Endoscopic Sleeve Gastroplasty

The procedure uses an endoscopic suturing system mounted on a flexible gastroscope. Working entirely through the mouth, the operator places a series of stitches that pass through the full thickness of the stomach wall and, when drawn tight, pull the wall inward in a pleated line running from near the outlet back towards the top of the stomach. The result is a narrow, tubular stomach with a much reduced volume, similar in outline to the shape created by surgical sleeve gastrectomy but achieved by folding rather than by removing tissue. Because the stomach is only reshaped, the procedure is reversible in the sense that the stitches can be released or will loosen in time, and it leaves the option of conventional bariatric surgery open for the future.

It is recommended for adults with obesity who have not achieved or maintained sufficient weight loss through diet, exercise and, where used, medication. It is particularly suited to people with a body mass index in the range of about 30 to 40, which includes many who fall below the threshold at which sleeve gastrectomy or bypass is usually offered, and to people who want to avoid an operation or are not medically suitable for one. It is also used for weight regain after a gastric balloon. Obesity-related conditions such as type 2 diabetes, fatty liver disease, sleep apnoea, joint pain and high blood pressure strengthen the indication. It is not suitable for people with a large hiatus hernia, significant reflux disease, a previous stomach operation, an active ulcer, an untreated eating disorder or an inability to commit to long-term follow-up.

The patient is asleep under general anaesthesia and lies on the side or the back with the airway protected. A gastroscope carrying the suturing device is passed through the mouth into the stomach, which is inspected first for hernia, inflammation or ulceration. Suturing then begins near the lower part of the stomach body. Each stitch takes several bites of tissue in a triangular or U-shaped pattern across the greater curve and is cinched tight, pulling the anterior wall, the greater curve and the posterior wall together. A series of such stitch lines is placed progressively upwards until the sleeve is formed, sparing the very top of the stomach so that the reservoir near the entrance remains. The endoscope is used throughout to check the shape and to confirm there is no bleeding. No abdominal incision is made at any point, and the patient wakes with no external wound. The procedure typically takes 60 to 90 minutes.

Assessment is by a team that includes an endoscopist, a dietitian and, where appropriate, a psychologist and an endocrinologist. It covers weight history, previous attempts at weight loss, eating patterns, obesity-related conditions, medicines and mental health. A gastroscopy is performed beforehand or at the start of the procedure to exclude a hiatus hernia, ulcer or significant reflux. Blood tests check for nutritional deficiencies, diabetes and thyroid function, and vitamin D and iron are corrected. Most centres ask for a period on a reduced-energy diet before the procedure to shrink the liver and make the stomach easier to work in. The nutrition programme that follows the procedure is explained and agreed in advance, because it is what determines the result. For international patients, the assessment and dietitian sessions can begin remotely, and the follow-up schedule is written before travel.

Most people go home the same day or the next morning. Cramping abdominal discomfort, nausea and a feeling of fullness are common in the first 48 hours and are managed with medicine given routinely for the first days. Diet advances in stages: clear fluids, then full liquids for about one to two weeks, then pureed and soft food, reaching normal textures at about six weeks, all in small volumes and eaten slowly. Fluids are taken between meals rather than with them. Proton pump inhibitors are prescribed for a period, and a multivitamin is started. Light activity resumes within a few days and full exercise at about two to four weeks. For treatment abroad, plan about 5 to 7 days so that the procedure is done, fluids are clearly tolerated and the first dietitian review takes place before flying. Dietitian follow-up then continues remotely, typically monthly for the first year, and this contact is strongly associated with how much weight is lost and kept off.

Endoscopic sleeve gastroplasty has a favourable safety profile compared with surgical options, with serious adverse events reported in a low percentage of cases in published series. Expected effects include abdominal pain, nausea and vomiting in the first days. Uncommon but recognised complications include bleeding from a suture site, a collection of fluid outside the stomach, leakage, injury from the endoscope, and pain requiring readmission. Because the stomach is not cut, the risks of staple line leak and of permanent nutritional malabsorption that accompany some operations do not apply in the same way, though vitamin supplementation is still advised. Reflux can occur and is treated medically. Reported weight loss averages roughly 15 to 20 percent of total body weight at 12 to 24 months, with improvements in blood sugar, blood pressure, liver fat and sleep apnoea. Results depend heavily on adherence to the eating plan; stitches can loosen over time, weight regain is possible, and the procedure can be repeated or converted to surgery if needed.