ESG

ESG (Endoscopic Sleeve Gastroplasty)

About

ESG, Endoscopic Sleeve Gastroplasty, is a non-surgical, incisionless, minimally invasive procedure that allows your gastroenterologist to reduce the overall size of the stomach to promote weight loss. Done under sedation, as an outpatient, the procedure is well tolerated and patients return to a normal routine after a few days of at-home recovery.

Who It's For

ESG is ideal for patients who have a BMI of at least 30 and have not been successful with diet and exercise alone. It is also a solution for those who don’t want to undergo gastric bypass or those whose physical condition makes them ineligible for surgery. The most important criterion is to be committed to the program and follow instructions for the prescribed period of time. We recommend ESG for individuals who are looking for a long-term weight loss solution.

How The Procedure Works

ESG is a completely endoscopic procedure, performed from inside the stomach and without the need for abdominal incisions. Your physician will advance an upper endoscope (a camera attached to a flexible tube) through your mouth and into your stomach. The endoscope is equipped with a suturing system that allows placement of stitches in the stomach. The procedure takes approximately 30 to 45 minutes. After the procedure, the stomach is 70-80% smaller in size, which limits the amount of food that is eaten before feeling full, limits the amount of calories absorbed by the stomach, and also prolongs the time food remains in the stomach, extending the feeling of fullness.

Who Should Perform My Endoscopic Procedure?

Due to the specific skill required, endoscopic procedures are best done by a gastroenterologist, as opposed to a surgeon. (Dr. McGowan was the first gastroenterologist in North Carolina and one of the first physicians in the country to perform the ESG procedure.) Endoscopy is the primary skill utilized by a gastroenterologist on a daily basis, whereas surgeons generally perform far fewer endoscopic procedures. For a procedure as technically challenging as ESG, this experience matters. Dr. McGowan has performed more than 15,000 endoscopic procedures to date. He frequently educates and trains other doctors from around the country, as well as internationally, on procedures such as the ESG. We're not bragging, we're just saying ... we know what we're doing.

How Much Weight You'll Lose

ESG is currently the most effective non-surgical weight loss procedure available, producing an average of 20% total body weight loss at 1 year. Though results may vary for each individual undergoing ESG, most patients will lose 70% of their excess weight, or more. Off the scale victories also include improved blood pressure numbers, better blood sugar control, and improvement in sleep apnea.

Commitment to the program is the single greatest factor in success. Follow your doctor’s recommendations carefully and make thoughtful decisions on nutrition and exercise. Your True You physician will partner with you to help you achieve your weight loss goals.
True You: The Nation's ESG Leaders
Endoscopic Sleeve for Weight Loss
Total body weight loss at three months, six months, and 12 months, post-ESG.

ESG Video Library

Why Choose True You for ESG?

Endoscopic Expertise
ESG is one of the most technically challenging endoscopic procedures and requires a high level of endoscopic skill. Dr. McGowan, a board-certified gastroenterologist and endoscopist, is a leader and educator in the field of endoscopic weight loss, and regularly trains physicians from around the nation in the technique of endoscopic suturing.
Bariatric Excellence
WakeMed Cary Hospital, where Dr. McGowan performs ESGs, is an accredited Comprehensive Center for Bariatric Surgery, Blue Distinction Center for Bariatric Surgery, and Cigna Center of Excellence in Bariatric Surgery. Though your ESG is a same-day, outpatient procedure, you will have the backing of a comprehensive, knowledgeable, and award-winning bariatric center.
24/7 Physician Access
Whether you live in North Carolina, or are traveling from another state, you will receive the highest level of concierge care, with 24/7 direct access to your physician via personal cell phone, text, email, and video chat. We remain committed to your success throughout your weight loss journey.
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Success Stories

Persistence Pays Off: Jay Leonard Changes His Life with Endoscopic Sleeve Gastroplasty (ESG)

Success has never been a stranger to Jay Leonard. A Raleigh, North Carolina, native, he graduated from North Carolina State University and worked his way up to vice president of a clinical research organization. He had also enjoyed a years-long, happy marriage to his husband, Carl. But until May 2020, Jay’s weight was always an issue, even […]

Read More
Lisa Larger

How Does ESG Compare to the Surgical Sleeve Gastrectomy?

ESG
LSG
Type of Procedure
Non-surgical (endoscopic)
Surgical
Is Hospitalization Required?
No. Same day procedure
Yes; 1-3 days
Return to Work
2-3 days
1-2 weeks
Average Excess Weight Loss
50-60%
60-70%
Average Total Body Weight Loss
20%
20-30%
Major Complications
Rare (<1%)
2-6% (0.11% mortality)
Reversible?
No
No
Covered by Insurance?
No
Yes (if eligible)
ESG

ESG

LSG

LSG

Pricing

The True You ESG

$10,995

  • Initial Physician Consultation
  • Comprehensive Bariatric Nutrition Consultation
  • ESG Procedure (inclusive of all facility, anesthesia, and physician fees)
  • Unlimited One-on-One Nutrition Counseling
  • Unlimited Medical Follow-Up
  • 24/7 Direct Physician Access
  • Post-Procedure Nurse Visit With IV Hydration
  • 90-Day Complication Coverage Policy
  • 12-Month Re-Suturing Coverage
  • Physician-Guided Weight Loss Medication Program
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Self-Pay Pricing
Many of our patients simply don’t want surgery. At the same time, they feel hopeless because the lifestyle modifications of diet and exercise simply aren’t effective. True You provides solutions when you feel as though you’re out of options. While the endoscopic sleeve gastroplasty procedure is not covered by insurance, we offer several financing options.
Traveling From Out of State?
Patients have traveled to True You for more than 45 states and 8 countries. Raleigh-Durham International Airport is only 10 minutes from True You Weight Loss. We also have made arrangements with several local hotels for your convenience. Our travel resources, along with recommendations from our program director, will position you for success.

Frequently Asked Questions

WHAT IS ENDOSCOPIC SLEEVE GASTROPLASTY?

ESG is an endoscopic, incisionless technique that reduces the size of the stomach through internal suturing. The stomach size is reduced by approximately 70% by internally “plicating” or folding the stomach with stitches. After completion of the procedure, the
stomach has a sleeve-like shape, similar to a surgical sleeve gastrectomy.

HOW IS ESG DIFFERENT THAN A SURGICAL SLEEVE GASTRECTOMY?

The key difference is that ESG is non-surgical. There are no incisions. It is performed entirely through the mouth using an endoscopic suturing system (Overstitch). This allows for a fast recovery and healing, as well as a lower rate of adverse effects. The procedure is done on a same-day, outpatient basis. While ESG reduces the size of the stomach to a similar degree as a surgical sleeve gastrectomy, it does not involve removal of any portion
of the stomach.

HOW MANY SUTURES ARE PLACED IN THE STOMACH?

An average of 5-7 sutures are placed along the greater curve of the stomach. The exact number will vary based on the size and shape of the stomach.

ARE THE SUTURES PERMANENT OR DISSOLVABLE?

The sutures are made out of Prolene (polypropylene), a very durable material. They are not dissolvable and are considered permanent.

WHAT HAPPENS TO THE SUTURES AFTER I HEAL?

Following the ESG procedure, the internal sutures will hold the stomach in the new, sleeve shape, until it fully heals. After the stomach heals, the sutures will remain in the stomach wall. Over time, the stomach stiffens or “fibroses” and tends to stay in its smaller shape. Therefore, the role of the sutures is less important over time. The sutures themselves do not pose any long-term risk to you, and you would not know they are there.

HOW LONG DOES THE PROCEDURE TAKE?

Approximately 30-40 minutes. The procedure is performed under sedation in an endoscopy suite. You will recover for 1-2 hours after the procedure. You will then be discharged home.

WHEN CAN I RETURN TO WORK?

We recommend taking 2-3 days off after the procedure, to rest and recover.

HOW MUCH WEIGHT CAN I LOSE WITH ESG?

Actual weight loss will vary based on starting weight, motivation level, and adherence to our dietary recommendations. Current studies suggest an average of 20% total body weight loss and 60% of excess weight loss. It may take 6-12 months, or more, to lose this amount of weight.

IS THE PROCEDURE PERMANENT?

Once the stomach heals, it should remain in a smaller size and shape long-term. U.S. studies tell us that weight loss after ESG is maintained for up to 5 years. The key to sustaining weight loss is to adhere to the recommended diet and to maintain a regular exercise regimen. We advise that overeating can lead to weight regain and/or failure of the sleeve over time, as with any weight loss procedure.

CAN THE SUTURES COME LOOSE?

When performed correctly, the sutures in an ESG should remain in place and not come loose. However, suture failure has been reported and has been experienced at a very small rate (less than 1%) in our program. If needed, re-suturing can be performed to further tighten the ESG.

WHAT DOES THE “RESTRICTION” FEEL LIKE AFTER ESG?

The feeling of fullness, or restriction, will vary from person to person and will typically change over time. For the first few days to weeks, you will only be able to consume very small amounts of liquids and eventually soft foods at a time. Some patients describe a feeling of indigestion, fullness, or even discomfort when they reach their new capacity. For some patients, this is very obvious and noticeable. For others, it may be subtler. We emphasize the important of eating slowly to allow your brain to register fullness. After many months, the feeling of fullness will still occur at a much earlier point in a meal, but you should be able to consume a balanced diet with a full variety of healthy foods.

WHAT HAPPENS TO THE PART OF THE STOMACH THAT IS SUTURED?

During ESG, the greater curve of the stomach is stitched together, creating a “thicker” stomach wall in that area. The blood supply remains completely intact. After the stomach heals, it looks like a normal stomach from the inside, albeit smaller. There are no known long-term risks of plicating the stomach in this manner.

CAN YOU SEE THE SUTURES WITH XRAY?

Each suture has a tiny, metallic anchor at its end. These are visible by x-ray. They are inert and do not pose any long-term risk. They are compatible with MRI. They are not detectable by metal detectors.

WHAT ARE THE MOST COMMON SIDE EFFECTS?

The most common side effects are upper abdominal pain, bloating, cramping, and sometime nausea. These are typically mild and treated with pain relievers and anti-nausea medication. Fatigue may occur for 1-2 weeks after the procedure, due to the initially low
caloric intake.

WHAT IS THE RISK OF SERIOUS SIDE EFFECTS?

While the risks related to ESG are far lower than bariatric surgery, there is a 0.5% to 1% risk of serious adverse effect, including bleeding, infection, or injury to the stomach.

AM I A CANDIDATE FOR THIS PROCEDURE?

Anyone who is obese and has not achieved their desired weight loss through diet and exercise is a candidate. There is no specific weight or body mass index (BMI) required for the procedure, though most patients will have a BMI somewhere between 30 and 40. However, this procedure has been performed in individuals with higher BMIs who are not interested in pursuing surgical treatments.

WHO CANNOT HAVE ESG?

The main contraindication to ESG would be the presence of a known stomach problem, such as a stomach ulcer or very large hiatal hernia. Major health problems or bleeding disorders would also be a contraindication.

DOES ESG AFFECT THE HUNGER HORMONE GHRELIN?

Ghrelin is key hormone involved in maintaining body weight. It is produced by the stomach and rises when we have an empty stomach, and decreases after we eat. With the surgical Vertical Sleeve Gastrectomy, ghrelin levels remain very low for months, since a large part of the stomach was removed. They then gradually return to normal. In comparison, early studies suggest that ghrelin levels may decrease after ESG, though likely to a lesser degree and for a shorter time. However, because the stomach is smaller after ESG, the amount of food that it takes to “turn off” ghrelin should be significantly less.

WHY DON’T YOU SUTURE THE TOP OF THE STOMACH?

With ESG, the top of the stomach (called the Fundus) is left intact. This part of the stomach has a very thin wall and is close to other organs (such as the spleen, diaphragm, and lungs) and therefore suturing in this area is felt to be higher risk. By leaving the fundus intact, the stomach configuration after ESG looks more like a small pouch sitting atop a narrow sleeve. This is different than the Vertical Sleeve Gastrectomy (VSG), which creates a long, narrow tube. The stomach in ESG tends to be more scrunched up and pouch-like, due to the plication that is performed.

CAN I EXERCISE OR LIFT WEIGHTS AFTER ESG?

Yes. There are no specific lifting restrictions immediately after ESG. However, we recommend starting first with light walking, even as soon as the day of your procedure. This helps with the recovery and passage of gas. Once you are meeting your protein and fluid goals on a consistent basis, you can begin to exercise more intensely. We generally recommend avoiding very strenuous exercise for 3-4 weeks, as your caloric intake may be too low to support this at first (you may get tired). After the first month, you should be able to do any form of exercise without limitation.

IS IT OK TO GET PREGNANT AFTER ESG?

After you have healed and recovered from your procedure, it is safe to become pregnant, though we generally recommend waiting a minimum of 6 months before trying to get pregnant. We advise patients that fertility may increase after ESG, due to the metabolic improvements associated with weight loss.

WHAT HAPPENS IF I DON’T LOSE AS MUCH WEIGHT AS I WANT, OR IF MY WEIGHT LOSS IS SLOWER THAN EXPECTED?

We will closely monitor your progress following the ESG procedure, to ensure that your weight loss is on track. It is very common and expected to have periods of slower weight loss during the 12-month process. If, despite optimizing your diet and exercise, you still need further assistance, we may recommend weight loss medications (pharmacotherapy). This would be provided under the guidance of your treating physician. These medications can greatly enhance your weight loss, when used in conjunction with the ESG procedure.

CAN THE ESG PROCEDURE BE REPEATED?

Yes. If the initial procedure was not completely successfully, it can be safely repeated or tightened.

IF I DON’T SUCCEED WITH ESG, COULD I GO ON TO HAVE BARIATRIC SURGERY?

Yes. Patients have safely converted to surgical procedures (such as gastric bypass, vertical sleeve gastrectomy, or duodenal switch) in select instances.

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