Post written by Vivek Kumbhari, MD, PhD, from the Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

This review focuses on the technical aspects required to perform an endoscopic sleeve gastroplasty (ESG). Though there is a growing body of literature on the clinical outcomes of ESG, there is little to describe the technical nuances learned over the 7 years since the procedure was first published. As the procedure is disseminating world-wide, it is ever more imperative that it be performed in an efficient, effective, and safe manner.

ESG appears to have been safely introduced into clinical practice, and thus it is imperative that bariatric endoscopists comprehend the technical nuances for completing a successful procedure and be armed with tips to avoid pitfalls. The ideal ESG is one in which the procedure duration is approximately 60 mins, it is performed as outpatient, the sleeve-like confirmation is durable, there are minimal intra- and postprocedural adverse events, and the patient loses at least 10% total body weight. The endoscopist has control over some but not all of these variables, with the durability of the sleeve-like confirmation and clinical outcomes being at least in part patient dependent.

In the manuscript, we present an overview of the procedure, strategies to optimize technical success, an overview of common and uncommon adverse events (AEs), and practical solutions for prevention and management. Post-ESG rate of severe AEs is approximately 2.2%, suggesting that ESG can be safely adopted as a minimally invasive procedure for successful and sustained weight loss. The learning curve for proficiency is steep (a small number of procedures required to reach proficiency). Based on our experience, we provide a strategy that will allow for the procedure to be performed proficiently and safely.

ESG, if performed successfully in the appropriate patient population, has the potential to be included in the treatment algorithm for obesity. For this to occur, it may be beneficial for the procedure to be performed in a homogenous manner using the techniques that have been demonstrated to be effective and safe. Further research is required to successfully ascertain the optimal suture pattern, number of sutures, and size of the stomach to induce optimal outcomes.

Figure 2. Different stitch patterns performed around the world. A, Z stitch pattern. B, W stitch pattern. C, U stitch pattern.

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