Reducing stomach volume has become an important solution for patients struggling with obesity who have not managed to lose enough weight through diet and exercise. Two modern stomach reduction procedures are available: the laparoscopic gastric sleeve and the endoscopic gastric sleeve.
The laparoscopic gastric sleeve (also known as laparoscopic longitudinal gastrectomy) is a bariatric operation in which approximately 70–80% of the stomach is removed, leaving behind a narrow gastric tube. The intervention is performed under general anesthesia, through 4–5 small incisions in the abdomen, using laparoscopic instruments. This procedure is generally addressed to obese patients (usually with a body mass index – BMI above 35–40, sometimes above 30 if there are associated health problems).
The endoscopic gastric sleeve (also called endoscopic gastroplasty or ESG) is a newer, minimally invasive procedure, performed without external stitches. The doctor inserts a thin flexible tube equipped with a camera and a suturing device – an endoscope – through the throat, reaching the stomach. From the inside, stitches (sutures) are placed through the full thickness of the stomach wall, tightening the stomach and turning it into a smaller tube. The endoscopic sleeve is mainly addressed to obese or overweight patients who do not meet the criteria for classic bariatric surgery or who want a less invasive option.
In what follows, we will clearly compare the two methods – how each procedure is performed, recovery time, effectiveness in weight loss, risks and possible complications, costs, and degree of invasiveness – to understand the advantages and disadvantages of each.
How the procedure is performed
Laparoscopic gastric sleeve: This is a surgical intervention. The patient is under general anesthesia, and the surgeon makes between 4 and 5 small incisions (about 1 cm) in the abdominal wall. Through these incisions a video camera and long surgical instruments are introduced. The stomach is visualized on a screen, and up to approximately 80% of the curved external part of the stomach (the greater curvature) is resected (cut and removed from the body). The remaining stomach has the shape of a tube (similar to a “sleeve,” which is where the name comes from) and will have a much reduced volume. At the end, the external incisions are sutured or glued.
The operation lasts, depending on experience, generally under 1 hour, and the patient spends a few more hours in intensive care for immediate postoperative monitoring. Being a laparoscopic procedure, no large cut is made (as in open surgery), which reduces trauma and scarring – the small incisions leave only pinpoint marks on the abdomen.
Endoscopic gastric sleeve: This procedure does not involve external cuts. The patient is usually under general anesthesia. The gastroenterologist introduces, through the oral cavity, a special endoscope fitted with a suturing system (such as the Apollo OverStitch system). Under endoscopic control, a series of stitches is placed along the length of the stomach, in a U or Z shape, bringing the gastric wall closer together and tightening the stomach like a pouch. Practically, 8–12 internal sutures are placed which reduce the stomach’s lumen, transforming it into a narrower gastric tube, without removing the organ. The procedure lasts approximately 60–90 minutes, making it longer in duration than the laparoscopic variant. At the end, the endoscope is carefully withdrawn, leaving the sutures in place. Because there are no incisions, the patient will have no external scars, and the internal trauma is minimal.
In short, the major difference in how it is performed is that the laparoscopic variant involves surgery with the permanent removal of part of the stomach, while the endoscopic variant involves only shrinking the stomach from the inside, without external cuts and without resection of the organ. Both procedures require anesthesia and specialized medical personnel (the surgical and anesthesia team).
Recovery after the intervention
After the laparoscopic gastric sleeve: Recovery is relatively fast given that the operation is minimally invasive, but, as it is still major surgery, it requires a few days of supervision. Generally, hospitalization lasts around 2–3 days, during which the patient is monitored for pain, resumption of feeding, and possible complications. In the first 24–48 hours the patient remains under observation (often the first day in intensive care for close monitoring). Postoperative pain exists, but it is much less than after open surgery. Many patients can begin to move gently as early as the day after the operation (early mobilization helps prevent blood clots). Feeding is resumed gradually: initially only clear liquids, then high-calorie/protein liquids, with pureed foods and later solid foods introduced in the following weeks, according to a regimen indicated by the doctor and nutritionist. In the first month it is normal to experience fatigue and an adjustment to very small amounts of food. Most patients return to usual activities (light work) approximately 2 weeks after the operation, but intense physical effort must be avoided for several months (as indicated by the doctor).
Internal healing of the suture line on the stomach requires caution: that is why the strict postoperative diet (no solid foods for ~4 weeks) is essential to allow the stomach to heal and to prevent complications.
After the endoscopic gastric sleeve: Being a minimally invasive procedure, recovery is usually even faster. Many patients can be discharged the next day after a very short hospitalization. Pain after the procedure is generally mild to moderate – some patients experience gastric discomfort, nausea, or cramps in the first 24–48 hours, because the stomach has been tightened by the sutures. As in the case of surgery, the patient will follow a strict dietary regimen: the first 1–2 days only clear liquids, then a liquid diet for about 3 weeks, followed by pureed foods and later healthy solid foods after ~1 month. This transition is necessary to protect the stomach sutures until healing. Usually, patients feel well enough to return to light daily activities in just 2–3 days after the procedure, and the return to normal life is very fast compared to abdominal surgery. Nevertheless, even if physical recovery is easy, it is important for the patient to follow the check-up schedule and nutritional advice.
In conclusion, recovery after the endoscopic method is shorter and less painful. The patient avoids the long recovery periods associated with an operation, but will still need to seriously follow the recommendations regarding diet and lifestyle. Recovery after the laparoscopic sleeve, although it involves a few days in the hospital and healing of the incisions, still remains relatively fast (compared to open surgery), with many patients being surprised by how quickly they can move around and adapt to the new eating style. Both procedures require medical follow-up and nutritional/psychological support for the best results.
Effectiveness in weight loss
Both the laparoscopic and the endoscopic sleeve lead to significant weight loss, but the degree differs.
Effectiveness of the laparoscopic gastric sleeve: This operation is currently a gold standard in bariatric surgery for obesity – weight loss results are usually very good. In the first year after the intervention, patients can lose on average between 50% and 70% of their excess body weight, which often corresponds to approximately 20–30% of total body weight. For example, a patient who weighed 120 kg (about 40 kg above their ideal weight) can lose 25–30 kg or even more over the course of the first year. The laparoscopic sleeve also helps reduce the sensation of hunger – by removing the fundus of the stomach, the level of ghrelin (the hunger hormone) is lowered, which gives patients a reduced appetite. Likewise, many health problems related to obesity (type 2 diabetes, hypertension, sleep apnea, etc.) show improvement after the massive weight loss.
Effectiveness of the endoscopic gastric sleeve: Being a newer procedure, the endoscopic sleeve also offers significant weight loss, but generally not as much as the laparoscopic operation. Studies and clinical experience to date show that patients can lose, on average, around 15–20% of their total body weight in the first year after endoscopic gastroplasty. For example, a 120 kg patient could lose approximately 18–24 kg in a year with the help of this procedure. Some data from specialized clinics report slightly higher percentages (20–25% of total weight), especially in highly cooperative patients, so the weight loss range can vary. The effectiveness of ESG approaches that of surgery in patients with mild obesity, but for moderate/morbid obesity (very high BMI), the weight loss with the endoscopic method may not be sufficient. In such cases, ESG can still be considered as a first step, with the patient losing some of the excess, and later – if necessary – surgical intervention may be added. One advantage of ESG is that, if results are suboptimal, the procedure can be repeated, or the patient can later be converted to surgical bariatric intervention (since the stomach remains anatomically untouched, a laparoscopic sleeve or gastric bypass can be performed later).
Comparing effectiveness directly: The laparoscopic sleeve generally produces greater and faster weight loss. This is why it remains recommended for patients with more advanced degrees of obesity. The endoscopic sleeve offers significant but more moderate weight loss, suitable especially for those with smaller excess weight or those who want a lower-risk procedure. Both methods require maintaining a healthy diet and an exercise program; neither is a permanent “magic solution” without the patient’s effort. It is important that, regardless of the procedure, weight loss is only sustainable if the new eating and lifestyle habits are maintained long-term – otherwise, weight regain can occur within a few years.
Risks and possible complications
Any medical procedure, whether surgical or endoscopic, involves certain risks. The good news is that both gastric sleeve variants have proven to be relatively safe compared to other interventions. Risks of the laparoscopic gastric sleeve: Being an operation, there are general risks associated with surgery and anesthesia. Major complications are rare, but can include: internal bleeding (hemorrhage from the cut edge of the stomach or from damaged vessels), infections (at the incision sites or intra-abdominal), leakage of gastric contents through the suture line (the so-called fistula), stenosis (excessive narrowing of the gastric tube), or venous thromboses (postoperative blood clots). The incidence of severe complications in experienced centers is relatively low. Nevertheless, because of these small but real risks, patients are closely monitored in the hospital and given prevention (such as anticoagulant medication to prevent clots, antibiotics, etc.).
Over the long term, some patients may develop gastroesophageal reflux (heartburn) or worsening of it, because with the stomach being smaller and under pressure, acid can more easily rise into the esophagus – a notable percentage of patients report reflux after the sleeve. Likewise, rapid weight loss can lead to gallbladder lithiasis (gallstones) in the first year. Nutritional deficiencies after the gastric sleeve are rarer compared to gastric bypass, but vitamin deficiencies can appear (B12, vitamin D, iron, etc.), which is why the doctor will recommend supplements and periodic check-ups. Finally, there are the risks of any general anesthesia and any abdominal intervention (for example, reactions to the anesthesia, cardiac/pulmonary problems, very rarely complications such as accidental injuries to other organs during the operation). Overall, however, the safety profile of the laparoscopic sleeve is well established, with most complications being prevented or treated if detected in time. To minimize the risks, it is essential that the patient be well prepared (complete preoperative evaluation) and operated on by an experienced surgical team, then strictly follow medical recommendations during the recovery period.
Risks of the endoscopic gastric sleeve:
The endoscopic procedure avoids many of the risks associated with surgical intervention, but it is not entirely free of possible complications. During or after ESG, bleeding may appear at the gastric mucosa – usually minor and stopping on its own, or controllable endoscopically right away or more rarely surgically. A rare but serious risk is gastric perforation (a hole in the stomach wall caused accidentally by instruments or by suture tension). The incidence of perforation is very low and, if it does happen, may require emergency surgical intervention to repair the stomach. Some patients may experience nausea, vomiting, or more intense abdominal pain after the procedure. As with the surgical variant, there is a risk of gastroesophageal reflux or of heartburn becoming more pronounced after the procedure, although some studies suggest that reflux may actually be less frequent and milder than in the case of the surgical sleeve (because the anatomy of the stomach is not changed as drastically).
Serious complications are very rare with the endoscopic sleeve. Overall, ESG has an excellent safety profile, in part due to its minimally invasive nature. Even so, the patient must strictly follow post-procedure instructions (especially the liquid diet at the beginning) to avoid premature tension on the internal sutures. In rare cases, if the sutures are not well tolerated or late complications appear, there is the possibility of endoscopic removal of the sutures or conversion to classic bariatric surgery.
Comparing the safety of the two methods:
The decision between the two will be based mainly on the patient’s profile and not only on fear of complications – a patient with severe obesity may have much more to gain from the massive weight loss of an operation, even if it involves slightly greater risks, compared to a patient with moderate obesity who can opt for a gentler procedure. Regardless of the method, careful medical supervision and adherence to post-procedure recommendations will reduce the risks and ensure a safe recovery.
Conclusion
Both the laparoscopic and the endoscopic sleeve can offer the chance of a new beginning to patients who are struggling with extra kilograms and their complications. Regardless of the method chosen, long-term success depends on the patient’s commitment to changing their lifestyle – healthy eating, portion control, regular physical activity, and medical monitoring. Through close collaboration with doctors (surgeon, gastroenterologist, nutritionist, psychologist), patients can reach their weight goals in a safe way and significantly improve their health and quality of life. The specialist consultation is the first step – an open dialogue with the doctor will clarify any uncertainties and lay the foundation for a personalized treatment plan, whether endoscopic or surgical, for a healthier life.
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