02 Oct Dr. Marvin Outlines the Advantages of ESG compared to LSG
Advantages of Endoscopic Sleeve Gastroplasty (ESG) compared to Laparoscopic Sleeve Gastrectomy (LSG)
ESG is not Surgery
Endoscopic Sleeve Gastroplasty is performed using an endoscope. An endoscope is a long, flexible device which is passed through the mouth, down the esophagus and into the stomach. Endoscopes have been used for decades to perform both diagnostic and therapeutic procedures. With ESG a suturing device is mounted on the end of the endoscope. The surgeon sutures the inside of the stomach drawing the lateral edge of the stomach together. A channel is left along the medial side of the stomach for the passage of food, much the same as the channel with the laparoscopic sleeve procedure. Since the shape of the stomach is changed the procedure is called a “gastroplasty”, which means to alter the shape of the stomach.
The LSG is a laparoscopic procedure where the surgeon makes several incisions in the abdominal wall, through which the laparoscope and narrow surgical instruments are passed. Usually the stomach is made more narrow by dividing it with a surgical stapling device. A majority of the stomach is removed. Thus, the operation is termed a “gastrectomy” because part of the stomach is removed.
ESG Requires No Incisions – No scars
ESG is performed using an endoscope. No abdominal wall incisions are required.
No Stomach Removed with ESG
During a LSG operation the surgeon divides the stomach with a surgical stapler. The lateral portion is removed. The remaining medial portion is a narrow tube or “sleeve” of stomach. Typically 60-80% of the stomach is removed.
During an ESG the surgeon sutures the inside of the stomach drawing it together to create a similar tubular pathway or sleeve. No stomach is removed.
ESG has you Home the Same Day
ESG is performed with the patient under general anesthesia, including tracheal intubation. However, the period of anesthesia is short and recovery occurs within a few hours. Patients are monitored for 3-4 hours at the facility, and are encouraged to start taking liquids and walking during that period. Most patients will go home the same day.
LSG patients are typically kept in the hospital overnight to manage pain and monitor vital signs for bleeding (although there are some centers that do send LSG patients home the same day). Because the risk of bleeding appears to be less with ESG, and the typical patient has less pain, ESG is more suited to release patients home the day of the procedure.
ESG Involves Less Pain
Patients do not feel pain sensation from the gastrointestinal tract (including the stomach) the same way that they do from the skin or muscular layer of the abdominal wall. The pain from ESG tends to be a dull ache in the upper abdomen, sometimes also under the left ribs. There is a wide spectrum of the intensity of this pain with ESG patients. Some have pain close to that of surgery patients, while others complain of little to no significant post-procedure pain. Of course, ESG patients experience no abdominal wall or skin level pain because there are no incisions. On average, patients who undergo ESG have a lower intensity of pain which resolves faster than patients who undergo LSG.
Earlier Return to Normal Activity/Work with ESG
Because for the average ESG patient there is less post-procedure pain, and because the pain resolves sooner, most ESG patients can return to normal daily activity sooner. This includes work related activity. Also, because there are no abdominal wall incisions, there is no risk of disruption of the incisions with development of hernias. Thus, ESG patients can resume strenuous activity, including lifting heavy objects and athletic/workout activity, sooner than LSG patients (who typically must wait 3 weeks after their procedure).
Less Risk with ESG
An outcome study of approximately 250 ESG patients from 3 centers showed a lower major complication rate than the average complication rate for LSG. Bleeding from placing sutures can be directly observed during the procedure, and are amenable to placing additional sutures. As a result, significant bleeding requiring transfusion or operation is very rare. Similarly, two cases of peri-gastric inflammation were reported in the study. These patients must be considered to have had a micro leak along a suture. Both were treated with antibiotics and neither of them required surgery to manage the leak. Conversely, gastric leak after LSG can be a life-threatening complication, which usually requires re-operation with a lengthy hospitalization.
ESG may be Reversible, LSG is not
LSG is performed by removing part of the stomach, and, therefore, is not reversible (LSG can be converted to other weight-loss procedures under certain circumstances). The reversibility of ESG is largely unknown. Theoretically, sutures could be cut out to release the stomach back towards a more normal shape, although the difficulty of doing this is uncertain. There have been reports of several ESG patients who have been converted to LSG later. Other revision surgeries should be possible after ESG.
The overall cost or total cost of ESG is significantly less than LSG. ESG requires fewer personnel, less reusable and disposable equipment, and does not require an overnight stay. There are likely other indirect cost savings. Although pricing depends on a number of factors it appears that ESG generally costs $2k to $4k less than LSG at the same centers.
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