Minimally invasive approaches to obesity: Evaluating the efficacy and safety of endoscopic gastroplasty

Abstract

Obesity is a major global health issue, contributing to numerous comorbidities such as type 2 diabetes mellitus, hypertension, and cardiovascular diseases. While bariatric surgery remains the gold standard for treating severe obesity, its invasive nature has led to the development of minimally invasive alternatives. Endoscopic sleeve gastroplasty (ESG) is a promising, minimally invasive procedure for weight loss, offering significant weight reduction without the need for surgical incisions. This editorial evaluates the efficacy and safety of ESG, highlighting its weight loss outcomes, safety profile, and comparison with other bariatric procedures, including intragastric balloon, laparoscopic sleeve gastrectomy, and robotic sleeve gastrectomy. ESG has shown substantial weight loss with a mean total weight loss ranging from 15.03% to 17.51% at 12 months and sustained weight reduction over 36 months. The safety profile is favorable, with low rates of serious adverse events and minimal complications compared to surgical alternatives. ESG is particularly suited for patients with mild to moderate obesity or those not eligible for surgical options. However, further long-term studies and standardized protocols are needed to refine patient selection and optimize treatment outcomes.

Key Words: Endoscopic sleeve gastroplasty; Obesity; Bariatric surgery; Minimally invasive procedure; Weight loss

Core Tip: Endoscopic sleeve gastroplasty (ESG) offers a safe and effective minimally invasive option for weight loss, achieving significant and sustained weight reduction, particularly in patients with mild to moderate obesity. With a favorable safety profile and reversibility, ESG serves as a promising alternative to traditional bariatric surgeries, including laparoscopic sleeve gastrectomy and intragastric balloon procedures.

INTRODUCTION

Obesity is a global health crisis with significant implications for both individual well-being and healthcare systems. It is associated with a multitude of comorbidities, including type 2 diabetes mellitus (T2DM), hypertension, cardiovascular diseases, and certain types of cancer. The rising global prevalence of obesity has driven the development of various therapeutic options, ranging from lifestyle interventions to surgical procedures. Bariatric surgery, particularly laparoscopic sleeve gastrectomy (LSG), remains the gold standard for significant weight loss. However, its invasive nature, irreversibility, and potential complications have prompted the search for less invasive alternatives.

Endoscopic sleeve gastroplasty (ESG) has emerged as a promising minimally invasive procedure for weight loss. ESG involves the use of endoscopic suturing devices to reduce the stomach's volume, mimicking the effects of traditional gastric sleeve surgery without the need for surgical incisions[1]. The editorial aims to evaluate the efficacy and safety of ESG, comparing it with other bariatric procedures and discussing its role in obesity management.

EFFICACY OF ESG

ESG has demonstrated significant weight loss outcomes across various patient populations. A range of studies have reported on the procedure's effectiveness, with results showing that ESG can achieve meaningful reductions in body weight and body mass index (BMI). In a study by Singh et al[2], the mean total weight loss (%TWL) at 12 months was found to range from 15.03% to 17.51%, with a corresponding excess weight loss ranging from 53.09% to 63%. These results are consistent across patients with class I, II, and III obesity, highlighting the procedure's broad applicability.

In patients with class III obesity, ESG has been particularly effective. Bove et al[3] reported a mean%TWL of 15.4% at 24 months, with substantial improvements in comorbidities such as T2DM and hypertension. Similarly, Maselli et al[4] found that ESG led to sustained weight loss and significant reductions in obesity-related complications.

The long-term efficacy of ESG further supports its potential as a viable weight loss solution. Studies indicate that ESG maintains weight loss for up to 36 months, with a mean%TWL ranging from 13.1% to 20.3%[4,5]. This durability makes ESG a promising option for patients who seek sustained weight loss without the risks associated with more invasive surgical interventions.

Beyond weight loss, ESG has significant metabolic benefits, particularly in improving glycemic control, lipid profiles, and insulin resistance. Studies have demonstrated a reduction in glycated hemoglobin (HbA1c) levels, reflecting improved glucose metabolism and better long-term control for patients with T2DM. Additionally, ESG has been shown to lower triglyceride levels and improve lipid profiles, contributing to cardiovascular health. These metabolic improvements are believed to result from both caloric restriction and the hormonal changes induced by ESG, such as enhanced secretion of glucagon-like peptide-1 (GLP-1) and peptide YY (PYY), which help regulate appetite and glucose homeostasis. Such benefits underscore ESG's broader utility in the treatment of obesity and related metabolic disorders.

ESG’S IMPACT ON GLYCEMIC CONTROL, LIPID PROFILES, AND LIVER FUNCTION IN METABOLIC SYNDROME

ESG has shown promising results in improving various metabolic parameters in patients with metabolic syndrome. In particular, ESG has been associated with significant reductions in HbA1c levels, indicating better glycemic control and improved insulin sensitivity. These metabolic improvements are particularly notable in patients with T2DM, where ESG has contributed to a reduction in insulin resistance and lower blood glucose levels. In addition to glycemic improvements, ESG has demonstrated efficacy in improving lipid profiles, including reductions in triglycerides and total cholesterol, contributing to overall cardiovascular health. Furthermore, ESG’s impact extends to liver function, with some studies reporting a decrease in liver enzyme levels, indicating potential benefits for patients with metabolic dysfunction-associated steatotic liver disease, a common comorbidity in individuals with obesity and metabolic syndrome. These metabolic benefits reinforce ESG's role in not only achieving weight loss but also improving key metabolic outcomes in patients with obesity-related conditions.

PHYSIOLOGICAL BASIS OF ESG-INDUCED WEIGHT LOSS

The weight loss efficacy of ESG is not only attributable to mechanical gastric restriction but also to its physiological modulation of gastrointestinal function. ESG has been shown to delay gastric emptying, which prolongs postprandial satiety and reduces caloric intake. Additionally, several studies have reported decreased levels of the orexigenic hormone ghrelin following ESG, reflecting reduced fundic distension and hormonal feedback. ESG may also influence incretin signaling, including elevations in GLP-1 and PYY, contributing to improved glycemic control and appetite regulation. These physiological mechanisms collectively enhance the metabolic benefits of ESG beyond its anatomic effects.

SAFETY PROFILE OF ESG

One of the primary advantages of ESG is its favorable safety profile. As a minimally invasive procedure, ESG is associated with a lower rate of serious adverse events (SAEs) compared to traditional bariatric surgeries. According to Singh et al[2] and Dayyeh et al[6], the rate of SAEs in ESG is generally less than 5%, which is considerably lower than that observed with LSG, which is associated with higher complication rates, including bleeding, infection, and gastroesophageal reflux disease (GERD)[7].

Common adverse events associated with ESG are typically mild and transient, including abdominal pain, nausea, and vomiting[8]. These side effects are usually well-managed with conservative treatments and are not associated with long-term complications. The procedure’s reversibility and the absence of anatomical alterations further reduce the risk of irreversible damage, making ESG an attractive option for patients who may be hesitant to undergo permanent surgical procedures[6,9].

Additionally, ESG offers a safer alternative for patients with higher surgical risk profiles or those who are not candidates for more invasive bariatric surgery. The reduced risk of complications associated with ESG is one of the primary factors contributing to its growing popularity among patients seeking weight loss interventions.

In addition to objective weight loss outcomes, patient-reported outcomes such as quality of life (QoL) and treatment satisfaction are essential metrics for evaluating the success of ESG. Studies have consistently reported significant improvements in QoL post-procedure, with patients noting reductions in obesity-related comorbidities and enhanced physical functioning. Satisfaction scores are generally high, with patients appreciating the minimally invasive nature of ESG and the absence of permanent anatomical alterations. These subjective outcomes underscore the value of ESG in real-world settings, where patient preferences and life improvements play a central role in treatment decisions.

COMPARISON WITH OTHER BARIATRIC PROCEDURES

ESG vs intragastric balloon

ESG has been compared to intragastric balloon (IGB) therapy in multiple studies, with ESG consistently showing superior weight loss outcomes. Singh et al[2] found that at 12 months, patients who underwent ESG experienced a mean%TWL of 17.51%, compared to 10.35% for IGB. Furthermore, ESG demonstrated more sustained weight loss, with minimal weight regain at 24 months, whereas IGB patients often experience significant weight regain following balloon removal.

While IGB is less invasive and offers a lower initial cost, its temporary nature and the potential for weight regain after balloon removal make ESG a more attractive long-term solution for many patients[2]. ESG offers a more durable and effective weight loss strategy, with comparable risks and fewer complications compared to IGB (Table 1).

Table 1 comparative overview of bariatric procedures: Endoscopic sleeve gastroplasty vs intragastric balloon vs laparoscopic sleeve gastrectomy vs Roux-en-Y Gastric Bypass.

Procedure	Mean total weight loss at 12 months	Serious adverse event rate	Reversibility	Key advantages
Endoscopic sleeve gastroplasty	15%–18%	< 5%	Yes	Minimally invasive, reversible, low complication rate, no anatomical alteration
Intragastric balloon	8%–12%	< 5%	Yes	Temporary, low cost, non-anatomical
Laparoscopic sleeve gastrectomy	25%–30%	5%–10%	No	Greater weight loss, long-term evidence base
Roux-en-Y Gastric Bypass	30%–35%	7%–15%	No	High metabolic efficacy, significant comorbidity resolution (e.g., type 2 diabetes mellitus remission)

ESG vs LSG

LSG remains the gold standard for bariatric surgery, offering more substantial weight loss than ESG. According to Mohan et al[7], LSG achieves a mean%TWL of 30.5% at 12 months, significantly higher than the 17.1% achieved by ESG. However, LSG is associated with higher complication rates, including bleeding, infection, and GERD. In contrast, ESG is associated with fewer adverse events and has a lower risk of long-term complications such as GERD[7,10].

Although LSG may be more suitable for patients with severe obesity seeking more significant weight loss, ESG offers a safer, less invasive alternative for patients with mild to moderate obesity or those who are not candidates for surgical interventions[10]. ESG's reversibility and minimal complications make it a valuable option for many patients who prefer non-surgical approaches.

ESG vs robotic sleeve gastrectomy

Robotic sleeve gastrectomy (RSG) is a more advanced form of laparoscopic surgery that utilizes robotic assistance for enhanced precision. Recent studies comparing ESG and RSG show similar weight loss outcomes, with ESG offering several advantages in terms of procedure duration and recovery time. Ansari et al[11] noted that ESG has shorter operative times and hospital stays compared to RSG, which is a significant benefit for patients seeking a minimally invasive procedure with rapid recovery.

In addition to its reduced operative time, ESG also offers a lower risk of complications, making it a favorable option for patients who prioritize quick recovery and fewer risks associated with surgery[11]. ESG is a highly effective and minimally invasive option for patients who seek weight loss but wish to avoid the complexity and recovery associated with more invasive surgical options.

PATIENT SELECTION AND INDICATIONS

ESG is primarily indicated for patients with a BMI of 30-40 kg/m² who are not suitable for or prefer not to undergo surgical bariatric procedures[4,6]. It has also shown efficacy in patients with class III obesity who are either unwilling or unable to undergo surgery due to comorbidities or other risk factors[3,4]. Furthermore, ESG has demonstrated success in patients with a BMI of 27-30 kg/m², leading to significant improvements in BMI and related comorbidities[12,13].

ESG is particularly beneficial for patients who are looking for a less invasive alternative to surgery. However, patient selection remains critical, as it is most effective for those with mild to moderate obesity or those who are not candidates for more invasive procedures.

TECHNICAL EVOLUTION AND INNOVATIONS

The technique for ESG has evolved significantly over the past few years. The introduction of more advanced suturing devices, such as single-channel suturing tools, has improved the technical feasibility and safety of the procedure. These innovations have reduced procedure times, minimized complications, and enhanced the overall patient experience[14,15].

Additionally, new suturing techniques, such as the Sander-Scarparo technique, have been developed to improve the durability and weight loss outcomes of ESG[16]. These advancements in technology and technique continue to enhance the safety, efficacy, and patient satisfaction associated with ESG, positioning it as a promising option for obesity treatment.

FUTURE DIRECTIONS

While ESG has demonstrated significant promise in treating obesity, further research is needed to solidify its place in the obesity treatment landscape. Long-term, large-scale studies are required to establish the durability of ESG's weight loss outcomes and its effectiveness in diverse patient populations[6,17]. Additionally, research into optimal patient selection criteria and the development of standardized protocols will improve the procedure’s outcomes and ensure its applicability across various patient groups[6,10].

Furthermore, as ESG becomes more widely adopted, comparisons with other bariatric procedures, such as LSG and RSG, will help clarify its role in the broader context of obesity management. Research into ESG’s effects on metabolic diseases and its role in weight maintenance will further elucidate its long-term benefits.

Despite growing interest and positive short-to-medium-term outcomes, patient selection criteria for ESG remain heterogeneous across studies and clinical practice. Current research lacks standardized inclusion and exclusion criteria, which may introduce selection bias and limit the generalizability of findings. Some trials include patients with BMI as low as 27 kg/m², while others focus on class III obesity, making direct comparisons difficult. Moreover, differences in baseline comorbidities, adherence to lifestyle interventions, and procedural expertise further contribute to variability in reported outcomes. Future studies should aim to establish uniform patient selection frameworks and control for confounding variables to enhance the validity and comparability of ESG research.

CONCLUSION

ESG represents a safe and effective minimally invasive alternative to traditional bariatric surgery. With its favorable safety profile, reversibility, and significant weight loss outcomes, ESG offers a promising solution for patients with mild to moderate obesity or those who are not candidates for surgical procedures. While ESG is not without its limitations, its role in obesity management continues to grow, and with continued technological advancements and long-term research, it may become a cornerstone in the treatment of obesity.