In medicine, endoscopic sleeve gastroplasty (ESG) is a minimally-invasive, non-surgical (incisionless), endoscopic weight loss procedure that is part of the field of endoscopic bariatric therapies. To perform ESG, a physician sutures a patient’s stomach into a narrower, smaller tube-like configuration. The result is a more restricted stomach that forces patients to feel fuller sooner, eating fewer calories, which facilitates weight loss . History Early iterations of endoscopic gastric remodeling for weight loss included the endoluminal vertical gastroplasty, which attempted to mimic the restricted stomach configuration of the vertical sleeve gastrectomy. Around the same time, similar endoscopic remodeling along the stomach’s larger curvature was performed through tissue acquisition with a suction-based device, though this was limited by suture loss. In 2012, this was modified and tissue was acquired with a full-thickness suturing device, which has been the basis of the present ESG procedure. In July 2022, the creation of the ESG using the Apollo Overstitch device was authorized by the United States Food and Drug Administration for the treatment of obesity in patients with a body mass index between 30–50 kg/m2. Description The ESG may be performed with slight variations by different physicians. It most commonly is performed using the Apollo ESG Device (formally OverStitch device). This device fits over a therapeutic, double-channel endoscope. To create a sutured row of stomach tissue, the tissue helix is advanced from the endoscope, put up against stomach tissue, and turned 2-4 rotations to access the gastric muscle layer. The helix is then retracted towards the scope, bringing the full-thickness acquired stomach tissue with it. Using the handle-operated needle driver, a needle attached to the suture wire is passed through the full-thickness tissue to the anchor exchange. This creates a full-thickness plication of stomach tissue. The needle is then passed back from the anchor exchange to the needle driver, and the process is repeated, threading the suture wire through each bite of stomach tissue. When enough full-thickness bites have been taken for a suture row, a cinch is passed through the scope over the suture. Typically, sutures are placed starting at the border of the antrum and gastric body at the incisura, then placed proximally up to the border of the gastric body and fundus. Each row of sutures can be a straight line or one of the variety of suture patterns reported in the literature, such as the “M,” “Z,” and “U” pattern as