how much did it cost? how long after your consultation did you have your surgery?

How is it going? How many lbs have you lost so far? Please i am highly considering this procedure.

Cost?

How is your progress thus far with weight loss? Some patients have reported bad side effects such as nausea and vomiting. What has been your experience with this?

Thanks Kim! We aren't located in South Dakota, though we've actually had patients travel from Sioux Falls for their ESG, believe it or not (in addition to 45+ other states). If you're comfortable traveling, my team would be happy to help you with logistics. Otherwise, hang tight until we open a South Dakota branch! --Dr. McGowan

Dumping syndrome is not a complication of ESG, because we do not alter the pylorus (the exit point of the stomach).

ESG is still a relatively new technique, with first studies reported in 2013. Awareness of ESG is now rapidly increasing, and as further studies and outcomes are published, we’ll see this continue to grow. There is an incredible need and demand for alternatives to traditional weight loss surgery. We expect that as high-quality studies continue to show favorable outcomes, insurance may begin covering ESG. This will be the most important factor in increasing availability. Thanks for the question!

@@DrMcGowanMD Thank you Doctor for answer!

Hi Vanessa, it is common for patients to experience increase anxiety around the time of any medical procedure, so that is definitely something that would need to be discussed with the physician.

Feel free to contact my team if you'd like to discuss further! trueyouweightloss.com

@@DrMcGowanMD Thank you for this video. I’ve made the decision to make an appointment to do one of the gastric sleeve procedures, but leaning more towards the ESG. Can one take Wegovy/Mounjaro post surgery to aid in keeping the weight off and from coming back? What about the medication prescribed for binge eating called Vyvanse? Is it safe to take any of the 3 meds post surgery?

@@ChiChi-vl1sx Congrats on making the decision! And yes, combination therapy can absolutely be helpful for weight maintenance, or to boost weight loss if needed.

@@DrMcGowanMD Thank you very much for your quick reply. I’m happy to hear that those meds (Wegovy/Mounjaro) can be combined post op. However, since Vyvanse isn’t a weight loss medication, but has been approved by the FDA for binge eating disorders, can it also be used post op ESG for assisting in the boost of weight loss?

We recommend a clear liquid diet the day before the procedure. After ESG, the protocol is 3 days clear liquids, then 2 weeks full liquids, 1 week pureed food, 1 week soft food, then solid food. This protocol is very similar to a typical bariatric post-op diet. This allows the stomach to heal and for your body to adjust to the smaller capacity. You can see our full procedural and dietary instructions here: newyouweightloss.com/wp-content/uploads/2019/03/ESG-Patient-Instructions2.pdf

The sutures are made of polypropylene (not metal), which is perfectly safe. The end of the suture, which we call an "anchor" IS metal, though. It's primarily stainless steel. There is no long-term risk of this remaining in the body, and it is similar to any surgical staples or clips that remain in the body (such as gallbladder surgery, appendectomy, bowel surgery, etc).

We have 2 year ESG results from several high quality studies. These showed that weight loss was maintained for the full 2 years. Longer term studies are still ongoing. Links below to the 24 month outcomes: www.ncbi.nlm.nih.gov/pubmed/28451929 www.ncbi.nlm.nih.gov/pubmed/28017845 Regarding the plicated stomach tissue -- all of the stomach is still there, but it will heal and "stick" together in the folded position. The blood supply is still completely intact. The end result is a thicker stomach wall. There are no long-term complications or implications of suturing the stomach in this way.

It's an important decision. The benefits of ESG are clearly: 1) significantly lower risk 2) faster recovery with less downtime 3) improved acid reflux. The downsides of ESG are 1) less weight loss compared to VSG (17-21% compared to 25-28%) and 2) less durability. You definitely need to consider the Pros and Cons of each!

We regularly revise surgical sleeves using similar techniques to ESG. It is very common to stretch a vertical sleeve gastrectomy or roux-en-y bypass over time. The good news is that we can restore the original sleeve or pouch with a brief, endoscopic suturing procedure. In the same way, if an ESG were to stretch over time, we could tighten it with additional sutures. We have not had to do this for any of our patients, though it would be an easy option. However, endoscopic revision of surgical (VSG) sleeves and gastric bypass patients is a common procedure that I perform.

Linda, all blood supply and stomach tissue remains intact. Over time, the sutured tissue with harden and become more fibrotic as scar tissue forms. There are no long term risks of this process. Major complications from ESG, though quite rare, occur within the first 1-2 weeks. There are no reported long-term complications.

great question

Some patient report a temporary change in taste, usually the first week or so, likely from the medications we give in the beginning. But that is not a long term issue. And it is essential to sip water in the beginning as the stomach is very tight to start. You can only drink 1-2 ounces at a time the first few days, but this gets easier as the stomach heals. Eventually you should be able to drink water freely. Thanks for the question. -Dr. McGowan

How much have you lost in total now?

Hi! How are you results at this point? Are you having any complications or is everything as expected?

Kim, I specialize in the endoscopic sleeve (ESG), which is different than the surgical sleeve (also known as laparoscopic sleeve or vertical sleeve gastrectomy). The main difference is that ESG is performed from within the stomach, and without external incisions or cutting of the stomach. There are many other minor differences, but that's the biggest. It translates into a faster recovery, lower risk, but with slightly less overall weight loss. Good luck to you.

Cravings are typically greatly diminished for quite some time (though it varies from person to person). But hunger and cravings are also a complex process, and some patients will experience them after any type of bariatric procedure. But overall, yes, they are typically reduced.

Yes! It's a very similar technique. Here's an overview: kzfaq.info/get/bejne/nb9yd6lixNG6ips.html

We do recommend waiting 30 minutes after (and before) meals to drink liquids. It's a good, general principle to follow. Combining liquids and solids can cause discomfort and bloating, particularly in the early post-procedural phase.

If you trust your doctor, then you can trust the process. It's a tough question. In general, it is fairly clear that you are likely to have a better and safer outcome at a high volume center, particularly with ESG. However, I greatly respect the honesty and transparency that your doctor has to tell you he's only done one or two ESGs. That's valuable, and a sign that your doctor is trustworthy. But ultimately, it's about your comfort level with the entire process. You do have to be confident in all aspects.

The gas pressure usually only lasts 1-2 days. We recommend GasX (simethicone) and anti-cramping medication

Hi Lori, weight loss will certainly vary from person to person, based on multiple factors (starting weight, consistency, sleep, stress, medications), so we generally don't recommend comparing one's self directly to others. That being said, in our program, the average weight loss at the 2 month mark after ESG is 10% of body weight. At 3 months, it's 12%, and at 6 months our patients lose an average of 16-17% of body weight. However, some patients will lose more slowly, and some faster. Everyone is different!

Great question. You are correct: with VSG, removal of the greater curve of the stomach leads to a reduction in ghrelin. This is significant, and greatly reduces appetite, but is not permanent. Ghrelin levels begin to rebound in 6-12 months and will return to baseline. With ESG, there appears to be a reduction in ghrelin, at least based on early studies. It is probably not as drastic as with VSG, or as long lasting. But most ESG patients tell us that their appetite is much less the first few months after the procedure. Then it will start to return. The good news is that with smaller portions, you will feel full and ghrelin levels will go down. That's the normal feedback loop. Hope that answer helps!

@@DrMcGowanMD Thank you for the prompt reply, doc! I understand much better now.

Rachel A it depends on the size of the hernia. A small or medium sized hernia (up to 4cm) is generally not a problem. You can reach my team directly at info@newyouweightloss.com if you’d like to discuss this further. Thanks for the question!

Hi Yazmin, that should not be an issue. We ask our patients to take a minimum of 2-3 days of downtime prior to returning to work. Most patients experience fatigue for an additional 2-3 days, then start to feel completely back to normal. Of course, everyone's recovery is a little different so it never hurts to budget more recovery time.

great question!

This is a very valid question. Hope dr can reply and put our concerns to rest.

Correct, currently it is a self-pay procedure. We anticipate that this will change as the results of ongoing randomized, controlled studies are released.

Ulcerative colitis, and Humira, are not considered contraindications to having ESG. So yes, you can. However, I do advise my patients on medications like Humira that the risk of infection may be slightly higher, since Humira alters the immune response to infection. But I've performed ESG procedures for many patients on anti-TNF medications without incident.

Christopher McGowan, MD I really appreciate the quick and thorough response! Would holding the Humira for two weeks in a stable IBD patient be potentially recommended? Like holding a anti-coagulant medication prior to a surgery.

@@themindfulnurse9252 Yes, that's a reasonable plan. Scheduling the procedure around the time you'd be due for Humira, then resuming it 1-2 weeks later would theoretically reduce your risk, while also not greatly affecting your UC. Hope that helps!

It’s sort of reversible. Once full healing occurs, you could only partially reverse it. You can find and cut sutures but the stomach won’t be exactly the way it was before the procedure. So maybe “semi-reversible” is a better description. It is stomach sparing, though, which is in contrast to the surgical sleeve or bypass. And it is convertible-meaning it can be converted to a bypass or vertical sleeve if needed. But I wouldn’t want people to think it can just be easily reversed. It’s not designed for that.

You would need to be able to stop your blood thinners temporarily - usually 3 days before the procedure and for 3-7 days after, so your pulmonary or hematology doctor would need to OK that

Thank you for this very important question! VSG is a high-pressure, tight, fast-emptying stomach. When you swallow food, it travels rapidly out of the stomach and into the small intestine. Food entering the small intestine triggers a feeling of fullness (satiety), at which point you stop eating. With ESG, even though the stomach is made smaller, it functions completely differently. ESG is a slow-emptying, low-pressure system. When you swallow food, it stays within the top of the stomach (the fundus) and slowly empties. We do not remove or suture the fundus during the ESG procedure. When the fundus stretches to accommodate to food, vagal nerve signals are sent to your brain, triggering satiety. This is completely the opposite of VSG. ESG = slow-emptying stomach (food stays in longer). VSG = fast-emptying stomach. Studies have shown that stomach emptying is greatly delayed after ESG, for up to 18 months. This is likely one of the primary weight loss mechanisms of the procedure. Thanks for the question!

​@@DrMcGowanMD Hi, thank you for getting back to me. Another question is it true that this procedure (ESG) works better for people with a lower BMI like 30?

@@pritikapdee6747 Not necessarily. The procedure is now FDA authorized for adults with a BMI of 30-50. The procedure can be performed outside of those bounds, but in my program I do not recommend it for a BMI less than 30 as it is clearly less effective for patients with low BMIs. But for 30 and above, the results are pretty consistent. I would say that the higher the BMI (for instance, over 40), the greater the weight loss overall. That's to be expected, though. I usually tell patients that the average weight loss at BMI 30-35 is 15%; between 35 and 40 it is 15-20%, and above 40 it is 20-25%. That is what my data show.

@@DrMcGowanMD Hi would you advise anyone with a BMI of 28 to do this? If they did weight loss would be around 15% correct?

No, there would be no long term risk to pregnancy after having this procedure.

Hi Melissa, thanks for the question. The price depends on the location/facility performing the procedure but in general the total cost is between $10k-12k USD. This is typically inclusive of all fees, though will vary from program to program.

What is your facility's price specifically?

In general, we would advise waiting a minimum of 6 to 12 months, since you would be losing weight during that time. However, it is certainly safe to become pregnant sooner than that. In fact, we advise our patients that fertility may very well increase as you lose weight, which is important to keep in mind.

Yes! Studies show that the majority of patients will experience improvement in hypertension, diabetes, cholesterol, and sleep apnea.

ESG really is a permanent procedure, if done properly. It would be incredibly difficult to reverse, as the sutures are deeply buried in the wall of the stomach. Finding them, and cutting them, to reverse the sleeve would be nearly impossible once the stomach has healed. Even at the immediate conclusion of the procedure, the sutures are no longer visible. I suppose some view this as theoretically "reversible" because we are not actually removing any part of the stomach like a surgical sleeve gastrectomy. More importantly, there would never be a reason that anyone would want or need to reverse an ESG. And as for the part of the stomach that is stitched together -- it basically just becomes a thicker part of the stomach wall. It stiffens and becomes what we call "fibrotic," which makes it less likely to stretch after eating. Thanks for the question!

@@DrMcGowanMD Thanks for the replies, doctor. Very, very informative. I've just watched a video (link below) of a colleague of yours from Blossom Bariatrics in Las Vegas. In this video he advices against ESG because of the metal permanently left behind in the stomach, and the potential complications that could arise whenever another surgeon, for whatever reason, would have to operate on the stomach again. Do you agree that is an added risk of ESG? Video: kzfaq.info/get/bejne/fcqnqbNz197PqmQ.html In another reply you wrote about the ESG not being reversible and why one would ever want want to. Would it be possible that some patients might want to reverse it if it turns out that they do not lose enough weight, while actually experiencing some or many negative side effects? Especially perhaps the not-super-obese, like people with a BMI of 30-35, that were functioning "relatively well" before the ESG? Many thanks in advance! Stijn

@@Stijnemansstijnemans Thanks for the question. ESG could potentially be reversed, though would be quite complex as the sutures are not visible internally once healing occurs. I think the question you are really asking is whether a patient could be CONVERTED to another surgical procedure if they did not respond to ESG. Yes, they can. This has been done before, and is in the published literature. The physician in the video that you mentioned is correct in stating that there are small metal anchors that are permanently in the stomach after ESG. These could get in the way if a surgeon then attempted to do a surgical sleeve gastrectomy. It could be done, but would need endoscopic assistance. But in reality, if a patient didn't respond well to ESG, they are not likely to do any better with sleeve gastrectomy, since it is very similar. They would benefit most from a gastric bypass. A bypass would not be affected by prior ESG, as we do not alter the very proximal part of the stomach with ESG, which is where the pouch is created during a bypass. I hope that answers your question. Of note, ghrelin levels DO go down after ESG. That's also in the published literature, so that statement is false in the video you cited. It also explains why our patients have little or no appetite for an extended period of time after ESG. And of course I would not discourage someone from having ESG based on the fact that we leave sutures and metal inside. The goal is to succeed with ESG, and most patients do extremely well. I suspect there may be some bias in that video!

@@DrMcGowanMD could the portion of the stomach that is Fibrotic cause any other issues like becoming cancerous

@@MybabiezMama Sarah, there have been no long-term adverse events documented after ESG. Fibrotic tissue should not be more likely to lead to cancer, or other problems.

It can be, technically, but the weight loss tends to be less than the average that we normally quote. For that reason, I don't generally recommend ESG for people with a BMI below 30.

We can never fully predict how much weight you will lose, since there are many factors that contribute. But speaking to our known statistics, the average patient in my program loses 21% of their body weight at 12 months. For you, that would equate to 23kg. Losing that amount of weight should greatly benefit your health and diabetes, as well.

That would be a very rare complication. I've never seen it. We prescribe an acid-reducing medicine (omeprazole) for 1 month after the procedure to facilitate healing and prevent any ulcer formation. We also advise patients to avoid ibuprofen and aspirin before and after the procedure, to reduce the risk of ulcer and bleeding. If both of those recommendations are followed, the risk of an ulcer would be exceedingly low.

United States (Cary, North Carolina)

Yes, frequently! The average weight loss in my program is 23% at 1 year. We routinely have patients lose 25%, 30%, even 35% of their body weight. That being said, the majority of patients will lose between 15-25%. I like to set realistic expectations -- if you follow the protocol, you can expect to lose the "average" amount. If you really embrace the tool and work hard, you can lose more.

The ESG was first demonstrated in 2012, and has rapidly and significantly evolved since then. In our program, we have treated more than 2,500 patients to date and continue to improve and optimize the technique.

@@DrMcGowanMD thank you. I had the sleeve 12 years ago and need a revision. This might be e the option for me.

The risk of major adverse event is approximately 0.5% to 1%, with the most common severe events being bleeding and infection. The risk of a blood clot would be significantly less than this, as the procedure is relatively brief and ambulatory.

Marlenne, here is a link to our current pricing: trueyouweightloss.com/about/pricing/. You can also read about our location and travel resources here: trueyouweightloss.com/about/resources/what-to-expect/

This is an area of uncertainty with ESG. You are correct, ghrelin is produced primarily by the stomach cells in the fundus, which means levels fall sharply after a surgical VSG. The fundus is left intact during ESG. So what happens to Ghrelin levels? We know from very small, early ESG studies that ghrelin levels do decrease after ESG. Clinically, our ESG patients rarely, if ever, have significant hunger. This lasts for quite a long time. The is somewhat surprising considering that we do not touch the fundus. I suspect that ghrelin levels remain low after ESG simply because very small portions lead to fullness. The stretch receptors in the fundus then trigger ghrelin to decrease. As a result, early satiety and minimal hunger. This is one of the surprising benefits of ESG. Though weight loss is a direct result of restriction and calorie reduction, it is much easier to accomplish this long-term due to the low level of hunger. Finally, keep in mind that after a surgical VSG, ghrelin levels typically return to normal within 1 year.

@@DrMcGowanMD all makes sense. Thank you for prompt reply

Yes! The sutures and anchors are fully compatible with MRI. The tiny metal anchors are made of stainless steel and cobalt chromium, if you are curious.

@@DrMcGowanMD Thank you! That's great information.

Yes! I've performed ESG procedures on several patients who have had prior Lap Bands, without any issue or difficulty. Thanks for the question!

Thanks for the response .. you think it’s fine that I’m doing this 6 months after slippage and removal (emphasising on the slippage part of the question )

In general, ESG could be performed for any patient with a body mass index (BMI) above 30, and there is no strict weight limit. The average BMI in our program is 38. However, we frequently perform the ESG procedure in patients with BMIs in the 40s, and occasionally in the 50s. The key is appropriate patient selection and ensuring that this is the absolute best option for each individual.