Endoscopic Sleeve Gastroplasty

Endoscopic Sleeve Gastroplasty (ESG) is the term given to a new weight loss procedure pioneered in 2012 and is now in use in a number of centres around the world. ESG is an incisionless procedure that uses an endoscope which can suture the stomach. The stomach volume is reduced by 50-70%. This is accomplished by a series of endoscopically placed sutures extending from the bottom 1/3 of the stomach to the upper stomach creating a “sleeve”. The procedure results in feeling full with reduced food intake and slowed gastric emptying, so that you feel full quicker and do not become hungry for a longer period of time.

Your initial appointment will be with Dr David Orr, Gastroenterologist. At this initial consultation you will be assessed as to whether endoscopic sleeve gastroplasty (ESG) is a procedure that is appropriate for you. The procedure will be discussed in more detail and you will be able to ask questions. Other family members or support people are welcome to attend this appointment. Prior to the appointment you will be given a form for blood tests and a stool sample to exclude the presence of Helicobacter pylori. If the stool sample is positive, you will be given treatment to eradicate these bacteria which can cause inflammation and ulcers in the stomach, before the ESG is undertaken.

ESG is undertaken using the OverstitchTM; Apollo Endosurgery device which attaches to the endoscope and performed under general anaesthesia. The procedure and changes made to the stomach are considered permanent. Although there is the possibility of reversing the changes, this is very rarely undertaken.

This procedure does NOT involve removal of any of the stomach as occurs with surgical laparoscopic sleeve gastrectomy’s and bypass surgeries undertaken for weight loss. As a result, the procedure is significantly safer with a faster recovery time.

To achieve the best results, a multi-disciplinary approach is used. The programme that has been developed incorporates regular clinical reviews with the gastroenterologist, specialist ESG nursing staff, dietitian and psychologist, to help you achieve the best possible outcome.

ESG is indicated for patients with a BMI of 30 kg/m2 to 45 kg/m2 and who have failed non-invasive weight loss measures, and are aged between 20- 60 years old.

Patients who have significant medical comorbidities may not be able to have the procedure. This will be assessed by your gastroenterologist at the initial consultation.

Exclusions to having an ESG include: patients with cirrhosis of the liver and/or portal hypertension, antiplatelet therapy (excluding low dose aspirin), severe cardiac or respiratory disease, previous gastric surgery, inflammatory bowel disease, or who are unable to follow dietary guidelines. Patients with a first degree relative (e.g. parent or sibling) with stomach cancer will not be able to undergo an ESG.

The procedure results in feeling full quicker with reduced food intake and slowed gastric emptying, so that you don’t become hungry for a longer period of time.

Your dietitian and a psychologist will meet with you throughout the program to help you implement positive dietary and lifestyle modifications.

Clinical evidence suggests an average weight loss of 17-20% of starting weight at 18-months to 2 years post procedure. (i.e a 100 kg person would lose 17-20kg on average). Most of the weight loss occurs in the first 6-months after the procedure but can continue out to 2 years post procedure.

The amount of weight loss is dependent on your starting weight and how well you adapt to the lifestyle changes. Your success depends on whether you make the necessary dietary and lifestyle adjustments and how well you apply them. To aid your weight loss, you will be seen by both a dietitian and psychologist who specialise in weight loss management. However, there is no amount of weight loss that is guaranteed.

The procedure is performed via a gastroscopy under a general anaesthetic. The procedure takes 1-1.5 hours and you will be able to go home the same day.

After general anaesthesia, the gastroscope is passed into the stomach to confirm that there are no contra-indications to proceeding with the ESG. The stomach is then marked to show the orientation of the stomach for the endoscopist during the procedure. Argon Plasma coagulation (heater probe) is applied to the body of the stomach to improve mucosal adherence, i.e. to fix the stomach in its new sleeve shape. The OverstitchTM device is then placed into the stomach. Approximately 5-8 stitches are placed to reduce the diameter and shorten the stomach.

After the procedure is completed, you will be woken up in the recovery room and monitored for up to 4-5 hours post procedure before being allowed to return home.

The following day you will return to MacMurray Centre for a clinical assessment and to be given intravenous fluids and pain relief as appropriate. If required this can be repeated on day 2 post procedure.

This is a day case procedure. After the procedure most patients return home within 4-5 hours of the procedure.

The recommendation would be to take up to 10 days off work to allow adequate recovery. It may be possible to return to work sooner if your work does not involve heavy exertion and lifting. It is advised not to lift anything heavy (≥5kg) for the first 6 weeks after the procedure. Also avoid doing abdominal exercises (e.g. sit-ups, lifting weights) for the first 6 weeks.

There are multiple clinical reports from around the world, which show very similar clinical outcomes. Median weight loss at 18 months to 2 years post procedure is 17-20% of starting weight. In conjunction with weight loss, there is significant improvement in diabetes control (reduced HBA1c), improved blood pressure, cholesterol profile, and lower liver function tests due to resolution of fatty liver disease.

A recent trial comparing endoscopic sleeve gastroplasty with the surgical alternatives of laparoscopic sleeve gastroplasty (LSG) and laparoscopic adjustable gastric banding (LAGB), showed patients with a BMI <40Kg/m2 all had a similar degree of weight loss irrespective of the bariatric procedure performed. However, the recovery from ESG was quicker with significantly fewer complications (2.2% for ESG vs 9.2% for LSG and 9.0% for LAGB).