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Page 4 of 20 Nwaiwu et al. Mini-invasive Surg. 2025;9:20 https://dx.doi.org/10.20517/2574-1225.2024.112

* ‡ † §
After 3 months; after 4 months; after 6 months; weight loss after multiple injections. EBMT: Endoscopic bariatric and metabolic therapy; ESG: endoscopic sleeve gastroplasty; BMI: body mass index; TBWL: total
body weight loss; EWL: excess weight loss; POSE: primary obesity surgery endoluminal; TOGA: transoral gastroplasty; IGBs: intragastric balloons; TPS: TransPyloric Shuttle; DJBL: duodenojejunal bypass liner; GJBS:
gastroduodenojejunal bypass sleeve; IMAS: incisionless magnetic anastomotic system; T2DM: type 2 diabetes mellitus; MS: magnetic anastomosis system; DMR: duodenal mucosa resurfacing; BTA: botulinum toxin
A.

GASTRIC REMODELING/ENDOSCOPIC SUTURING DEVICES
Endoscopic sleeve gastroplasty
[11]
Endoscopic sleeve gastroplasty (ESG) was first reported by Abu Dayyeh et al. in 2013 and has gained more popularity in recent years . It is performed using
an endoscopic suturing device, such as the Overstitch Endoscopic Suturing System (Boston Scientific, Marlborough, MA). The procedure involves incisionless
transoral endoscopic full-thickness suturing of the wall of the stomach along its greater curvature, typically beginning at the angular notch and progressing

[12]
toward the gastric body while keeping the fundus and antrum intact [Figure 1A] . The goal of this gastric plication and remodeling is to mimic the effects of a
[13]
surgical SG by restricting the gastric volume and slowing gastric emptying , leading to a prolonged feeling of fullness along with reduced caloric intake.
Although the original greater curvature ESG was performed in 2008, the current full-thickness device was first used in 2012 to perform ESG as an innovative,

organ-preserving bariatric procedure [14,15] . Since then, it has gained momentum as a less invasive and safer alternative to traditional bariatric surgery. ESG is the
most common EBMT today.

Studies have demonstrated significant weight loss and metabolic improvements with mean total body weight loss (%TBWL) of 14.86%-16.9%, 16%-16.43%, and
12.8%-20.01% at 6, 12, and 24 months, respectively. Excess weight loss (%EWL) has been reported to be as high as 49.9%-61.84% within the first year and
39.3%-60.4% at 24 months. %EWL within the first month after ESG has been reported to be an early predictor of success at 24 months. Studies have reported

sustained weight loss and metabolic benefits up to five years after ESG, rivaling some surgical bariatric procedures. ESG has also been associated with
remission of diabetes (55.4% of patients), hypertension (62.8%), dyslipidemia (56.3%), and OSA (51.7%) .
[16]

A systematic review and meta-analysis of studies that compared ESG and laparoscopic sleeve gastrectomy (LSG) demonstrated that ESG is significantly less
effective than LSG. Pooled %TBWL at 6, 12, and 24 months was 15.2, 19.1, and 16.4, respectively, for ESG compared to 18.8, 28.9, and 22.3 for LSG [16,17] . %EWL
for ESG at 6 and 12 months were 66.7 and 71.04, respectively, and 76.6 and 94.9 for LSG. Although ESG had a lower incidence of adverse events than LSG,

[16]
which was not statistically significant , the incidence of gastroesophageal reflux disorder (GERD) was significantly lower after ESG (1.3%) than LSG
[18]
2
(17.9%) . Another study (216 patients, average baseline BMI 39 ± 6 kg/m ) reported 5-year outcomes after ESG at 1-, 3-, and 5-year follow-up . Average
[16]
EWL was 47.9%, 45.1%, and 45.3%, respectively (P < 0.001), whereas average TBWL was 15.6%, 14.9%, and 15.9%, respectively. At 5 years, 74% of patients
maintained 25% EWL, whereas 90% and 61% of patients maintained 5% and 10% TBWL, respectively. The rate of moderate adverse events was 1.3%, but there
were no severe or fatal adverse events.