How to Perform Endoscopic Sleeve Gastroplasty (ESG): Step-by-Step Tutorial

Disclaimer: For professional use only. This guide is intended for trained endoscopists with experience in therapeutic endoscopy and suturing techniques.

I. PRE-PROCEDURAL CONSIDERATIONS

1. Patient Selection

• BMI ≥30 kg/m² (typically 30–40 kg/m²)
• Failed lifestyle modification (diet, exercise)
• No large hiatal hernia, active peptic ulcer, or severe GERD
• Psychologic evaluation and multidisciplinary clearance

2. Preparation

• Informed consent
• Liquid diet 24–48 hours prior
• Fasting: 8h for solids, 2–4h for clear liquids
• General anesthesia with endotracheal intubation

II. EQUIPMENT SETUP

• Endoscope: Therapeutic gastroscope (e.g., Olympus GIF-2TH190 or Olympus GIF-1TH190)
• Suturing System: Apollo OverStitch™ or Apollo OverStitch Sx™
• Accessories:
  • Helix tissue retractor
  • Suture cinch device
  • CO₂ insufflation
  • Irrigation pump
  • Hemostatic tools

III. PROCEDURAL STEPS

1. Diagnostic Evaluation

• Perform full diagnostic EGD
• Clean stomach of residual contents
• Check for contraindications

2. Device Mounting and Setup

• Mount the OverStitch™ system on the endoscope
• Load suture and test mechanics

3. Positioning

• Navigate to ~4 cm above the pylorus
• Alternate forward and retroflex views for orientation

IV. FULL-THICKNESS SUTURING TECHNIQUE

Goal

To create a tubular sleeve by imbricating the anterior, greater curvature, and posterior gastric walls using full-thickness running or interrupted sutures.

A. Suturing Maneuver (OverStitch™ System)

1. Grasping the Tissue

• Insert the tissue helix through the working channel
• Rotate clockwise to penetrate and anchor full-thickness gastric wall
• Pull tissue into view between suturing arms

2. Advancing the Needle

• Align tissue centrally between drive (left) and capture (right) arms
• Activate needle driver:
  • Needle passes left to right through the tissue
  • Needle tip locks into receiving arm

3. Releasing and Repositioning

• Rotate helix counterclockwise to release tissue
• Withdraw helix for next bite
• Adjust scope or device to align next suture site

4. Retrieving the Needle Back

• Activate device to retrieve needle from right to left
• Suture now bridges the tissue bite
• Repeat steps to continue the stitch pattern (typically 6–8 bites)

5. Cinching the Suture

• After final bite, pull suture to tighten plication
• Deploy cinch to lock the suture
• Cut the suture with integrated cutter

6. Repeat Rows

• Perform 5–7 rows of plications from the distal body toward the fundus
• Leave a small proximal pouch to avoid fundic ischemia

V. FINAL INSPECTION

• Use retroflexion to assess sleeve formation
• Check for bleeding, gaps, or perforation
• Document with photos/video

VI. POST-PROCEDURE CARE

1. Immediate Recovery

• Observe in PACU for 4–6 hours
• IV hydration, analgesics, antiemetics
• Discharge same day or next morning

2. Diet Advancement

3. Follow-Up

• Regular review with nutritionist and care team
• Monitor for complications

VII. COMPLICATIONS

VIII. TIPS & TRICKS

• Always use CO₂, not air
• Ensure full-thickness bites with the helix
• Avoid bites too close to the GEJ or pylorus
• Rotate scope/elevator smoothly to control bite angle
• Practice in models or animal labs before clinical use