What Is ESG?
Endoscopic sleeve gastroplasty is a procedure in which an endoscope passed through the mouth, together with an attached suturing device, is used to place sutures along the inner surface of the stomach and reduce its volume. No incision is made in the abdominal wall, and no tissue is removed.
The procedure is usually performed under anaesthesia. The term 'without surgery' is often used to convey that no incision is made, but this does not remove the interventional nature of the procedure. Like any interventional procedure, ESG has risks that need to be assessed, a preparation process, and follow-up requirements.
How It Differs From a Gastric Balloon
A gastric balloon is a temporary device placed in the stomach endoscopically and removed after a set period. Stomach tissue or shape is not permanently altered; once the balloon is removed, the stomach returns to its previous volume.
In ESG, no device is placed — the stomach itself is narrowed with sutures. For this reason, the two are not 'two versions of the same product': one is a temporary supportive device, and the other is an endoscopic procedure that changes the shape of the stomach.
What they have in common is that both are endoscopic and neither promises a permanent result on its own. With both methods, the outcome depends on whether dietary and behavioural changes can be sustained.
How It Differs From Surgical Sleeve Gastrectomy
Surgical sleeve gastrectomy is performed laparoscopically, and a large portion of the stomach is removed. This is a permanent anatomical change with both volumetric and hormonal effects.
In ESG, no tissue is removed; the stomach is folded and narrowed with sutures. The nature and permanence of the anatomical change are therefore different.
These two methods cannot be presented as interchangeable alternatives for the same group of patients. Which approach is appropriate is determined by evaluating body mass index, coexisting conditions, previous treatments, and the patient's ability to adhere to follow-up.
What Does ASMBS's 2026 Guidance Emphasise?
ASMBS's patient information on endoscopic sleeve gastroplasty describes ESG as one of the options in obesity treatment and states that it may be considered in carefully selected patients.
The key point emphasised is that the procedure should be approached not as a stand-alone solution, but within a comprehensive, multidisciplinary programme that includes nutrition support, behavioural support and regular follow-up.
The same source also makes clear that endoscopic methods are not classified in the same category as metabolic-bariatric surgery. For this reason, presenting ESG as 'equivalent to surgery' would not be accurate. This article deliberately does not provide numerical figures for weight loss, success or complication rates — these vary between individuals and should not be used as a promise of expected outcomes in patient education.
Who Might Consider It?
Endoscopic methods are generally discussed in selected people who fall below the surgical indication threshold, or who prefer not to have surgery. This assessment is still carried out by a specialist team.
Questions worth asking when deciding include: which treatment steps have already been tried, what coexisting conditions are present, whether follow-up can realistically be sustained, and whether expectations are realistic.
Suitability cannot be assessed from a website. This content is intended to help you understand the options and ask the right questions during a consultation.
The Common Thread: Follow-Up and Managing Expectations
What the gastric balloon, ESG and surgical methods have in common is that none of them is sufficient on its own. In all three, diet, physical activity, behavioural support and regular check-ups determine the outcome.
Whichever method is being discussed, the first step is always a comprehensive assessment. The choice of method is the outcome of that assessment, not its starting point.
References
- ASMBS — Endoscopic sleeve gastroplasty (ESG): frequently asked questions (2026) (opens in a new tab)
- ASMBS / IFSO — 2022 Indications for Metabolic and Bariatric Surgery (opens in a new tab)
- NICE NG246 — Overweight and obesity management (opens in a new tab)
- NHS — Weight loss surgery: recovering (opens in a new tab)
The results of any surgical or interventional procedure may vary from person to person. It is recommended that you obtain detailed advice from your physician before the procedure.
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