Endoscopic Sleeve Gastroplasty (ESG)

Endoscopic Sleeve Gastroplasty (ESG) is a non-surgical, incisionless procedure that reduces stomach volume to support weight loss. Using an endoscope passed through the mouth, a physician places a series of internal sutures that fold and narrow the stomach, limiting how much food it can hold at one time. Because there are no external incisions, ESG is generally performed as an outpatient procedure under general anesthesia. It is often considered by patients looking for a less invasive alternative to traditional bariatric surgery.

ESG is generally considered for adults with a body mass index (BMI) over 30 who have not reached their weight-loss goals through diet, exercise, or medication alone. It may also suit patients with a BMI over 40 who are not ready for, or do not qualify for, traditional bariatric surgery, as well as those seeking a less invasive option at a lower BMI. Candidacy also takes into account overall health history, prior weight-loss attempts, and personal goals for the outcome. Certain conditions, such as prior stomach surgery, some digestive disorders, or bleeding risks, may affect eligibility and are reviewed during screening. Because these factors vary from patient to patient, a consultation with a qualified provider is the best way to confirm candidacy and set realistic expectations for results.

ESG can serve as an alternative to traditional bariatric surgery for some patients, particularly those who want meaningful weight-loss support without incisions or a permanent change to their anatomy. It is sometimes considered for patients with a lower BMI who don't meet typical surgical criteria, or for those who are not ready for, or do not qualify for, procedures like gastric sleeve or bypass surgery. That said, ESG generally produces more modest weight loss than surgical bariatric options and isn't the right fit for every patient. A consultation helps determine whether ESG, surgery, or another approach best matches a patient's goals and health needs.

ESG and laparoscopic gastric sleeve surgery both reduce stomach size, but they differ in several important ways:

• ESG is incisionless and done endoscopically, while gastric sleeve surgery involves surgical removal of part of the stomach through small incisions

• ESG is potentially reversible, whereas gastric sleeve surgery is permanent

• Recovery from ESG is generally shorter, with less post-procedure pain

Gastric sleeve surgery tends to produce greater average weight loss, while ESG carries a lower risk of complications like acid reflux

The right choice depends on a patient's BMI, health history, and personal goals, which is best discussed with a qualified provider.

ESG is often most effective when combined with other weight-loss supports rather than used alone. Common complementary approaches include:

• Structured nutrition counseling or a dietitian-guided eating plan

• Behavioral or lifestyle coaching programs to build sustainable habits

• Regular physical activity introduced gradually after recovery

• In some cases, physician-prescribed weight-loss medication alongside the procedure

For patients not suited to ESG, alternatives may include intragastric balloons, medication-only approaches, or surgical options like gastric sleeve or bypass. A provider can help determine which combination of approaches fits a patient's goals and health profile.

Before ESG, patients typically have a consultation to review their weight-loss history, current health, and candidacy for the procedure, along with any required bloodwork or imaging. Providers often ask patients to follow a specific pre-procedure diet for a short period beforehand to reduce liver size and improve visibility during the endoscopy. Patients are usually asked to fast for several hours prior to the appointment, since general anesthesia is used, and to arrange for someone to drive them home afterward. This is also the time to discuss expected results, risks, and the total cost of care with the provider.

ESG is performed under general anesthesia, so patients are asleep and feel no pain during the procedure. A physician guides a flexible endoscope with a suturing device through the mouth and down into the stomach, no external incisions are involved. Using the device, the physician places a series of internal stitches that fold and narrow the stomach, reducing its overall capacity. The procedure itself typically takes 60 to 90 minutes, after which patients spend an hour or two in recovery before being discharged home the same day with a friend or family member.

ESG is done as an outpatient procedure, and most patients go home the same day after a short observation period. Many people feel back to normal within two to three days, with mild nausea, cramping, or fatigue being common in the first day or two. Patients can typically return to work and light daily activities within one to three days, while more strenuous exercise is usually reintroduced gradually over two to four weeks. Full recovery, including the transition back to regular solid foods, generally takes about four weeks. Recovery pace can vary based on individual health and how closely post-procedure diet guidance is followed.

Diet after ESG progresses gradually to allow the stomach to heal:

• Clear liquids for the first few days

• Full liquids and protein shakes for about one to two weeks

• Pureed or soft foods for the following one to two weeks

• A gradual return to regular, solid foods by around one month

Portion sizes generally stay smaller going forward to match the stomach's reduced capacity. A provider or dietitian typically supplies a specific schedule and guidance tailored to individual healing and nutritional needs.

Most patients begin noticing weight loss within the first few weeks as the stomach heals and portion sizes adjust, with more significant results building over the following months. Clinical studies show average total body weight loss of around 15-20% by 12 to 24 months after the procedure. Results tend to continue for several years, with many patients maintaining a meaningful portion of their weight loss up to 5 years later, particularly when paired with ongoing nutrition and lifestyle habits. Individual results vary based on starting weight, adherence to post-procedure guidance, and overall health, so a provider can offer a more personalized outlook during consultation.

Yes, ESG is generally considered a reversible and repeatable procedure, which is one of its key differences from surgical options like gastric sleeve surgery. Because the stomach is reshaped using sutures rather than being surgically removed or permanently altered, a provider can adjust, remove, or redo the stitching if needed. This flexibility does not guarantee the same outcome if reversed, and reversal is typically only considered for specific medical reasons. Anyone weighing this option should discuss it directly with their provider.

Like any medical procedure, ESG carries some risks, though serious complications are uncommon. Mild, short-term side effects are the most frequent and usually resolve within a few days:

• Nausea, vomiting, or abdominal pain

• Bloating or mild cramping

• Temporary changes in bowel habits

Less common but more serious risks include stomach leaks, bleeding, or infection. Sutures can also loosen or come undone over time, which may reduce the procedure's effectiveness or reverse it altogether. Patients should contact their provider promptly if they experience severe or worsening abdominal pain, persistent vomiting, fever, or signs of bleeding after the procedure. Reviewing individual risk factors, such as prior stomach surgery or certain medical conditions, is an important part of the consultation process with a qualified provider.

Choosing a qualified ESG provider starts with confirming the physician's specific training and experience in endoscopic bariatric procedures, not just general endoscopy or surgery. Helpful questions to ask include:

• How many ESG procedures has the provider performed, and what are their outcomes?

• Is the clinic accredited, and does it have protocols for managing complications?

• What does the aftercare program include, such as nutrition counseling or follow-up visits?

Are before-and-after patient results or reviews available?

A thorough consultation should cover candidacy, expected results, and risks in detail. Beautifi can help connect patients with vetted providers experienced in ESG.

In Canada, Endoscopic Sleeve Gastroplasty typically costs between $8,000 and $15,000, since it is performed in private clinics and is not covered by provincial health plans like OHIP. The final price depends on several factors:

• The clinic and physician's experience and location

• Whether pre-procedure assessments and anesthesia are bundled into the quoted price

• The length and depth of the post-procedure aftercare or coaching program included

• Any additional follow-up endoscopies or touch-up sessions

Because pricing structures differ between providers, it's worth asking exactly what is included before comparing quotes. Beautifi can help patients explore financing options to spread the cost of ESG into manageable monthly payments.