How to Determine if You're a Candidate for Endoscopic Sleeve Gastroplasty (ESG)

Published on: August 31, 2023

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How to Determine if You're a Candidate for Endoscopic Sleeve Gastroplasty (ESG)


The global rise in obesity rates represents a pressing healthcare challenge that often requires medical intervention beyond traditional weight loss methods [1]. Severe obesity hinders the quality of life and brings many associated health complications. Medical professionals have developed several surgical and non-surgical weight loss procedures to address this growing concern. Endoscopic Sleeve Gastroplasty (ESG) stands out as a promising and less invasive alternative to conventional bariatric surgeries like gastric bypass and gastric banding [2]. 

ESG offers distinct benefits, primarily its non-surgical nature, which translates to reduced risks and complications. It also boasts a commendable efficacy rate in aiding significant weight loss and consequent health improvement [3]. However, only some qualify for this procedure. Factors like Body Mass Index (BMI), prior weight loss attempts, certain gastrointestinal conditions, and mental and emotional well-being are crucial in determining ESG candidacy [4]. 

This article provides a comprehensive guide on discerning if one is an ideal candidate for ESG, shedding light on the procedure’s benefits and risks, and emphasising the importance of a thorough consultation with a bariatric specialist [5]. By the end, potential candidates will be better equipped to make informed decisions regarding their weight loss journey and overall health.

Background on Obesity

The Growing Epidemic

Obesity, characterised by excessive fat accumulation, has seen an alarming surge in recent decades. A significant proportion of the world’s population now grapples with obesity, making it a health crisis of global proportions[6]. This increase is often attributed to lifestyle changes, including sedentary habits and increased intake of high-calorie, nutrient-poor foods. Urbanisation, reduced physical activity, and a shift towards processed food consumption have all significantly contributed to this epidemic[7].

Health Implications of Severe Obesity

Severe obesity isn’t just a cosmetic concern; it’s a multifaceted health hazard. Individuals who fall into the category of severe obesity often face an elevated risk for a variety of chronic conditions. Cardiovascular diseases, type 2 diabetes, certain types of cancers, and even mental health disorders like depression often have direct links to obesity[8]. Moreover, the strain excessive weight puts on joints can lead to orthopaedic problems. The combination of these health complications reduces overall life expectancy and deteriorates the quality of life[9]. To curtail these risks, medical interventions, such as Endoscopic Sleeve Gastroplasty, have become essential tools in the armamentarium against obesity, especially when conventional weight loss methods fail[10].

What is Endoscopic Sleeve Gastroplasty (ESG)?

A Detailed Overview of the Procedure

Endoscopic Sleeve Gastroplasty (ESG) is a novel, minimally invasive weight loss procedure that reduces the size of the stomach using an endoscope — a flexible tube with a camera and suturing device attached[11]. Unlike traditional surgical methods, ESG doesn’t involve any external incisions. Instead, the endoscope is inserted through the patient’s mouth and advanced to the stomach. The procedure entails placing sutures in the stomach, effectively reducing its volume. This smaller stomach capacity promotes early satiety, making patients feel full with lesser food intake, consequently leading to weight loss[12].

ESG vs Other Bariatric Procedures

While numerous weight loss interventions are available, ESG stands out due to its less invasive nature. Traditional bariatric surgeries, such as gastric bypass or gastric banding, involve significant surgical interventions, which come with increased risks and longer recovery periods. ESG, on the other hand, eliminates the need for large surgical incisions, resulting in a reduced risk of complications, shorter hospital stays, and a quicker recovery process[13]. Moreover, the reversibility of ESG gives it an advantage over some permanent surgical procedures. If required, the sutures can be removed, returning the stomach to its original size[14]. However, it’s crucial to note that while ESG has its merits, it may only be suitable for some. Therefore, patients need to undergo thorough evaluations to determine the best weight loss procedure tailored to their needs[15].

Benefits of ESG

Non-surgical Nature

One of the most prominent advantages of Endoscopic Sleeve Gastroplasty (ESG) is its non-surgical approach. Unlike conventional bariatric surgeries, ESG doesn’t require external incisions. Instead, the procedure is carried out via an endoscope inserted through the mouth, significantly reducing risks associated with wound infections and large surgical scars[16]. The absence of external cuts lessens post-operative discomfort and minimises the chances of external scar formation, a common concern among patients undergoing surgical weight loss procedures.

Reduced Risks and Complications

With its minimally invasive nature comes a reduction in potential complications. ESG boasts a favourable safety profile, with fewer adverse events reported compared to traditional surgeries. Common issues like surgical site infections, prolonged hospitalisation, and complications from general anaesthesia are considerably minimised in ESG[17]. Moreover, the recovery time is notably shorter. Patients can typically resume their daily activities sooner than they would after a traditional surgical procedure[18].

Efficacy in Weight Loss and Health Improvement

Beyond its safety and procedural benefits, ESG has demonstrated compelling outcomes in terms of weight reduction. Studies indicate that individuals who undergo ESG can expect a significant percentage of their excess weight to be shed within the first year post-procedure[19]. Additionally, this weight loss often improves obesity-associated conditions like hypertension, type 2 diabetes, and sleep apnea, enhancing overall quality of life and reducing long-term health risks[20].

Primary Criteria for ESG Candidates

Body Mass Index (BMI)

Body Mass Index (BMI) is a primary factor for ESG candidacy. Generally, ESG is recommended for individuals with a BMI between 30 and 40 who still need to achieve adequate weight loss through traditional methods like diet and exercise. In some cases, those with a BMI above 40 may also be candidates, depending on associated health conditions and their healthcare provider’s recommendation [21].

Prior Weight Loss Efforts

Another significant criterion is the patient’s history of weight loss attempts. ESG is typically reserved for those who have unsuccessfully tried to lose weight through diet, exercise, or pharmacological interventions. This procedure is considered when these measures have proven inadequate or when the patient faces significant health risks due to their obesity[22].

Gastrointestinal Conditions

Some gastrointestinal conditions may influence the suitability of ESG. For instance, those with severe gastroesophageal reflux disease (GERD), large hiatal hernias, or other significant upper gastrointestinal issues are not ideal candidates, as these conditions could complicate the procedure[23].

Psychological and Emotional Well-being

An often overlooked but crucial criterion is the mental and emotional readiness of the patient. ESG requires a long-term commitment to lifestyle changes and regular follow-ups. Therefore, psychological and emotional stability is vital to ensure adherence to post-procedure recommendations and successful weight loss[24]. Before proceeding with ESG, a comprehensive evaluation, including a psychological assessment, is often conducted to ascertain the patient’s ability to cope with these requirements and their readiness for the procedure[25].

Additional Factors to Consider

Age and General Health

While age alone isn’t a disqualifying factor, younger patients tend to recover faster and adapt better to the post-procedural lifestyle changes. However, older adults might also be candidates, provided they are in good general health and free from conditions that could complicate the procedure or recovery[26]. An individual’s overall health, including heart, liver, and kidney functions, is crucial to assess as they may influence the safety and efficacy of the ESG.

Commitment to Lifestyle Changes

ESG is a tool, not a miracle solution. Its success largely depends on the patient’s commitment to long-term dietary and lifestyle modifications. Post-procedure, candidates must follow a strict dietary regimen, incorporate regular physical activity, and attend follow-up sessions with healthcare professionals. Individuals must be prepared for this long-term commitment to ensure sustained weight loss and health benefits[27].

Financial and Insurance Considerations

While ESG is less invasive and often less expensive than traditional bariatric surgeries, it’s still a significant investment. Patients should evaluate their financial capacity and explore insurance coverage options. Many insurance companies might not cover ESG, so out-of-pocket expenses or financing solutions might be necessary[28].

Expectations and Post-Procedural Support

Realistic expectations are vital. While significant weight loss is attainable, individuals need to understand that results can vary. Additionally, post-procedural support, whether through support groups, counselling, or regular medical follow-ups, can play a pivotal role in ensuring the procedure’s success in the long term[29].

Risks of ESG

Procedure-Related Complications

Like any medical procedure, Endoscopic Sleeve Gastroplasty (ESG) isn’t without its risks. During the procedure, there’s a slight possibility of perforation or bleeding, particularly when placing sutures in the stomach lining[31]. Moreover, while the endoscopic approach minimises many surgical risks, complications such as infections or adverse reactions to anaesthesia can still occur, albeit rarely.

Post-Operative Issues

After undergoing ESG, some patients may experience gastrointestinal complaints like nausea, vomiting, abdominal pain, or gastritis. While these are often temporary and can be managed with medications, they can be distressing for the patient[32]. In some cases, there’s also the risk of the stomach returning to its original size, especially if the sutures loosen or are not adequately maintained, thereby undermining the weight loss objectives of the procedure[33].

Nutritional Concerns

Given the reduced stomach size post-ESG, patients might face challenges in getting adequate nutrition. There’s a risk of malnutrition or vitamin and mineral deficiencies if dietary recommendations aren’t followed strictly. This underscores the importance of regular follow-up with nutritionists to ensure that patients receive the essential nutrients while still losing weight[34].

Psychological and Emotional Challenges

Substantial weight loss and lifestyle changes can bring about psychological and emotional challenges. Some patients might face issues like body dysmorphia, depression, or anxiety post-procedure. Having a support system in place and possibly seeking therapy can be essential to navigate these challenges effectively[35].

Consultation and Evaluation

Initial Consultation

The journey towards Endoscopic Sleeve Gastroplasty (ESG) begins with a comprehensive initial consultation. During this meeting, healthcare professionals assess the patient’s medical history, physical condition, and prior weight loss attempts. This consultation provides an opportunity for patients to discuss their weight loss goals, apprehensions, and expectations. Equally, it allows the clinician to gauge the patient’s overall suitability for the procedure and offer insights into what the procedure entails and the lifestyle changes it necessitates[36].

Multidisciplinary Assessment

Given the holistic challenges associated with obesity and the complexities of weight loss procedures, a multidisciplinary assessment is often required. This assessment involves a team of experts, including dietitians, psychologists, and physical therapists. Nutritionists ensure the patient understands the post-procedure dietary requirements. Psychologists evaluate emotional and psychological readiness, ensuring that patients are prepared for the challenges and changes post-ESG. On the other hand, physical therapists provide guidance on exercise and movement, which are vital for recovery and long-term success[37].

Diagnostic Procedures

Before undergoing ESG, several diagnostic tests might be necessary. These may include blood tests, endoscopic evaluations, and imaging studies like ultrasounds or MRIs. These diagnostics aid in determining the health of the gastrointestinal system and any potential contraindications to the procedure. They also help in spotting any unforeseen issues that could complicate the ESG[38].

Final Evaluation

After the consultation, assessment, and diagnostics, a final evaluation takes place. At this stage, the final decision about proceeding with ESG is made. The healthcare provider will weigh the benefits against potential risks and ensure that the patient is fully informed and committed to the post-procedure lifestyle[39].

Alternative Procedures

Gastric Bypass (Roux-en-Y)

The gastric bypass, often referred to as Roux-en-Y gastric bypass (RYGB), is a well-established bariatric procedure that involves creating a small stomach pouch and bypassing a segment of the small intestine. This dual approach reduces food intake and decreases nutrient absorption, leading to substantial weight loss. RYGB has proven efficacy and has been associated with significant improvements in obesity-related comorbidities like type 2 diabetes[41].

Gastric Banding

Gastric banding, commonly known as laparoscopic adjustable gastric banding (LAGB), involves placing an adjustable band around the upper part of the stomach. This band can be tightened or loosened to control the size of the stomach’s opening, regulating food intake. Though less invasive than gastric bypass, its weight loss outcomes are generally more modest and might necessitate periodic adjustments to maintain its effectiveness[42].

Gastric Sleeve (Sleeve Gastrectomy)

Sleeve gastrectomy, or gastric sleeve, entails removing a significant portion of the stomach, leaving behind a tubular “sleeve.” This procedure restricts food intake and impacts gut hormones, influencing hunger and satiety. It’s gained popularity due to its straightforward approach, significant weight loss results, and fewer complications compared to other surgical methods[43].

Intragastric Balloon

The intragastric balloon is a non-surgical procedure wherein a saline-filled silicone balloon is placed inside the stomach, occupying space and promoting early satiety. Typically kept in place for six months, it’s a temporary measure designed to kick-start weight loss and is often accompanied by an intensive lifestyle modification program[44].


Endoscopic Sleeve Gastroplasty (ESG) offers a promising and less invasive alternative to traditional bariatric surgeries for those battling obesity. By understanding the nuances of the procedure, its benefits, potential risks, and the primary criteria for candidacy, individuals can make an informed decision about pursuing ESG. 

While ESG stands as a valuable tool in the weight management arsenal, it’s vital to remember that lasting weight loss is a multifaceted journey. It requires medical interventions and a commitment to lifestyle changes, including nutrition and physical activity. When considering ESG, thorough consultation and evaluation are indispensable, ensuring the procedure aligns with an individual’s health profile and goals[46]. 

Furthermore, it’s crucial to recognise that while ESG is beneficial for many, alternative procedures might be more suitable for others based on specific health conditions and objectives[47]. Ultimately, the best approach is tailored to the individual’s unique needs, championing their journey towards a healthier, more fulfilled life[48].


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