Overview
After extensive review and analysis of safety and effectiveness data and extensive feedback from ASMBS members, the American Society for Metabolic and Bariatric Surgery (ASMBS) has added Endoscopic Sleeve Gastroplasty (ESG) to its list of approved procedures. During our comment period, the majority of ASMBS members favored approval, and the majority of the ASMBS Board of Directors granted the endorsement.
The ASMBS recognizes a defined set of endorsed procedures as safe, effective, and evidence-based interventions for the treatment of obesity. These procedures reflect current clinical best practices and are suitable for use as primary surgical treatments at MBSAQIP-accredited centers.
1. Why did ASMBS consider ESG for endorsement?
- At least one active ASMBS member submitted an application for review.
- ESG is an increasingly used endoscopic procedure for treating obesity.
- A growing body of data shows clinically meaningful weight loss and improvements in metabolic conditions for selected patients.
- ESG has a Category I CPT code with emerging coverage and benefit design.
- Surgeons and programs are being asked by patients, payors, and hospital systems to address ESG’s role in care pathways.
2. What is the ASMBS position on ESG?
The ASMBS endorses ESG as an endoscopic option for carefully selected patients within a comprehensive, multidisciplinary obesity treatment program, ideally within a MBSAQIP-accredited center. While the ASMBS does not consider ESG equivalent to metabolic and bariatric surgery (e.g., sleeve gastrectomy, gastric bypass) in terms of expected weight loss or metabolic impact, it does fall within a multi-modal treatment continuum that includes lifestyle therapy, obesity management medications (OMMs), and metabolic and bariatric surgery. Accredited centers will submit their procedure data to MBSAQIP.
3. Who is a candidate for ESG?
Based on current evidence and member feedback, ESG may be considered for:
- Adults with obesity who have not achieved adequate weight loss with lifestyle therapy and OMMs alone, and who desire non-operative, procedural treatment for obesity.
- After a thorough review of the data, to optimize outcomes, ASMBS recommends ESG primarily in the BMI range 30-40. However, there is a role for ESG in patients with BMI outside of this range with specific clinical presentations and risk profiles. Patients who are unwilling, not ready, or at relatively higher risk for laparoscopic/metabolic surgery but still seek procedural therapy.
- Patients who understand the difference between endoscopic and surgical therapies for obesity.
- Patients who have been counseled on the expected weight loss, metabolic outcome, and metabolic condition reduction typically associated with ESG.
4. How does ESG compare to sleeve gastrectomy (VSG) and gastric bypass (RYGB)?
Expected weight loss
- ESG: The MERIT randomized trial reported a mean TBW of 13.6% at 12 months. Peer-reviewed longitudinal series report mean TBW 15-17.5%.
- VSG/RYGB: generally greater and more durable weight loss, with robust long-term data.
Metabolic effect
- ESG is primarily a restrictive, volume-reduction procedure that preserves the gastric fundus and slows gastric emptying.
Evidence maturity
- More ESG evidence is emerging and evolving; data quality and durability remain active areas of debate. As an endorsed procedure, ASMBS can collect and analyze data and monitor appropriate adoption of the procedure. Most data to date are from patients with BMIs of 30 to 40.
Treatment Continuum
- ASMBS endorses ESG as an adjunct and complement in the continuum of obesity management, not a replacement for established metabolic and bariatric procedures.
5. How does ESG compare to GLP-1 and other obesity management medications?
From a treatment continuum perspective:
- ESG and GLP-1/OMMs can yield similar weight-loss ranges in some populations.
- ESG may be used with or without adjunctive OMMs. As with operative therapies, many experts expect combined approaches to become more common.
- GLP-1/OMMs have ongoing medication costs and adherence considerations; ESG has upfront procedural risk and cost, with no incisions, and published serious adverse event rates are between GLP-1 injection therapy and operative therapies.
6. What benefits of ESG did supportive members emphasize?
- ESG is a less invasive, incisionless option with lower wound morbidity and faster recovery for most patients.
- Consistent moderate weight loss (~15–20% TBWL) and improvement in obesity-related conditions in published series.
- Unlike GLP-1 Injection therapy, results in published ESG series mirror results in randomized trials.
- Cost-effectiveness versus long-term medical therapy in some economic models.
- ESG may be a critical tool for BMI 30–40 patients and for the prevention of progression to Class III obesity.
- The need for ASMBS to lead in endoscopic therapies that are part of a comprehensive obesity treatment approach.
7. What were the most significant concerns raised by members?
- Inferior outcomes and durability compared with metabolic and bariatric surgery.
- Real-world complication rates are perceived as higher than those reported in the literature.
- Revisional complexity: ESG can distort anatomy, leave permanent anchors, and may make later VSG/RYGB/SADI more challenging and possibly higher risk.
- Industry influence and conflict of interest in the ESG evidence base.
- Encroachment by GI and procedure-only business models lacking IH, nutrition, and psychological support.
- ASMBS acknowledges these concerns and has explicitly incorporated them into its guardrails and ongoing evaluation plans.
8. How is ASMBS addressing concerns about GI encroachment and program structure?
ASMBS endorses ESG only in the context of comprehensive care, with the following expectations:
- ESG should be performed within or tightly integrated with multidisciplinary metabolic and bariatric programs (surgeon, pharmacology, nutrition, psychology, etc.).
- ESG should not be offered as a stand-alone, “one-off” procedure without robust pre- and post-procedure care and long-term follow-up.
- Credentialing and privileging should require appropriate training, competency assessment, and case volume, with careful tracking of outcomes and complications.
9. How should surgeons think about ESG and revisional surgery?
- ESG may make subsequent operations more complex, depending on the suture pattern, the number of plications, and the presence/position of anchors.
- Conversion to VSG, gastric bypass, or duodenal switch after ESG may require revisional expertise and carry increased risk.
- As with any secondary metabolic and bariatric procedure, Surgeons should incorporate the possible increased complexity into patient counseling, informed consent, and institutional privileging decisions.
ASMBS will continue to monitor and study revisional outcomes after ESG and may refine guidance as more data emerge.
10. What standards does ASMBS expect for ESG training, reporting, and follow-up?
ASMBS expects ESG to be:
- Performed by physicians with formal training in metabolic and bariatric endoscopy and ESG-specific techniques.
- Supported by structured follow-up, including nutritional, behavioral, and medical care similar to other metabolic and bariatric procedures.
- Prospectively tracking outcomes, including weight loss, comorbidities, complications, and revisions.
- Included in institutional quality improvement and registry participation whenever feasible.
As experience grows, ASMBS may recommend minimum volume thresholds, competency benchmarks, and standardized reporting metrics.
11. Does ESG endorsement change ASMBS’s advocacy priorities?
Endorsement of ESG does not:
- Diminish ASMBS’ commitment to advocating for coverage and access for metabolic and bariatric surgery, the gold standard treatment.
Instead, the endorsement of ESG provides surgeons with:
- An additional option in the treatment continuum, especially for specific patient subgroups.
- A procedure that will be subject to appropriate standards and quality requirements, similar to other obesity interventions.
ASMBS will continue to advocate for comprehensive coverage that supports the right treatment for the right patient at the right time.
12. Which other organizations have endorsed the procedure?
| Society / Organization | Document Type | Year | Key Citation |
|---|---|---|---|
| IFSO – Bariatric Endoscopy Committee | Position Statement (Obes Surg) | 2024 | Abu Dayyeh BK et al., Obes Surg 2024 |
| ASGE + ESGE | Joint Guideline (GIE / Endoscopy) | 2024 | Jirapinyo P et al., GIE 2024 |
| NICE (UK) | IPG783 Interventional Guidance | 2024 | NICE IPG783, 2024 |
| SOFFCOMM (France) | National Position Statement (Rev Fr Chir Obésité) | 2025 | Baratte C et al., Rev Fr Chir Obésité 2025 |
| SICOB (Italy) | National Guideline (Updates Surg) | 2024-2025 | SICOB Guidelines 2025 |
| BOMSS (UK) | Society Statement / Training Framework | 2025 | Bariatric News, May 2025 |
| AGA (US) | Clinical Practice Update (Gastroenterology) | 2017 | Thompson CC et al., Gastroenterology 2017 |
Feedback Mechanisms
ASMBS members may provide ongoing feedback or share ESG outcomes by participating in ASMBS committees, task forces, and registries focused on endoscopic therapies. They may also share clinical experience and outcomes data through ASMBS channels, including meetings and publications, and communicate concerns, complications, or best practices to ASMBS leadership so that guidance can be updated and refined over time.