Minimally Invasive Approaches to Obesity: Evaluating the Efficacy and Safety of Endoscopic Gastroplasty
Published on: 16 Aug 2025
Introduction
Obesity is a profound global health crisis impacting millions worldwide, significantly increasing the risk of various comorbidities including type 2 diabetes mellitus (T2DM), hypertension, cardiovascular diseases, and certain cancers. The escalating prevalence of obesity has urged the medical community to develop effective therapeutic interventions ranging from lifestyle modifications to surgical procedures.
Bariatric surgery, particularly laparoscopic sleeve gastrectomy (LSG), stands as the gold standard for severe obesity treatment due to its substantial and sustained weight loss outcomes. However, the invasive nature, irreversibility, and potential complications associated with surgical interventions have driven the search for safer, less invasive alternatives. One such promising innovation is endoscopic sleeve gastroplasty (ESG), a minimally invasive procedure that reduces stomach volume using endoscopic suturing devices, thereby mimicking the effects of surgical sleeve gastrectomy without surgical incisions or permanent anatomical changes.
Efficacy of Endoscopic Sleeve Gastroplasty
ESG has demonstrated robust efficacy in inducing significant weight loss across a broad spectrum of obesity classes. Multiple studies report a mean total weight loss (%TWL) ranging between 15% and 18% at 12 months post-procedure, with excess weight loss percentages exceeding 50% in many cases. These outcomes are observed consistently in patients with class I, II, and III obesity, highlighting ESG’s versatility and applicability.
In patients with severe obesity (class III), ESG offers notable benefits, achieving substantial weight loss sustained over long periods. Follow-up data extending to 24 and even 36 months indicate durable outcomes, with mean %TWL ranging from approximately 13% to over 20%. Importantly, these weight reductions are accompanied by meaningful improvements in obesity-related comorbidities such as T2DM and hypertension, suggesting ESG’s dual role in weight management and metabolic health enhancement.
Beyond mere weight reduction, ESG exerts beneficial metabolic effects. Patients undergoing ESG show improved glycemic control, indicated by significant reductions in glycated hemoglobin (HbA1c) levels, enhanced insulin sensitivity, and lowered insulin resistance. Lipid profiles also improve, with reductions in triglycerides and total cholesterol, contributing to better cardiovascular risk profiles. Additionally, liver function markers often improve post-ESG, suggesting a positive impact on obesity-associated steatotic liver disease. These metabolic outcomes are thought to arise from both mechanical gastric restriction and hormonal modulations induced by ESG, including increased secretion of appetite-regulating hormones such as glucagon-like peptide-1 (GLP-1) and peptide YY (PYY).
Physiological Mechanisms Underlying ESG
The weight loss and metabolic benefits of ESG stem not only from the physical reduction in gastric volume but also from profound physiological changes in gastrointestinal function. ESG delays gastric emptying, thereby prolonging feelings of fullness after meals and reducing overall caloric intake. Moreover, hormonal shifts include decreased levels of ghrelin—the hunger hormone—due to reduced fundic distension, and increased levels of GLP-1 and PYY, which promote satiety and improve glucose metabolism.
Collectively, these changes create a synergistic effect that enhances appetite regulation, improves glycemic control, and supports sustained weight loss. This multifaceted physiological impact distinguishes ESG from simpler restrictive procedures and underscores its growing role in managing both obesity and its metabolic consequences.
Safety Profile of ESG
One of ESG’s most compelling advantages is its favorable safety profile. As a minimally invasive endoscopic procedure, ESG is associated with significantly fewer serious adverse events (SAEs) compared to traditional bariatric surgeries like LSG. The incidence of SAEs following ESG is typically below 5%, whereas surgical alternatives report higher complication rates, including bleeding, infections, and postoperative gastroesophageal reflux disease (GERD).
Common side effects of ESG, such as mild to moderate abdominal pain, nausea, and vomiting, are usually transient and manageable with conservative therapy. Unlike surgical interventions, ESG does not involve permanent anatomical alterations, allowing for reversibility and reducing the risk of irreversible complications. This feature makes ESG particularly attractive for patients hesitant about surgery or those with higher surgical risk profiles.
Additionally, patient-reported outcomes highlight significant improvements in quality of life (QoL) and treatment satisfaction post-ESG. Patients often report better physical functioning, reduced obesity-related symptoms, and appreciation for the minimally invasive nature of the procedure. These subjective benefits complement the objective clinical outcomes and reinforce ESG’s value in real-world clinical practice.
Comparative Analysis with Other Bariatric Interventions
ESG vs. Intragastric Balloon (IGB):
ESG consistently outperforms IGB therapy in terms of both the magnitude and durability of weight loss. At 12 months, ESG patients typically achieve approximately 17.5% total weight loss compared to roughly 10% with IGB. Moreover, ESG’s effects are sustained over longer periods, whereas IGB patients often experience weight regain after balloon removal. While IGB is less invasive and initially less costly, its temporary nature and limited long-term efficacy make ESG a more attractive option for sustained weight management.
ESG vs. Laparoscopic Sleeve Gastrectomy (LSG):
LSG remains the gold standard bariatric surgery, delivering more pronounced weight loss—around 30% total weight loss at 12 months—compared to ESG’s 17%. However, LSG carries higher risks of complications such as bleeding, infection, and GERD. ESG offers a safer, less invasive alternative, particularly suited for patients with mild to moderate obesity or those unfit for surgery. The reversibility and minimal complication profile of ESG make it an appealing option for patients seeking effective weight loss without surgical risks.
ESG vs. Robotic Sleeve Gastrectomy (RSG):
Robotic sleeve gastrectomy, an advancement over traditional laparoscopic surgery, offers precision and efficacy comparable to LSG. Recent comparisons indicate that ESG and RSG yield similar weight loss outcomes, but ESG boasts shorter procedure times, quicker recovery, and lower complication rates. These advantages position ESG as a highly effective minimally invasive option for patients desiring weight loss while avoiding the complexity and recovery burden of robotic surgery.
A summarized comparison of these procedures highlights ESG’s unique niche: achieving meaningful weight loss with low complication rates and reversibility, situated between non-surgical approaches like IGB and more invasive surgical options such as LSG and RSG.
Patient Selection and Indications
ESG is primarily indicated for patients with a body mass index (BMI) ranging from 30 to 40 kg/m² who prefer a less invasive approach or are unsuitable for surgery. It also shows promise in selected patients with class III obesity who cannot undergo surgery due to comorbidities or personal preference. Furthermore, ESG has demonstrated efficacy in overweight individuals with BMI as low as 27 kg/m², contributing to significant improvements in weight and metabolic parameters.
Careful patient selection remains crucial for optimizing outcomes. ESG is most effective in those with mild to moderate obesity or in patients contraindicated for surgical procedures. As the procedure becomes more widely adopted, establishing standardized inclusion and exclusion criteria will be vital to ensure consistent results and avoid selection bias.
Technical Evolution and Future Directions
The ESG technique has evolved rapidly with the development of advanced suturing devices, including single-channel tools that simplify the procedure, reduce operative time, and enhance safety. Innovations such as the Sander-Scarparo suturing technique have further improved the durability of gastric plication and weight loss outcomes.
Looking forward, large-scale, long-term studies are essential to validate the durability of ESG’s weight loss and metabolic benefits across diverse patient populations. Establishing standardized protocols and patient selection frameworks will enhance comparability across studies and clinical practices. Additionally, further research comparing ESG with established surgical procedures will clarify its role in comprehensive obesity management.
Understanding ESG’s impact on weight maintenance and metabolic disease remission will also deepen its clinical utility. With ongoing technological advances and expanding evidence, ESG is poised to become a cornerstone in the minimally invasive treatment of obesity.
Conclusion
Endoscopic sleeve gastroplasty represents a transformative minimally invasive approach to obesity management. Offering significant and sustained weight loss with a low risk of complications, ESG fills an important therapeutic gap between lifestyle interventions and invasive bariatric surgeries. Its favorable safety profile, reversibility, and metabolic benefits make it especially suitable for patients with mild to moderate obesity or those ineligible for surgery.
While ESG does not yet match the weight loss magnitude of surgical sleeve gastrectomy, its advantages in safety and patient satisfaction are compelling. Continued research and refinement will likely expand its indications and optimize outcomes, potentially making ESG a mainstay in the multidisciplinary arsenal against obesity and its associated metabolic disorders.
SOURCE/READ FULL ARTICLE: https://pubmed.ncbi.nlm.nih.gov/40838153/
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