Introduction
Obesity has emerged as a major global health concern, affecting over 650 million adults worldwide. Characterized by excessive fat accumulation, it significantly raises the risk of chronic diseases such as cardiovascular conditions, type 2 diabetes, and certain cancers. Traditional weight loss strategies—ranging from diet and exercise to pharmacological and surgical interventions—often present limitations in terms of efficacy, long-term adherence, invasiveness, or accessibility.
Amid this landscape, the development of minimally invasive alternatives has garnered growing interest. Among these, the Endosleeve—formally known as Endoscopic Sleeve Gastroplasty (ESG)—offers a promising new option for weight loss. Designed to mimic the effects of bariatric surgery without the need for incisions, this endoscopic procedure represents a novel approach that is both safer and more accessible for a broader patient population.
This article explores the fundamentals of the Endosleeve, including its mechanism, clinical outcomes, benefits, limitations, and considerations for patient selection. Through a review of emerging clinical evidence, we aim to clarify its role in the evolving field of obesity treatment and outline its potential as a bridge between conservative and surgical therapies [1].
Overview of Obesity and Current Treatments
Obesity is a complex condition influenced by genetic, environmental, behavioral, and metabolic factors. It is associated with numerous comorbidities, including insulin resistance, sleep apnea, osteoarthritis, and depression. The Body Mass Index (BMI) remains the primary tool for classifying obesity, with a BMI ≥30 kg/m² indicating obesity and ≥40 kg/m² defining severe obesity.
Current treatments fall into three primary categories: lifestyle modifications, pharmacotherapy, and surgical interventions.
- Lifestyle modifications, including caloric restriction and physical activity, are the first-line strategy. While essential, these often yield modest and unsustainable long-term results due to metabolic adaptation and behavioral factors.
- Pharmacotherapy includes medications such as orlistat, liraglutide, and semaglutide. These drugs can support weight loss by suppressing appetite or altering nutrient absorption but may lead to side effects, and long-term adherence is often challenging.
- Surgical options, such as gastric bypass and laparoscopic sleeve gastrectomy, offer the most significant and sustained weight loss. However, they come with operative risks, prolonged recovery, high costs, and are generally limited to patients with severe obesity or serious comorbidities.
In response to these limitations, minimally invasive procedures like the Endosleeve have emerged as an intermediate solution. They aim to provide meaningful weight loss with fewer risks and shorter recovery times than traditional bariatric surgeries [2].
The Endosleeve: Definition and Mechanism
The Endosleeve, or Endoscopic Sleeve Gastroplasty (ESG), is a non-surgical weight loss procedure that involves using an endoscope—a flexible tube equipped with a camera and suturing tools—to reduce the stomach’s volume from the inside.
During the procedure, the endoscopist places full-thickness sutures in the stomach, folding it into a tube-like shape that resembles a surgical sleeve gastrectomy. This configuration limits the amount of food the stomach can hold and slows gastric emptying, leading to early satiety and reduced caloric intake.
Unlike surgical approaches, ESG does not involve incisions, gastric resection, or rerouting of the intestines. The procedure typically takes 60 to 90 minutes, and patients are often discharged the same day or within 24 hours. Most individuals resume normal activities within a few days [1].
This anatomical modification affects hunger-regulating hormones, such as ghrelin, further enhancing satiety. While not as profound as surgical changes, these hormonal shifts contribute to the procedure’s effectiveness. ESG is generally reversible and repeatable, making it an attractive option for patients hesitant about permanent alterations.
Clinical Evidence and Efficacy
Multiple studies have evaluated ESG’s safety and effectiveness. One of the largest international prospective trials showed an average excess weight loss of 15–20% at one year, with sustained benefits beyond 24 months [2].
In a U.S.-based study, over 90% of patients achieved clinically meaningful weight loss, with a BMI reduction of 5 to 10 points. Importantly, comorbid conditions such as type 2 diabetes, hypertension, and dyslipidemia improved significantly in many participants [3].
Another important outcome is the low incidence of complications. ESG has a complication rate of less than 2%, with most adverse events being minor and self-limiting, such as abdominal discomfort, nausea, or transient dysphagia.
One meta-analysis reported that ESG not only resulted in weight loss comparable to laparoscopic sleeve gastrectomy in select patients but also maintained a more favorable safety profile. However, weight loss outcomes vary depending on patient adherence to follow-up care and lifestyle changes.
Long-term durability remains under study. Some data suggest that while ESG leads to durable weight loss over two to three years, a subset of patients may experience partial weight regain. Ongoing monitoring, behavioral support, and possible touch-up procedures can help maintain outcomes [4].
Overall, the clinical evidence supports ESG as a safe and effective alternative for patients with moderate obesity or those not ready for surgery.
Advantages and Limitations
Advantages
- Minimally Invasive: ESG avoids incisions, offering faster recovery, less pain, and minimal scarring.
- Low Risk Profile: With a complication rate under 2%, it poses fewer risks than surgical options.
- Reversible and Repeatable: Unlike sleeve gastrectomy or gastric bypass, ESG is potentially reversible and does not involve permanent removal of stomach tissue.
- Shorter Hospital Stay: Many patients can return home the same day or within 24 hours.
- Improved Quality of Life: Patients often report enhanced well-being, better mobility, and resolution or improvement of obesity-related comorbidities.
Limitations
- Limited Long-Term Data: While short- and mid-term results are promising, data beyond 5 years are sparse. More research is needed to assess durability.
- Lower Weight Loss Compared to Surgery: ESG typically results in less total weight loss than surgical options, making it less ideal for patients with severe obesity (BMI ≥40).
- Operator Dependency: Outcomes vary based on the endoscopist’s skill and experience. ESG is technically demanding and requires specialized training.
- Potential for Weight Regain: Without proper lifestyle changes and follow-up, some patients may regain weight.
- Uncertain Insurance Coverage: ESG is still considered investigational by some insurance providers, limiting access for certain patients [3].
Despite these limitations, ESG fills a critical gap in obesity treatment, especially for patients seeking effective, low-risk alternatives to surgery.
Patient Selection and Post-Treatment Considerations
Proper patient selection is vital to achieving favorable outcomes with the Endosleeve. ESG is typically indicated for individuals with a BMI between 30 and 40 who have failed to lose weight through diet, exercise, or medication. It may also be considered for those with a BMI >40 who decline surgery or are medically unfit for invasive procedures.
Ideal candidates should be:
- Committed to lifestyle change: Success depends on long-term adherence to a healthy diet, exercise, and follow-up.
- Free of contraindications: Patients with significant gastric pathology (e.g., ulcers, previous gastric surgery) or high surgical risk may not be eligible.
- Supported by a care team: Psychological screening, nutritional counseling, and physician monitoring are essential before and after the procedure.
Post-procedure, patients begin with a liquid diet before progressing to solids over several weeks. Most experience reduced appetite and early fullness, aiding caloric restriction. Side effects, including nausea or abdominal discomfort, are usually mild and transient.
Long-term follow-up includes:
- Regular clinic visits to monitor weight, metabolic markers, and dietary adherence.
- Behavioral counseling to prevent relapse and address emotional or binge eating.
- Nutritional monitoring to prevent deficiencies and maintain lean muscle mass.
Weight loss plateaus or partial regain can occur. In such cases, re-intervention or escalation to surgical procedures may be discussed. Nonetheless, ESG can serve as an important tool in a staged approach to obesity management, improving health outcomes while minimizing risks [4].
Conclusion
As obesity continues to rise globally, there is an urgent need for treatment strategies that balance efficacy, safety, and accessibility. The Endosleeve, or Endoscopic Sleeve Gastroplasty, is a compelling minimally invasive option that bridges the gap between lifestyle interventions and surgery.
With a favorable safety profile, promising short- to mid-term efficacy, and reduced recovery times, ESG presents a valuable alternative for patients who are not candidates for—or are unwilling to undergo—traditional bariatric surgery. Clinical evidence highlights its capacity for meaningful weight loss and improvement in obesity-related comorbidities.
However, it is not a panacea. ESG demands a comprehensive, multidisciplinary approach, careful patient selection, and long-term lifestyle changes to ensure success. Limitations such as technical complexity, potential for weight regain, and a lack of long-term data must be acknowledged and addressed through ongoing research.
As the field of metabolic and bariatric endoscopy advances, the Endosleeve has the potential to become a cornerstone in the treatment of obesity, offering hope and health improvement to many individuals who might otherwise remain untreated [5].
References
- Abu Dayyeh BK, Kumar N, Edmundowicz SA. Endoscopic Sleeve Gastroplasty for Treatment of Obesity: A Large International Study. Gastrointestinal Endoscopy, 2015
- Fisher L, Aloi M. Endoscopic Sleeve Gastroplasty: A Novel Weight-Loss Procedure. Clinical Gastroenterology and Hepatology, 2017.
- Sharaiha RZ, Kedia P, Kumta NA. Initial Guru Outcomes with Endoscopic Sleeve Gastroplasty for Treatment of Obesity. Clinical Gastroenterology and Hepatology, 2015.
- Barrichello S, Baptista A, Orso F. Endosleeve in the Management of Obesity: A Multicenter Retrospective Study from Brazil. Obesity Surgery, 2019.
- Kumar N. Evolving Role of Endoscopic Therapy in Management of Obesity: A Review on Primary Endoscopic Bariatric Therapies. Gastroenterology Research and Practice, 2018.
