Endoscopic sleeve gastroplasty gains momentum as a step forward in obesity care
- owenhaskins
- May 11
- 8 min read
About one in six European adults now live with obesity, putting them at greater risk for type 2 diabetes, heart disease and some cancers.(1) Globally, one in eight people are affected by obesity, according to a report from the World Health Organisation.(2) With obesity rates rising, so too is the use of treatments such as pharmaceuticals initially designed to treat diabetes.(3) Across Europe, there are major differences in the clinical indications, utilization and funding of bariatric surgery. For example, England has one of the lowest rates of utilising bariatric surgery(4) – despite obesity-related healthcare challenges hitting £6.5 billion(5) annually for the National Health Service (NHS). Now, a growing number of obesity societies have issued endorsements for endoscopic sleeve gastroplasty (ESG) as a treatment for patients with obesity. ESG is a minimally invasive medical procedure that uses sutures to reduce the size of the stomach from the inside with no external incisions or scars.
The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) recently endorsed ESG as an effective, safe and cost-effective treatment for obesity(6), after doing a comprehensive systematic review and meta-analysis of 44 studies involving over 15,700 patients who received an ESG procedure using the Boston Scientific OverStitch™ Endoscopic Suturing System.
Patients with class I and II obesity would benefit from having an ESG procedure, as well as those with class III obesity who would not qualify for bariatric metabolic surgery, according to IFSO. “ESG provides significant weight loss outcomes and demonstrates a favourable safety profile with a low rate of serious adverse events,” says IFSO in its Position Statement(6). “Despite the limitations of the included observational studies, the randomised controlled trial included in the analysis reinforces the efficacy and safety of ESG and provides an evidence-based foundation for the position statement.”
Country-level support for ESG is growing
SOFFCOMM recognition
In February, France’s Bariatric Society, Société Française et Francophone de Chirurgie de l'Obésité et des Maladies Métaboliques (SOFFCOMM), published a Position Statement and guidelines on ESG(7). SOFFCOMM recognised that ESG is more effective than lifestyle modifications alone for weight loss. “ESG is an integral part of the therapeutic arsenal available to bariatric and metabolic surgeons, offering an effective and valuable treatment option for obesity in specific patient populations,” said SOFFCOMM.
SOFFCOMM said that a multidisciplinary team should care for patients undergoing ESG in an accredited centre authorized to perform bariatric and metabolic surgery. The Position Statement recommended that adherence to follow-up visits is a significant predictor of successful weight loss outcomes after ESG. Another key consideration is appropriate patient selection – again echoing IFSO’s criteria.
GIRO guidance
The Spanish GIRO Guide(8) was developed by Sociedad Española de Obesidad (SEEDO), a multidisciplinary scientific society for obesity. Collaborating with thirteen national scientific societies, SEEDO’s guidance aims to recognise obesity as a chronic, multifactorial pathology requiring comprehensive management. The GIRO guide recommends improved communication strategies among different specialties involved in obesity management.
The same quality criteria for bariatric surgery should apply to endoscopic weight loss options. Although patients may lose less weight applying endoscopic treatment, its less invasive nature offers significant advantages like better tolerance, fewer complications and the possibility of sequential therapies to improve clinical outcomes.
The GIRO guidance states that endoscopic treatment, with few complications, can be considered in these situations:
Patients with mild to moderate obesity (BMI 30.0-39.9 kg/m2) where combined nutritional, behavioral and pharmacological treatment fail to meet weight loss or maintenance goals, and they seek less invasive options than surgery.
Patients with inadequate weight response post-bariatric surgery, where combined treatment fails to meet goals and they do not wish for a second invasive surgery.
Technology evolution
Boston Scientific manufactures minimally invasive medical devices, including the OverStitch Endoscopic Suturing System which is used during the ESG procedure. This involves a thin, flexible tube with a small camera being passed through the mouth and into the stomach. The OverStitch device is attached to the end of the tube to stitch and fold together parts of the stomach wall to reduce its volume by 70%–80%. This reduces food intake by creating a sensation of fullness. When combined with diet and exercise, the ESG procedure can help those affected by obesity to lose weight.
Updates in the next-generation OverStitch NXT™ system – including the device’s improved retroflexion, or ability to be bent back – now enhance the physician’s control in performing ESG. “OverStitch NXT allows a physician to work more independently, with full control during the tissue targeting phase, resulting in simplified steps and less need for assistance during the procedure,” says Astrid Monteau, vice president of Endoscopy in EMEA for Boston Scientific.
OverStitch NXT is designed for use on single-channel gastroscopes and compatible with a wide range of models. Inserted through the mouth into the stomach, the device is then used to place six to eight running stitches in a U-shaped pattern along the greater curve of the stomach. When tightened and secured, the sutures draw together the anterior and posterior walls of the greater curve to reduce the size of the stomach. A study shows that patients normally returned to routine daily activities three days after an ESG procedure(9).
NICE approves ESG
Whilst societal momentum for ESG endorsement has recently picked up, the UK has experienced traction in making ESG available in the NHS. In its guidance recommending the procedure, the National Institute for Health and Care Excellence (NICE) said ESG can offer hospital capacity efficiencies in terms of reduced hospital stays and less risk of adverse effects or of readmission.9 With the correct training and support, ESG can be performed by an endoscopist or by a surgeon as a day-case procedure. Patients selected by a multidisciplinary team can be offered this procedure in specialist centres by a clinician, who has received specific training.
Under the NHS’s long-term plan, tackling obesity is a priority as it is estimated that 26% of adults in England are living with obesity and a further 38% are overweight(9). “The minimally invasive nature of the ESG procedure helps reduce pressure on healthcare systems which are facing multiple challenges, including increased patient demand,” Monteau says.
The MERIT trial(10), a large-scale randomized study, found that ESG resulted in significant weight loss. Other studies, following the progress of patients five years after ESG, further support the durability of the procedure.
The British Obesity and Metabolic Surgery Society(11) has endorsed ESG along with training programs for physicians that will allow ESG to become more widely available across the UK. To date, there are 30 centres in the UK – including NHS and private – that are offering ESG.
Training and proctorship needed
To help hospitals meet the growing demand for ESG, Boston Scientific has developed a comprehensive training program and opened the Institute for Advancing Science, a dedicated training centre for ESG and other minimally invasive procedures in the UK(11).
“The guidance from the different societies emphasize that quality of care is critical for advancing patient outcomes,” says Monteau. “We are committed to providing training and clinical support to a number of specialist weight management centres in the UK to meet the increasing demand for ESG procedures triggered by the NICE guidance”.
Located in County Durham, Darlington Memorial Hospital has benefitted from Boston Scientific’s ESG training programme. It was the first ESG centre to open outside of London in north-east England. County Durham council’s data reveals that “the proportion of adults classified as overweight or obese in County Durham 2021/22 (75.2%) is statistically significantly worse than England (63.8%) and the North East (70.5%)”(12). Professor Anjan Dhar, consultant gastroenterologist, together with Mr Akeil Samier, consultant bariatric surgeon, at County Durham and Darlington NHS Foundation Trust went through the ESG training programme, and then did their first live cases under the supervision of one of two in-theatre proctors: Professor Bu'Hussain Hayee, consultant gastroenterologist at King’s College Hospital in London, and Dr Vincenzo Bove, medical director of gastrointestinal endoscopic surgery at Gemelli University Hospital in Rome.
They then transitioned to remote proctoring through live video links for the next few cases.
Seeing a primary care provider is the first step in the UK’s tiered weight management patient pathway. ESG is now included as part of the management of obesity in an updated Clinical Knowledge Summary (CKS)(13) from NICE for general practitioners, nurses and pharmacists. The CKS goes into more detail about who would most benefit from ESG, including those with a body mass index (BMI) of 35 or more for whom invasive bariatric surgery would be considered high risk, as well those low-risk obesity (BMI of 30.0 to 34.9) for whom the procedure could prevent the progression of obesity and associated comorbidities.
“To increase ESG uptake, primary care healthcare professionals must be convinced that this treatment option is going to improve health outcomes for patients on a long-term basis,” says Professor Dhar. However, there are constraints in the healthcare system to increase the availability of ESG in the UK and the government’s emphasis is to reduce waiting lists. “We're doing probably between two to four cases every month, subject to theatre space being available. On average we are aiming to do between 30 to 40 cases a year,” explains Dhar. “I don't see that capacity increasing because of lack of theatre space as this is a non-cancer procedure. We struggle to get theatre space.”
Patients have a variety of choices for weight loss– weight loss medications, bariatric surgery and ESG. “Obesity is a chronic multifactorial disease that increases patients’ comorbidity risks and affects emotional wellbeing and mental health,” says Monteau. “ESG is an effective weight loss option for patients with obesity. As a minimally invasive procedure, it provides an option to clinicians over traditional surgery that addresses the burden on health care systems facing staff shortages.” Greater adoption of medical technology and procedures requires a focus on systemic change and investment in technology so that patients can succeed in their weight loss journey.
References
OECD publication Health at a Glance: Europe 2020 https://www.oecd.org/en/publications/health-at-a-glance-europe-2020_82129230-en.html
World Health Organisation, One in eight people are now living with obesity, March 2024
Clinical Indications, Utilization, and Funding of Bariatric Surgery in Europe - PMC
Department of Health and Social Care. Government plans to tackle obesity in England. Updated 2 February 2024. [Accessed March 2025].
IFSO Bariatric Endoscopy Committee Evidence-Based Review and Position Statement on Endoscopic Sleeve Gastroplasty for Obesity Management, December 2024 https://pubmed.ncbi.nlm.nih.gov/39482444/
Guía de Práctica Clínica de Obesidad en Adultos, Version 2.0, Nov 2024
Endoscopic Sleeve Gastroplasty for Obesity, National Institute for Care and Excellence, February 2024
In the MERIT study, patients generally returned to routine daily activities in 2-3 days.
Abu Dayyeh BK, Bazerbachi F, Vargas EJ, Sharaiha RZ, Thompson CC, Thaemert BC, Teixeira AF, Chapman CG, Kumbhari V, Ujiki MB, Ahrens J, Day C; MERIT Study Group; Galvao Neto M, Zundel N, Wilson EB. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet. 2022 Aug 6;400(10350):441-451. doi: 10.1016/S0140-6736(22)01280-6. Epub 2022 Jul 28. PMID: 35908555.
Review of healthy weight approaches, County Durham, October 2023Boston Scientific. Investing in clinician training in the UK to transform patient outcomes. 20 February 2025. [Accessed March 2025].
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