Endoscopic Sleeve Gastroplasty (ESG)
Common Questions (FAQs)
The procedure is non-surgical and is performed by a specialist doctor using endoscopic techniques in an accredited hospital under general anaesthesia.
Once asleep, the specialist inserts a camera (ie. endoscope) through the mouth and into the stomach via a protective tube that protects the oesophagus (food pipe) from injury. Following an examination to ensure it is safe to proceed, a series of stitches are made within the stomach to create a tube-shaped stomach which significantly decreases the stomach’s capacity. The procedure takes approximately 60 minutes to perform and the patient is able to be discharged from hospital on the same day.
While the stitches are not dissolvable, over several years the stitches may loosen or come undone – this may happen with vomiting or over-eating. While this is not dangerous at all, this may decrease effectiveness of the procedure over the course of several years.
- ESG following gastric balloon: Recent research has revealed that people who’ve had a gastric balloon do less well following ESG in terms of weight loss. For this reason, we do not recommend ESG to anyone who’s has previously had a gastric balloon.
- ESG following gastric sleeve: Endoscopic revision of a gastric sleeve is possible, however the weight loss that results is only approximately 10% of the baseline weight. There are likely more effective options which you can talk through with your Bariatric Specialist.
- ESG following gastric bypass: Endoscopic suturing is possible via a procedure called TORe, Transoral Outlet Revision.
During the first week of the procedure you should not plan any heavy activities. Once you are able to manage adequate amounts of fluids, you can continue your normal activities. Starting a regular exercise program is highly recommended and will improve your success.
Yes! Exercise is an important part of losing weight and keeping it off. We encourage exercise as part of your weight loss strategy – all activities are encouraged and safe. Your Bariatric Endoscopist or Surgeon will provide you with specific recommendations for starting exercise at your post-procedure review appointment, and following any adjustments (for patients with a Spatz3 adjustable balloon only).
It is important to understand that ESG is a tool to aid weight loss and is most effective when combined with a comprehensive lifestyle program delivered by your doctor and trained allied health team.
Patients lose an average of 20% Total Body Weight (Total Body Weight Loss; ie a 100kg person could expect to lose 20kg on average). Ultimately, the amount of weight you lose and maintain will depend on how closely you follow the advice of your doctor and allied health team.
The Endoscopic Sleeve Gastroplasty (ESG) involves the placement of internal stitches inside the stomach to lessen the volume of the stomach therefore limiting food intake. The procedure not only forms a tubular-shaped stomach which is significantly more narrow, but also shortens the length of the stomach by approximately 50%. It is thought that the volume reduction of the stomach following ESG is approximately 75%.
Furthermore, the ESG slows the ability of the stomach to empty, which further enhances the appetite suppression and allows the patient to feel fuller for longer.
Generally speaking, as there is no resection of the stomach, the ESG is considered a much safer option than the surgical sleeve.
You should plan at least three days of inactivity to recover from the procedure and to allow symptoms to resolve. We advise patients to wait until they are able to tolerate suitable volumes of fluid before resuming exercise to minimise the risk of dehydration. We encourage low to moderate intensity exercise during weeks 1-2 post-ESG, with a return to higher intensity exercise possible after one month.
Most patients are able to return to work within the week (unless travelling from interstate, as you are required to remain in Sydney for the 7-10 days following your procedure). You may be able to resume normal activity sooner or later than this depending on how quickly your body adjusts to the ESG.
The stitches used in the procedure are permanent and do not dissolve, however they may break over time if under too much tension, as might be seen with repeated overeating. However scar tissue frequently replaces the stitches over time and even if the stitches fail, the ESG is only partly reversed. One study showed up to 25% of patients lost one stitch by the end of 12 months, but this was not associated with weight gain.
It’s important to keep in mind that although the anatomical change is permanent, the functional change is not.
Alcohol in moderation is fine, however keep in mind that excessive or regular alcohol intake will compromise your weight loss efforts given it is high in calories.
When it comes to eating AND drinking post procedure, Dr Sartoretto recommends these three Golden Rules to minimise the risk of symptoms, optimise the chances of weight loss and improve the odds of keeping the weight off
- Small, single portions
- When eating, use a small plate (eg a bread plate or a child’s plate) and serve a portion only the size of the palm of your hand.
- Use a small cup – no large tumblers.
- Do not set your table with food; instead, serve your portion (and anyone else’s) and pack the leftovers away before you eat.
- It is OK to leave some leftover food on your plate – pack it away for lunch tomorrow.
- Go slow!
- Your meal should take no less than 20 minutes to finish – this ensures you chew your food thoroughly and prevents you feeling unwell after you eat.
- Sip on your cup of liquid slowly – drinking too quickly will make you feel bloated and uncomfortable.
- Wait 30 minutes before you go back for seconds
- The brain’s connection with the stomach is delayed – eating too soon after a meal increases the chances of overeating and the chances of developing discomfort.
These rules prevent you from overeating and allow you to get back in touch with your feeling of fullness. If you break them, you are likely to suffer some reflux or cramping, so sooner or later you’ll change your ways!
The follow-up program is critical to your weight loss success as you’ll learn new lifestyle skills. You will meet with your allied health team at least once a month, during the first six months and then monthly to bi-monthly for the remainder of your program. During this time your progress will be evaluated and you will learn valuable principles of health, nutrition and exercise that will provide you with a foundation for long-term success.
Endoscopy is an internal examination performed with a camera by a specialist doctor, and in this case it refers to the examination of the stomach. All endoscopies must be performed in accredited hospitals and by accredited doctors. Before the endoscopy begins, the patient is deeply sedated by a specialist anaesthetist. The camera (or endoscope) is then inserted through the mouth and into the stomach where an examination is performed to ensure it is safe to proceed with the procedure.
In total, the endoscopy can generally be expected to take approximately 20 minutes for balloon procedures (including insertion, adjustment or removal of the balloon). Some procedures, such as an ESG (Endoscopic Sleeve Gastroplasty) may take up to an hour or sometimes even a little longer. Once the procedure is finished, the patient is allowed to wake up and returns home the same day.
The risks relating to endoscopy are very low: typically, the risk of any complication is much less than 1%, and the risk of major complication is less than 0.1%. Your doctor will discuss endoscopy and any relevant risks specific to your health in your consultation.
The ESG is suitable for patients who:
- have tried modifying their diet and exercise, however have not been able to keep the weight off
- have around 25kg or more to lose
- have a BMI of ≥30
- are considering a surgical procedure such as a gastric band, gastric sleeve or bypass, however do not want the higher risk of complications that can sometimes result from surgery.
Any plans for a future pregnancy should be discussed with your Bariatric Specialist at your initial consultation. We advise our ESG patients to avoid pregnancy for at least 18 months following an ESG, to allow time for your weight and body composition to stabilise.
It is important to note that there is no data on ESG and pregnancy as yet, which represents one of the ‘risks of the unknown’.
We generally recommend about 5 days off work following the procedure to ensure the symptoms have resolved. If you are travelling from interstate, you will be required to remain in Sydney for 7-10 days post-procedure, as it is during this time that you are most at risk of an uncommon complication.
Absolutely, we work with patients from all around Australia and currently have many patients located interstate or outside Sydney.
If you are able to travel to Sydney to attend your initial consultation with the doctor in person, Medicare will bulk bill this consultation entirely. If you would rather this initial consultation occur remotely via video conference, you may be eligible for a Medicare bulk billed appointment, pending your residential address.
When it comes to the procedure itself, you will be required to remain in Sydney for 7-10 days post-procedure, as it is during this time that you are most at risk of an uncommon complication. We will also schedule your post-procedure review with your Specialist during this time.
To further support patients who are unable to attend their allied health consultations face-to-face, we offer the option of a video consultation bundle which can be added on to any of our programs. This ensures you are able to access the full support of your care team and get the most out of your included allied health consultations.
We require all patients to remain in Sydney for 7-10 days following their procedure, as the first two weeks are when a patient is most at risk of an uncommon complication. Once you have progressed to a solid diet, you are able to travel.
You will be provided with specific dietary advice, including suitable foods and portion sizes, from our expert team of dietitians who you will meet with regularly across the duration of your program.
You will need to follow a restricted, fluid diet prior to your ESG procedure, and will be advised to follow a diet progression of various food textures for a period of 5 weeks following your ESG. However, beyond this, you are able to enjoy most foods without concern and within the context of a healthy, balanced diet.
Portion creep can compromise your weight loss efforts, as it leads to a greater number of calories being consumed. Regular contact with your Dietitian and Bariatric Physician provides a valuable point of accountability to ensure you are maintaining small portion sizes and not experiencing symptoms after eating (symptoms of reflux, bloating and cramping can suggest your portions are too large).
Losing weight and keeping it off is a lifetime undertaking. Your body will always remember its peak weight and your metabolism will adapt to drive you back to this weight. We understand that weight regain (relapse) is part of obesity, being a chronic disease, and needs to be proactively managed.
Current research indicates that weight loss following ESG is maintained at 2 years.
The key to preventing weight regain after any intervention is proactive management. On completion of our program you will be provided with an action plan to monitor your weight with a stepwise approach to preventing its rise. We expect to continue to see you at least on an annual basis after you graduate from our program to monitor your progress and to help you avoid regaining weight.
Most people have minimal appetite after the ESG procedure and become full on very small portions (eg. half to one cup of fluid). You will need to follow a liquid diet for three weeks following the procedure, however your appetite will remain minimal during this time.
After 1-2 weeks, your appetite may start to return but is typically blunted, and when you do eat, you will get full VERY easily. Our patients tell us they get full on a couple of tablespoons of yoghurt! During this time, you must eat very slowly and cautiously, as overeating can very easily occur. If you overeat, your body will give you a signal, whether it be bloating, reflux, hiccups or indigestion. It is very important to pay attention to your body signals, as the aim is to learn when you’ve had enough without developing those signals.
Over the next 6-8 weeks, you will gradually be able to increase the amount you eat, although not to what it was previously. You will be guided by your dietitian on healthy and nourishing food options and suitable portion sizes to keep you feeling well during this time.
ESGs have been in use by our practice and worldwide for over a decade, and the risks of complications are surprisingly small. There have been no deaths documented with this procedure with well over 2,000 cases having been performed worldwide. To date, complications that have occurred have been able to be managed with endoscopies, medications or minor procedures. No complication has yet required surgery to resolve, however there is a very small risk that this may be required.
Complications are very rare and are generally easily managed. They may include:
- 1% risk of major complications has been documented in the literature, with the most common complication being infection around the stomach. This is treated with antibiotics and rarely requires surgery.
- Trauma to the stomach or surrounding structures (such as the liver or gall bladder), which may rarely require surgery to fix.
- Clots in the legs
To date, no patient of The BMI Clinic has had any of these complications. The rate of major adverse events at our clinic is 0.1%, as our management practices are unique and unlike any other practice in the world.
In order to allow the stitches to mature, it is important that the diet progresses slowly. Thankfully, appetite is strongly suppressed by this therapy and hunger is not an issue. Our patients are required to maintain a liquid only diet for approximately 3 weeks before progressing to a puree diet, then soft diet. Our patients are able to return to a normal diet approximately 5 weeks after the procedure, however portion sizes are much smaller than previous, and will remain so for many months and even years.
It is not expected that tablets be affected by ESG, however medication may take longer to act if in pill form. Anti-inflammatory medications may irritate the stomach more than they typically do following the procedure.
As you lose weight, other health markers may also improve and you may find that some medications may not be necessary (such as anti-hypertensives and diabetic medications). We ask all patients to meet with our Bariatric Physicians on a regular basis to assess their requirements for medication, before making any changes.
The side effects of the ESG procedure are usually limited to the first 5 days after it is performed, with the first 3 days being most severe. After this period, the symptoms disappear completely and will only recur (and are typically mild) when one of the ‘golden rules’ are broken.
Our doctors have worked tirelessly to optimise the treatment of our patients. You will be provided with our highly advanced, unique and comprehensive treatment program to minimise the occurrence of side effects.
You will also be prescribed medications to assist in controlling symptoms and it is important that you purchase these medications and take them as directed. If symptoms persist or worsen, you should contact the clinic immediately (on our 24/7 patient support number, 1300 376 026).
Most patients of our clinic now typically experience only mild side effects (if any), with the most common being:
- Cramping is common in the first 3-4 days after the procedure and can be treated with medications.
- Overeating or drinking too much at a time can also bring on cramping.
- Reflux (including heartburn and some belching)
- You will be required to take acid medication for the first week following your procedure to manage any reflux. Over the counter antacid medications can also be used.
- Overeating, overdrinking, eating rich (creamy/oily) foods or drinking wine will typically bring on acid reflux symptoms.
- Typically mild to moderate in the initial days after insertion.
- Typically due to the medications used to manage side effects and resolves after 3 days. We recommend resting during this period to hasten your recovery.