The Endoscopic Sleeve Gastroplasty (ESG), also known as the “accordion procedure”, “scarless sleeve” or “Apollo Method,” is a weight loss procedure that reduces the size of the stomach. As a result, patients:
Read and click the sections below for everything you need to know about Endoscopic Sleeve Gastroplasty.
An endoscope equipped with a suturing device is inserted into the patient’s mouth, down the esophagus, and into the stomach. This gives the doctor a full view to perform the procedure.
The doctor then sutures the stomach using specialized patterns to decrease stomach size. The goals of endoscopic sleeve gastroplasty are as follows:
Endoscopic sleeve gastroplasty is an evolving weight loss treatment and best practice is not firmly established. Endoscopic doctors meet multiple times a year to discuss stomach folding, optimal locations for suturing, and effective suturing patterns to increase weight loss potential.
Ongoing research and investigation into effective methods will likely improve this procedure. Despite the ongoing research, it is currently recognized as an effective weight loss procedure with a strong safety record.
Studies on endoscopic sleeve gastroplasty suggest it is an effective weight loss option.
The most comprehensive study to date followed up with 215 patients two years after the procedure. Average total body weight loss was 18.6% (1). This means a patient who is 300 pounds should expect to lose around 55 pounds.
There has been limited research regarding long-term weight loss. Results in the table below are promising, but more data is needed to demonstrate long term weight loss efficacy.
All patients who undergo weight loss procedures need to make lifestyle changes. Patients who eat and exercise right are usually able to maintain weight loss, or lose even more. Patients who let their dedication slip may regain weight.
Successful patients avoid weight regain by:
See our Weight Gain After Bariatric Surgery page to learn more.
There is limited research on the health benefits of endoscopic sleeve gastroplasty. So far, studies are pointing in a positive direction.
Endoscopic sleeve gastroplasty has not been linked to the following health conditions, but weight loss usually improves:
See our Obesity Health Problems page for more information.
How to qualify for endoscopic sleeve gastroplasty will vary by doctor. Common requirements and guidelines include:
The endoscopic sleeve gastroplasty cost ranges from $10,000 to $16,000. It is less expensive than procedures like gastric sleeve or gastric bypass because less overhead is required:
Is endoscopic sleeve gastroplasty covered by insurance?
Unfortunately, not yet. However, due to its excellent safety profile and a growing number of studies demonstrating weight loss efficacy, this may change. Talk with your surgeon to discuss what parts of treatment they can get covered.
Here’s how endoscopic sleeve gastroplasty costs compare to other weight loss procedures:
Recovery from endoscopic sleeve gastroplasty is typically fast, and same day release from the hospital is standard. Patients often return to work within 24-48 hours following the procedure.
The endoscopic sleeve gastroplasty also has no exercise or lifting restrictions upon returning home, adding to its impressive recovery profile.
For more information, see our page on bariatric surgery recovery.
Weight loss after endoscopic sleeve gastroplasty is usually the focus, but it’s important to consider how your daily life will change. The procedure is only a tool and long-term success requires diligence and lifestyle change.
The following sections give you an idea about what to expect before and after the procedure.
Endoscopic sleeve gastroplasty reviews indicate that the procedure is effective for weight loss, especially for patients who maintain a healthy diet. Building healthy habits around eating is just as important as the procedure itself.
Before the procedure, you may think, “You’re getting a weight loss procedure soon, so now’s the time to live it up!” You must have the complete opposite mentality. Unhealthy meals before surgery can increase your risk of complications.
2+ Weeks Before Surgery
2 Weeks Before Surgery
1 Week Before Surgery
2 Days Before Surgery
Midnight Before Surgery to 7 Days After Surgery (Varies by Surgeon)
In Hospital (Varies by Surgeon)
Day 1 to Week 2 After Surgery (Varies by Surgeon)
Day 2 to Week 3 After Surgery (Varies by Surgeon)
Day 3 to Weeks 4+ After Surgery (Varies by Surgeon)
Timeframe(Varies Widely By Surgeon) – Diet Requirements
Practice your post-procedure diet
2+ Weeks Before Surgery – Practice your post-procedure diet
High protein, low sugar, low carbs
2 Weeks Before Surgery – High protein, low sugar, low carbs
Stop or change some medications
1 Week Before Surgery – Stop or change some medications
Clear liquids only
2 Days Before Surgery – Clear liquids only
Nothing to eat or drink
Midnight Before Surgery – Nothing to eat or drink
Clear liquids only
In Hospital to 7 Days After Surgery (Varies by Surgeon) Clear liquids only
Add thicker drinks & smooth foods (no chunks)
Week 2 After Surgery – Add thicker drinks & smooth foods (no chunks)
Slowly test pureed & soft solid foods
Week 3 After Surgery – Slowly test pureed & soft solid foods
Slowly test solid foods
Day 3 to Weeks 4+ After Surgery (Varies by Surgeon) Slowly test solid foods
Prior to your endoscopic sleeve gastroplasty, the diet your doctor recommends will most likely be high-protein and low-carbohydrate with plenty of fluids. The night before the procedure, your doctor will likely require you consume no food or liquid after midnight.
In order to allow your sutures to properly heal, avoid all carbonated beverages and solid food for the first month. Damaging the sutures may significantly impact your weight loss, lead to premature reversal of the procedure, or have unintended health consequences.
Around 4 hours after the procedure you can begin drinking low-sugar liquids. This may include water, broth, low sugar sports drinks, or iced tea. Patients remain on this low-sugar liquid diet for one to two weeks.
Two weeks later, semi-solid foods can be incorporated into your diet. Be mindful of what semi-solid entails and be sure to speak with your doctor if you’re unsure about specific foods. Here are some basic guidelines:
Examples of foods with a semi-solid consistency:
Ask your doctor about these foods:
The semi-solid food diet will last for approximately two weeks depending on how you’re feeling. Your doctor will let you know when it is appropriate to transition. Foods that cause heartburn are not approved at this time.
See our page on bariatric eating to learn more about healthy eating habits for successful, long term weight loss.
The Endoscopic Sleeve Gastroplasty does not usually require patients to take additional vitamins or supplements. Because there is no resection or altering of the small bowel, there is little to no risk of malabsorption.
Exercise is almost as important as your diet when it comes to long-term success:
How much exercise do you need to for noticeable results?
One study of gastric bypass patients found that 2.5 hours per week resulted in 5.7% greater excess weight loss (8).To help you stay on track, block out time to exercise at the same times on the same days of the week.
Also, spread your 2.5 hours per week out over 3 or 4 days (in other words, 30 to 45 minutes 3 or 4 days per week). This will make it less intimidating to get started each day and will help you build endurance.
There should be 3 main goals of your exercise routine:
For more information, see our page on exercise for bariatric surgery patients
In addition to the many physical benefits following endoscopic sleeve gastroplasty, one important organ often goes overlooked: the brain. This organ consumes 20% of our energy and impacts our cognition, executive function, and moods. Endoscopic sleeve gastroplasty will affect how the brain works.
Multiple studies suggest that obesity is linked to cognitive decline. Links to dementia, and an earlier onset of symptoms have been established (9). Other studies suggest that short term memory and attention deficits impair the population (10).
While there are varying theories as to why obesity contributes to cognitive issues, a popular school of thought suggests it is related to blood flow within the brain. Obesity is considered a risk factor for cerebrovascular disease (11), a condition where blood does not properly move throughout the brain. Dysregulated blood flow may cause a variety of issues including stroke and vascular dementia.
Fortunately, studies also indicate that weight loss procedures may improve cognition and brain health. In one study of patients, scores measuring cognitive function demonstrated improvement up to three years following surgery (12). Measured variables in the study included executive functioning, short term memory and attention span.
When your stomach is empty, it secretes a hormone called ghrelin into your bloodstream. This causes your brain to generate hunger impulses.
After you eat, the amount of secreted ghrelin drops then slowly rises until your next meal. Since your stomach will be so much smaller after the endoscopic sleeve gastroplasty, the amount of ghrelin it secretes may also go down. Less ghrelin in your system means you will feel less hungry than you did before surgery.
See our page about Obesity & Genetics for more information.
Our bodies secrete certain hormones (like ghrelin) that tell us when we’re hungry. Junk food may override those hormone signals by overstimulating our reward centers. This is just like the way our bodies and brains react to an addictive drug.
You may have food addiction if your desire for food takes priority over other important parts of your life, such as:
If left unchecked, food addiction can lead to obesity. If not addressed before surgery, it can also lead to weight regain.
To find out if you may be suffering from food addiction, take our Food Addiction Quiz.
Being thin again, or being thin for the first time, may be a shocking experience. Many patients express amazement at:
But there may be negatives to being thin as well. People who you’ve known for a long time will not be used to the way you look and may not know how to act around you. For example:
And what about the new “skinny lens” you see the world through? For example:
Be prepared for both the good and the challenging “shocks” of dramatic weight loss following surgery.
For real life experiences and advice from other patients, see our Relationships After Weight Loss Surgery page.
The endoscopic sleeve gastroplasty has no known deaths directly related to the procedure. It does carry a risk of complications and side effects, but there appears to be less downside than other more invasive weight loss surgeries.
The most common endoscopic sleeve gastroplasty side effects include nausea and mild pain following the procedure. These symptoms typically subside within a few days and can be treated with pain and anti-nausea medication. Some patients report no side effects.
In some cases, more serious side effects occur. For example, in a Mayo Clinic study of 25 patients, three (12%) had serious adverse events that include a perigastric inflammatory collection, a pulmonary embolism, and a small pneumothorax. All patients fully recovered and no surgical treatments were required.
More studies on the short and long term effects of endoscopic sleeve gastroplasty are needed for a better safety profile.
The prospect of regaining weight is a reality after all weight loss procedures, including endoscopic sleeve gastroplasty. Improper nutrition, overeating, and lack of exercise are all contributors to weight gain and stomach stretching even if you originally lost weight. If you’re unwilling to make a long term commitment to modifying your lifestyle, this procedure probably isn’t for you.
Fortunately, by following bariatric eating recommendations, you greatly improve the odds of maintaining weight loss.
For more information, see our page on weight gain after bariatric surgery.
For many patients pursuing bariatric procedures, the skin has been stretched out for so long to accommodate their extra weight that it has lost its elasticity. Endoscopic sleeve gastroplasty causes many patients to lose a lot of weight very quickly, and your skin simply can’t keep up. The extra skin may be embarrassing. It can also cause several issues ranging from minor to severe, including:
In some cases, patients manage sagging skin with body-contouring undergarments. In more serious cases, patients have plastic surgery to remove the excess skin. Surgery to remove excess skin is often covered by insurance.
See our page on Before and After Gastric Sleeve Surgery to see photos of patients who’ve undergone plastic surgery to remove excess skin.
A few facts stand out when comparing endoscopic sleeve gastroplasty to more invasive weight loss procedures like gastric sleeve, gastric bypass, duodenal switch, and LAP-BAND®.
What’s the difference between the endoscopic sleeve gastroplasty and the popular gastric sleeve procedure?
The end result of endoscopic sleeve gastroplasty and gastric sleeve is similar; they both reduce the size of the stomach and make patients feel full sooner. But there are a few key differences patients should know about:
1. After the endoscopic sleeve gastroplasty, the patient’s entire stomach remains intact.
However, food is cut off from the majority of the stomach because the sutures block its movement. Just like gastric sleeve, patients feel full sooner after eating significantly less food because there is less space for food to go.
2. At any time following the procedure, your doctor can use an endoscopy to remove the sutures. In other words, the endoscopic sleeve gastroplasty is reversible and patients have the option to redo the procedure if the stomach stretches again. Gastric sleeve surgery cannot be reversed.
3. Studies are currently demonstrating that endoscopic sleeve gastroplasty results in slightly lower weight loss than gastric sleeve. While the reason for this is unknown, it may be related to procedural differences in removing part of the stomach vs. keeping part of your stomach unused. Future studies on this procedure may provide more insight into why gastric sleeve has a slight weight loss advantage.
4. While early weight loss results are promising, there is currently not enough data available to give definitive estimates. One small study of 25 reported that excess weight loss at 6 and 12 months was respectively 53% and 56%. More data is needed to compare this procedure against other established weight loss procedures.
|3 Months||6 Months||1 Year||2 Years||3 Years||5 Years||8 Years||11 Years|
|Gastric Bypass||30%||50%||65%||60%||60%||60%||no data yet||no data yet|
|Gastric Balloon||15%||30%||varies (balloon removed after 6 mo)||varies (balloon removed after 6 mo)||varies (balloon removed after 6 mo)||varies (balloon removed after 6 mo)||no data yet||no data yet|
|Endoscopic Sleeve Gastroplasty||TBD||TBD||TBD||TBD||TBD||TBD||TBD||TBD|
|Duodenal Switch||30%||45%||65%||70%||70%||70%||no data yet||no data yet|
|LAP-BAND®||20%||30%||40%||55%||55%||55%||no data yet||no data yet|
|vBloc Therapy||10%||20%||25%||25%||25%||25%||no data yet||no data yet|
|Aspire Assist||20%||25%||30%||no data yet||no data yet||no data yet||no data yet||no data yet|
More comparisons (assuming longer-term studies prove out the existing limited research):
For a more-detailed comparison of weight loss procedures, see our Types of Bariatric Surgery page.
If you’re interested in the endoscopic sleeve gastroplasty, see the steps below for a breakdown on what you need to do:
Both gastroenterologists and surgeons practice the endoscopic sleeve gastroplasty. See our directory below to find a top doctor.
You will have completed your pre-op tests, physical, and any other required steps. You should also be well on your way towards developing your diet and lifestyle habits. In the week or two leading up to surgery, you’ll go to the hospital pre-surgery department.
They will perform an EKG, blood work, and any last minute tasks or other pre-op tests.
You’ll meet with your endoscopic sleeve gastroplasty doctor one more time to wrap up final tests and forms. The night before surgery, do not eat or drink anything starting at midnight.
Wear comfortable clothes and have a friend or family member transport you to the hospital. Because you’ll be under anesthesia during the procedure, you won’t be allowed to drive home.
Doctors generally advise a clear liquid diet for two days prior to the surgery, but be sure to ask your doctor about their specific recommendations.
It is common for patients to be nervous prior to any weight loss procedure. This is totally normal. Remember that your decision carries less risk than remaining obese.
Recovery from this procedure is typically fast with minimal/moderate pain for 1-3 days. Contact your doctor if you have excess pain, nausea, bloating, breathing or other issues you believe are related to the procedure.
As previously discussed, diet and exercise are essential to your long term success. Fortunately, the recovery time after endoscopic sleeve gastroplasty is minimal and you can begin an exercise regimen shortly after the procedure.
Finding new hobbies such as going outdoors or getting a gym membership is a great way to stay active and help keep off the weight. Others activities may include hiking or signing up for a recreational sports team. Barring any physical health concerns that limit mobility, there is no excuse for not exercising.
Regular support group participation leads to:
Your surgeon will be able to recommend an in-person group near you.
Your surgeon will schedule a follow up visits to ensure you are recovering well and to answer any questions. Doctors typically have follow up visits at 1 week, 1 month, 3 months, 6 months, 9 months and 12 months post surgery. Yearly visits are recommended afterward.
For more information, see our page on preparing for weight loss surgery.
Well-educated patients are more likely to be successful over the long-term. Test your knowledge to ensure that you’re ready to take the next step!
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To Whom It May Concern, I’ve been comparing two different procedures: Endoscopic Sleeve Gastroplasty (ESG) and Laparoscopic Sleeve Gastrectomy (gastric sleeve). Endoscopic Sleeve Gastroplasty cost is partly why I’m leaning…