].

Benefits

The primary allure of the Gastric Bypass is its potential for rapid and substantial weight reduction. Patients undergoing this procedure often witness a significant decline in their Body Mass Index (BMI), with many reaching their weight loss goals within a year [8]. Additionally, Gastric Bypass has demonstrated efficacy in improving or even resolving obesity-related conditions. Diseases such as type 2 diabetes, hypertension, and obstructive sleep apnea often show marked improvements post-surgery, enhancing patients’ overall quality of life [9].

Risks and Complications

Like any surgical intervention, Gastric Bypass comes with its share of risks. Common postoperative challenges include surgical site infections and leakage at the anastomotic junction. Over the long term, some patients might experience nutritional deficiencies due to the malabsorptive component of the procedure. It’s also worth noting the potential for “Dumping syndrome”—a condition where ingested foods move too quickly from the stomach to the small intestine, leading to nausea, dizziness, and diarrhea [10].

Eligibility and Candidacy

While Gastric Bypass presents promising results, it is only for some. Candidates typically possess a BMI of 40 or above or a BMI of 35 with accompanying obesity-related health issues. A thorough medical evaluation and psychological assessment precede the surgery to ensure patients are well-prepared for the procedure and the ensuing lifestyle changes.

Overview of Endoscopic Sleeve Gastroplasty (ESG)

What is ESG?

Endoscopic Sleeve Gastroplasty (ESG) is a weight loss procedure that reduces the stomach size without requiring surgical incisions. Instead, it utilizes an endoscope inserted through the mouth and into the stomach. During the procedure, the stomach is sutured internally to decrease its volume, limiting the amount of food it can hold and slowing digestion [11].

Advantages and Disadvantages

One of the primary advantages of ESG is its minimally invasive nature. Since there’s no external incision typically results in reduced pain, shorter hospital stays, and a faster recovery compared to more invasive procedures [12]. This makes it an appealing option for patients seeking a less intensive approach to weight loss surgery.

However, ESG has its disadvantages. The weight loss achieved with ESG may be less significant than that following a gastric bypass. As with any procedure, inherent risks are involved, such as potential infection or complications from the sutures [13]. It’s also worth noting that ESG is a relatively new procedure, and long-term data on its efficacy and potential complications is still emerging [14].

Candidacy for ESG

Only some people are suitable candidates for ESG. Ideal candidates are typically those with a BMI between 30 and 40, who have struggled with weight loss through traditional means but who may not qualify or wish to undergo more invasive bariatric surgeries. A thorough evaluation by a bariatric specialist is essential to determine if ESG is the right choice for an individual [15].

Direct Comparison: ESG vs. Gastric Bypass

Procedure and Invasiveness

Endoscopic Sleeve Gastroplasty (ESG) is markedly different in its approach compared to Gastric Bypass. ESG uses an endoscope introduced through the mouth to suture the stomach, reducing its size without any external incisions [16]. This non-surgical method is less invasive than Gastric Bypass, which requires surgical alteration of the stomach and digestive tract. Due to its minimal invasiveness, ESG promises quicker recovery and reduced hospital stay [14].

Efficacy and Outcomes

Both ESG and Gastric Bypass have demonstrated weight-loss efficacy. However, Gastric Bypass generally results in a more significant weight reduction, often surpassing 70% of excess weight loss within a year [17]. ESG, on the other hand, facilitates around 15-20% of total body weight loss in a comparable period [18]. Besides weight loss, Gastric Bypass often leads to improvements in comorbidities like type 2 diabetes, with some patients even achieving remission. ESG, while beneficial, does not consistently demonstrate similar results in comorbidity resolution.

Risks and Complications

Every procedure has its unique set of risks. While Gastric Bypass poses complications like surgical site infections and nutrient deficiencies, ESG’s non-surgical nature reduces such risks. However, ESG can lead to potential gastrointestinal complications like gastric leaks or perforations, albeit rarely [19].

Cost Implications

Financial considerations also play a pivotal role for many patients. Generally, as a surgical intervention, Gastric Bypass tends to be costlier, encompassing surgical fees, hospital stay, and associated care. ESG, due to its outpatient nature and reduced recovery time, is often more economical, though prices can vary significantly based on location and facility.

Personal Considerations When Choosing a Procedure

Health Status and Comorbidities

When contemplating ESG and Gastric Bypass, one’s current health condition and associated comorbidities are pivotal. While both procedures can lead to weight loss, Gastric Bypass is particularly effective for individuals with severe obesity-related conditions such as type 2 diabetes, making it an attractive option for those hoping for both weight loss and improvement in these conditions [20]. However, for individuals without these pressing health issues or those with a lower BMI, ESG might be more appropriate.

Recovery and Lifestyle Adaptations

Both procedures demand lifestyle adaptations post-operation, but their intensities vary. Gastric Bypass, being more invasive, often requires a more extended hospital stay and post-operative recovery period [21]. This might necessitate taking extended work leave or arranging additional support at home. ESG, due to its less invasive nature, usually allows for quicker resumption of daily activities. However, dietary restrictions and regular follow-ups are crucial in both procedures to ensure optimal outcomes and prevent complications.

Psychological Preparedness

The decision to undergo a weight loss procedure isn’t solely physical. Psychological readiness plays a crucial role. Patients must be prepared for the changes, challenges, and potential emotional roller-coasters post-procedure. Some individuals may benefit from pre-surgical counselling to address concerns, set realistic expectations, and develop coping strategies [22].

Financial Constraints

Lastly, financial implications must be addressed. With Gastric Bypass generally costlier than ESG, one’s budget might significantly influence the decision. However, patients should also consider long-term costs, such as potential follow-up appointments, dietary supplements, or unforeseen complications arising from either procedure [23].

Conclusion

Deciding between ESG and Gastric Bypass is profoundly personal and multifaceted. Both procedures have demonstrated efficacy in promoting weight loss, albeit with distinct methods, outcomes, and potential complications [3]. While Gastric Bypass often results in more pronounced weight loss and improved outcomes for severe obesity-related conditions, ESG offers a less invasive alternative with quicker recovery [24]. The considerations extend beyond the physical realm, encompassing psychological, lifestyle, and financial aspects that need thorough deliberation. Prospective patients must discuss comprehensively with their healthcare professionals, exploring their choice’s risks, benefits, and potential long-term implications[25]. With the advancements in medical technology and increased understanding of obesity management, the goal remains to equip individuals with the best possible tools and knowledge to make an informed decision tailored to their unique circumstances [5]. Ultimately, the path to a healthier future is paved with careful thought, informed choices, and steadfast commitment.

References

Kumar, N., & Abu Dayyeh, B. K. (2017). Bariatric endoscopy: current and future applications. *Surgical Endoscopy*, 31(3), 936-949. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9005302/
World Health Organization. (2022). Obesity and overweight. WHO.
Schauer, P. R., Kashyap, S. R., Wolski, K., Brethauer, S. A., Kirwan, J. P., Pothier, C. E., … & Bhatt, D. L. (2012). Bariatric surgery versus intensive medical therapy in obese patients with diabetes. *New England Journal of Medicine*, 366(17), 1567-1576. https://www.nejm.org/doi/full/10.1056/nejmoa1200225
Sullivan, S., Swain, J. M., Woodman, G., Antonetti, M., De La Cruz-Muñoz, N., Jonnalagadda, S. S., … & Ponce, J. (2017). Randomised sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss. *Surgical Obesity and Related Diseases*, 13(12), 1905-1909.
Courcoulas, A. P., Christian, N. J., Belle, S. H., Berk, P. D., Flum, D. R., Garcia, L., … & Mitchell, J. E. (2013). Weight change and health outcomes three years after bariatric surgery among individuals with severe obesity. *JAMA*, 310(22), 2416-2425.
Buchwald, H., Avidor, Y., Braunwald, E., Jensen, M. D., Pories, W., Fahrbach, K., & Schoelles, K. (2004). Bariatric surgery: a systematic review and meta-analysis. *JAMA*, 292(14), 1724-1737. https://jamanetwork.com/journals/jama/fullarticle/199587
Schauer, P. R., Burguera, B., Ikramuddin, S., Cottam, D., Gourash, W., Hamad, G., … & Eid, G. M. (2003). Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. *Annals of Surgery*, 238(4), 467.
Adams, T. D., Gress, R. E., Smith, S. C., Halverson, R. C., Simper, S. C., Rosamond, W. D., … & Hunt, S. C. (2007). Long-term mortality after gastric bypass surgery. *New England Journal of Medicine*, 357(8), 753-761.
Mingrone, G., Panunzi, S., De Gaetano, A., Guidone, C., Iaconelli, A., Leccesi, L., … & Bornstein, S. (2015). Bariatric–metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5-year follow-up of an open-label, single-centre, randomised controlled trial. *The Lancet*, 386(9997), 964-973.
Tack, J., Arts, J., Caenepeel, P., De Wulf, D., & Bisschops, R. (2009). Pathophysiology, diagnosis and management of postoperative dumping syndrome. *Nature Reviews Gastroenterology & Hepatology*, 6(10), 583-590. https://www.nature.com/articles/nrgastro.2009.148
Abu Dayyeh, B. K., Rajan, E., & Gostout, C. J. (2013). Endoscopic sleeve gastroplasty: a potential endoscopic alternative to surgical sleeve gastrectomy for treatment of obesity. *Gastrointestinal endoscopy*, 78(3), 530-535.
Kumar, N. (2015). Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration. *World Journal of Gastrointestinal Endoscopy*, 7(9), 847.
Hill, C., El-Zein, M., Agnihotri, A., Dunlap, M., Chang, A., Agrawal, A., … & Abu Dayyeh, B. K. (2017). Endoscopic Sleeve Gastroplasty: the Learning Curve. *Endoscopy International Open*, 05(11), E900-E904.
Sharaiha, R. Z., Kumta, N. A., Saumoy, M., Desai, A. P., Sarkisian, A. M., Benevenuto, A., … & Aronne, L. (2017). Endoscopic Sleeve Gastroplasty Significantly Reduces Body Mass Index and Metabolic Complications in Obese Patients. *Clinical Gastroenterology and Hepatology*, 15(4), 504-510.
Storm, A. C., Abu Dayyeh, B. K., & Thompson, C. C. (2017). Endoscopic Sleeve Gastroplasty for Obesity. *JAMA Surgery*, 152(3), 271-278. https://pubmed.ncbi.nlm.nih.gov/26748219/
Abu Dayyeh, B. K., Acosta, A., Camilleri, M., Mundi, M. S., Rajan, E., Topazian, M. D., … & Gostout, C. J. (2017). Endoscopic Sleeve Gastroplasty Alters Gastric Physiology and Induces Loss of Body Weight in Obese Individuals. *Clinical Gastroenterology and Hepatology*, 15(1), 37-43.e1.
Kumar, N., & Sahdala, H. N. (2015). Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration. *World Journal of Gastrointestinal Endoscopy*, 7(9), 847-859.
Chang, S. H., Stoll, C. R., Song, J., Varela, J. E., Eagon, C. J., & Colditz, G. A. (2014). The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012. *JAMA surgery*, 149(3), 275-287.
Lopez-Nava, G., Asokkumar, R., & Rull, A. (2018). Endoscopic sleeve gastroplasty: How I do it? *Obesity Surgery*, 28(12), 3872-3877.
Schauer, P. R., Bhatt, D. L., Kirwan, J. P., Wolski, K., Aminian, A., Brethauer, S. A., … & Cohen, R. V. (2017). Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. *New England Journal of Medicine*, 376(7), 641-651.
Courcoulas, A. P., Yanovski, S. Z., Bonds, D., Eggerman, T. L., Horlick, M., Staten, M. A., & Arterburn, D. E. (2014). Long-term outcomes of bariatric surgery: a National Institutes of Health symposium. *JAMA surgery*, 149(12), 1323-1329.
Livhits, M., Mercado, C., Yermilov, I., Parikh, J. A., Dutson, E., Mehran, A., … & Gibbons, M. M. (2012). Preoperative predictors of weight loss following bariatric surgery: systematic review. *Obesity surgery*, 22(1), 70-89.
Martin, M., Beekley, A., Kjorstad, R., & Sebesta, J. (2010). Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis. *Surgery for Obesity and Related Diseases*, 6(1), 8-15.
Sullivan, S., Edmundowicz, S. A., & Thompson, C. C. (2017). Endoscopic bariatric and metabolic therapies: new and emerging technologies. *Gastroenterology*, 152(7), 1791-1801.
Sogg, S., Lauretti, J., & West-Smith, L. (2016). Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. *Surgery for Obesity and Related Diseases*, 12(4), 731-749.