90% of patients and at least 15% total body weight loss was maintained in 61% of patients. Safety Mild to moderate gastrointestinal side effects (such as nausea, cramping, bloating, and abdominal discomfort) are common after ESG (reported in over 70% of patients), but these are predictable, temporary, and can be managed with medications. Most will resolve within one week after ESG. Due to the minimally invasive nature of ESG, serious complications are rare. These include pain or nausea requiring hospitalization (1.08%); upper gastrointestinal tract bleeding (0.56%); peri-gastric leak or infected fluid collection (0.48%); pulmonary embolism (0.06%); perforation (0.06%). Similar rates of serious adverse events were reported in the multicenter, randomized controlled MERIT study. No deaths have been observed in the published ESG literature. Physiologic mechanisms of weight loss from ESG Peripheral appetite signaling/gastric sensorimotor function Mechanisms of weight loss from ESG remains an area of active study. There are at least two mechanisms of peripheral appetite signaling thought to be mediated by ESG: first, increased sense of fullness during a meal leading to meal termination, potentially a result of the intact gastric fundus that serves as a food reservoir and the restriction to gastric expansion (accommodation) during a meal; and second, from delayed emptying of the stomach, which promotes a prolonged sensation of fullness after a meal. Hunger and satiety hormones Unlike the surgical sleeve gastrectomy, the ESG does not appear to affect central appetite signaling through the hunger hormone, ghrelin. This is thought to be because the surgical sleeve removes the fundus, the primary site of ghrelin production, and the relatively thinner-walled fundus is avoided in the ESG for safety concerns. Furthermore, in cases where the fundus was sutured in ESG, this did not benefit weight loss outcomes. Further application of ESG with other weight loss treatments Combination ESG and pharmacologic therapy ESG can safely be combined with weight loss medications to improve weight loss or prevent weight regain after the procedure. The daily injectable medication liraglutide showed greater total body weight loss when combined with ESG compared to ESG alone at 7 months (approximately 25% vs 20% respectively). Similar results are anticipated with other incretin agents, such as semaglutide and tirzepatide, though no studies have directly assessed these combinations. ESG after surgical sleeve gastrectomy (Revisional ESG) Weight regain after surgical sleeve gastrectomy has historically been managed with medications or a more invasive revisional surgery. Recent data suggested that