Understanding endoscopic bariatric weight loss: A conversation with Daniel Hashimoto, MD, FACS

DAH: The FDA has approved ESG for individuals with a body mass index between 30 and 50 kg/m2. It’s particularly suitable for those who may not want to undergo traditional bariatric surgery, though most patients who qualify for ESG are also candidates for these procedures. This option is ideal for patients seeking significant weight loss and a better chance of putting obesity-related health issues into remission, especially those who are at the lower BMI range and may not qualify for bariatric surgery (BMI 30-40 kg/m2).

Patients with more metabolic comorbidities, like diabetes, hypertension, and obstructive sleep apnea, may want to consider undergoing a more traditional surgical option. But for patients whose primary goal is more permanent weight loss than may occur with just lifestyle changes or medications but who do not want to undergo surgery for one reason or another, ESG is a really good option.

As for total body weight loss, patients will have an average weight loss of 5% to 15% of total body weight over a year’s time with the new weight loss medications, as compared to 12% to 15% with ESG, depending on which studies you're looking at. Importantly, studies have shown that adding GLP-1 drugs enhances weight loss with ESG.

DAH: In the surgical sleeve procedure, or vertical sleeve gastrectomy, the greater curve of the stomach is stapled off and removed from the body. A comparative advantage of the ESG is that it’s a non-surgical approach, which means we don’t make incisions in the body, nor do we remove any parts from the body, or reconnect parts of the GI anatomy. Instead, multiple sutures are placed using a camera that goes through the mouth and into the stomach to plicate or fold the stomach inward so that a part is no longer available to hold food or liquid. The ESG is considered permanent but reversible because the sutures can be removed if needed and a balloon can stretch the stomach back into its prior configuration.

Another interesting element of ESG is that it alters the stomach’s motility. Studies have shown that folding the stomach and changing the confirmation of the stomach changes its motility and improves the sensation of satiety for patients, so patients will feel full earlier. Early satiety and feelings of fullness are one of the ways the sleeve gastroplasty helps patients get on top of any hunger or cravings they may otherwise be experiencing.

DAH: We might consider certain patients to be at somewhat higher risk for ESG—patients who have underlying bleeding disorders or in whom we cannot temporarily pause blood thinners, patients who have significant liver disease that would otherwise make them too high risk for a procedure. This highlights the importance of going to a comprehensive weight management center, like Penn Medicine, that can provide multiple approaches to obesity care.

DAH: There are a couple of options. As I mentioned, we can simultaneously prescribe weight loss medications, such as the GLP-1 medications, to try to get a synergistic effect between the ESG procedure and the medications.

Other options include conversion to a surgical procedure, whether it's converting to a traditional sleeve gastrectomy or converting to a Roux-en-Y gastric bypass. The thought is that if the narrowed stomach hasn't helped with their weight loss, then it makes sense to proceed to what we know is a superior procedure for weight loss, which is a gastric bypass. This involves reverting the stomach to its normal configuration and performing a gastric bypass. This is all done in one step.

DAH: A CPT code for ESG just got approved and will go live in January of 2026. We know that there's already a hospital-based C code, so there is reimbursement at the hospital level for ESG and certain insurances are now beginning to cover it. We check everyone’s insurance benefits as part of our program, so we can help determine if this is something your insurance will pay for on a case-by-case basis.

DAH: I think what sets us apart the most is that Penn Metabolic and Bariatric Surgery Program is a comprehensive metabolic and weight management center with expertise in the continuum of treatment options. We’re an American Society for Metabolic and Bariatric Surgery Center of Excellence, and currently, we're the only program in the city of Philadelphia offering endoscopic bariatrics. The program is a collaborative effort between GI Surgery, GI Medicine, and Metabolic Medicine. It includes team members ranging from physicians to dietitians to psychologists, all specializing in the complex management of obesity.

The Program offers state-of-the-art personalized care, including diet and lifestyle intervention, medication management with weight loss medications, and bariatric surgery (such as sleeve gastrectomy, Roux-en-Y gastric bypass, and revisional surgery). In addition, as part of our comprehensive program, we can offer patients alternatives such as endoscopic gastric remodeling, which includes ESG, which offers them the opportunity to have a procedure that is permanent and can offer them similar, if not greater, weight loss than what they've experienced on medication and approach the weight loss seen after bariatric surgery.

We have a centralized pathway. All patients come in through the Penn Metabolic and Bariatric Surgery Program for initial assessment and education. From there, they can learn about the different options to develop a personalized plan. We strongly believe that the patient should be involved in the decision-making to determine which procedure or treatment strategy will be the best fit.

The evaluation, testing, and education is the same for patients across all the procedures. All patients will undergo a period of medical weight management working with a registered dietitian, which is required by insurance companies prior to approval for any medication or procedure. They’ll get the appropriate tests like blood work, X-ray studies, and fluoroscopy studies to ensure that they are candidates for this procedure, and it also helps determine if any procedures may not be appropriate for them.

As they complete these steps, they can move on to the actual procedure, which is decided between the patient and the physician who is guiding them through their weight loss journey.

DAH: You can connect with our Penn Metabolic and Bariatric Surgery Program team at 215-615-7500.