Endoscopic Sleeve Gastroplasty has become an important topic in the development of minimally invasive obesity treatment, offering an endoscopic approach to gastric remodeling without the external incisions and gastric resection associated with conventional bariatric surgery. At WALS 2025, Dr. Prabu Doss discussed the current status and future prospects of ESG, examining its technical development, clinical applications, metabolic implications, limitations, and potential future directions. The World Laparoscopy Hospital conference material identifies the session as a discussion of today's advances and tomorrow's potential in Endoscopic Sleeve Gastroplasty.

ESG is performed using a flexible endoscope introduced through the mouth, together with an endoscopic suturing system. The stomach is remodeled by placing a series of sutures that reduce its effective volume and create a sleeve-like configuration. Unlike laparoscopic sleeve gastrectomy, ESG does not involve surgical removal of a large portion of the stomach. This incisionless approach is one of the principal reasons ESG has generated interest among clinicians working in therapeutic endoscopy and obesity medicine.

The development of ESG represents an important example of how endoscopy has moved beyond diagnostic procedures toward advanced therapeutic interventions. Modern endoscopic platforms can now be used for tissue approximation, suturing, resection, hemostasis, defect closure, and metabolic procedures. ESG extends this concept into obesity treatment by using endoscopic suturing to produce a deliberate change in gastric anatomy.

Dr. Prabu Doss's WALS 2025 session provides an opportunity to examine the procedure beyond its technical execution. Understanding ESG requires consideration of the entire patient pathway, including evaluation before the procedure, nutritional preparation, anesthesia and procedural planning, gastric remodeling, postoperative dietary progression, lifestyle modification, and long-term follow-up.

Patient selection is therefore a fundamental component of ESG. Candidates require evaluation of obesity severity, associated medical conditions, previous treatment attempts, medication use, eating patterns, psychological factors, and expectations. ESG should be considered within an overall obesity-management program rather than as an isolated procedure.

The role of endoscopic suturing technology is central to ESG. The ability to capture tissue and place full-thickness sutures has allowed endoscopists to create reproducible patterns of gastric remodeling. The WALS 2025 material identifies continuing improvement in suturing systems as one of the important areas shaping the future of ESG.

Technical standardization is another important consideration. As ESG becomes more widely performed, standardized approaches to suture placement, tissue capture, gastric configuration, postoperative care, and outcome assessment can help clinicians compare results between centers. Training and procedural experience are equally important because the quality of gastric remodeling can influence the effectiveness and safety of the intervention.

The potential benefits of ESG extend beyond reduction in stomach volume. Weight loss may be accompanied by improvements in obesity-associated metabolic conditions. Reported areas of interest include type 2 diabetes, hypertension, dyslipidemia, and metabolic fatty liver disease. However, these effects vary between patients and should be evaluated through appropriate clinical follow-up rather than assumed from the procedure alone.

One of the important physiological questions surrounding ESG concerns how gastric remodeling influences appetite and satiety. A smaller functional gastric volume may promote earlier fullness, while changes in gastric emptying and gastrointestinal signaling may also contribute. Research into gut hormones, gastric motility, and other metabolic pathways is continuing.

The current evidence base has reported clinically meaningful weight reduction following ESG. World Laparoscopy Hospital's WALS 2025 material describes total body weight loss of approximately 15–20% at one to two years in reported studies, while emphasizing the importance of lifestyle modification and multidisciplinary follow-up. Individual outcomes can differ and should not be interpreted as a guaranteed result for every patient.

Long-term durability remains an important research question. Some cohorts have demonstrated continued weight reduction several years after ESG, but longer follow-up is still needed to fully characterize durability across different patient groups. Weight regain can occur, particularly when behavioral and lifestyle components of treatment are not maintained.

This is why postoperative management is an essential component of ESG. Patients may require staged dietary progression, nutritional counseling, physical activity planning, behavioral support, and monitoring of weight and metabolic health. Endoscopic gastric remodeling is only one component of a broader treatment strategy.

Dr. Doss's presentation also considers the possibility of combining ESG with pharmacological therapy. The rapid development of anti-obesity medications, including GLP-1 receptor agonists and other agents, has created new opportunities for combination approaches. Research is investigating whether medications and endoscopic interventions can complement one another in selected patients. However, combination treatment should be guided by clinical evidence and individualized medical assessment.

The future of ESG may also involve improvements in the suturing platform itself. Next-generation devices could potentially improve precision, tissue capture, suture placement, procedural efficiency, and consistency of gastric remodeling. Research into adjustable or evolving endoscopic configurations represents another area of technological interest.

Artificial intelligence may eventually contribute to patient selection and follow-up. Algorithms could potentially analyze baseline clinical characteristics and early post-procedure responses to identify patterns associated with treatment response. AI could also support endoscopic imaging and procedural documentation. These applications remain developmental and require rigorous validation before being relied upon for clinical decisions.

Another future direction involves expanding the populations in which ESG may be considered. Research is examining its potential role in patients with different degrees of obesity, individuals who are not appropriate candidates for surgery, and patients experiencing weight regain after previous bariatric operations. These applications remain areas for clinical investigation rather than universally established indications.

The possibility of using ESG as part of a staged treatment pathway is also important. Some patients may begin with lifestyle and pharmacological treatment, while others may undergo endoscopic intervention earlier. In certain circumstances, ESG could potentially serve as a bridge or intermediate therapy. The most appropriate sequence depends on the individual's clinical status and treatment goals.

The comparison with surgical bariatric procedures is another major area of interest. Laparoscopic sleeve gastrectomy and gastric bypass remain established surgical approaches for appropriately selected patients. ESG differs in its mechanism, invasiveness, anatomical alteration, recovery profile, and evidence base. Understanding these differences is important when discussing treatment options with patients.

ESG is also distinct from temporary endoscopic devices such as intragastric balloons. Whereas a balloon occupies space within the stomach, ESG creates a structural alteration through suturing. Each approach has different technical characteristics and indications. Continued comparative research can help clarify the appropriate role of each therapy within modern obesity care.

Safety remains a central consideration. Although ESG avoids external abdominal incisions and gastric resection, it is still an advanced therapeutic procedure. Potential adverse events can include post-procedural pain, nausea, vomiting, bleeding, dehydration, and other gastrointestinal complications. Rare but serious complications can occur, making appropriate patient selection, procedural expertise, and post-procedure monitoring essential.

The training requirements for ESG are therefore significant. Endoscopists must understand therapeutic endoscopy, gastric anatomy, tissue capture, suturing, device handling, and complication management. Structured training and simulation can help develop these skills before independent clinical practice.

For bariatric endoscopists and gastrointestinal specialists, the WALS 2025 lecture also illustrates how multidisciplinary collaboration is becoming increasingly important. Gastroenterologists, bariatric surgeons, nutritionists, obesity physicians, psychologists, anesthesiologists, and other healthcare professionals may contribute to comprehensive patient care.

The economic and accessibility aspects of ESG are also relevant to its future development. Procedure costs, availability of specialized endoscopic equipment, operator training, institutional infrastructure, and insurance coverage can all influence access. As evidence develops and technology becomes more widely available, these factors will continue to shape the adoption of ESG.

Long-term research will be particularly important. Future studies need to examine sustained weight loss, metabolic outcomes, quality of life, adverse events, weight regain, retreatment, combination therapy, and comparisons with medications and surgical procedures. Standardized reporting can help establish a clearer understanding of ESG across different populations and healthcare systems.

Dr. Prabu Doss's WALS 2025 presentation therefore provides a comprehensive educational perspective on both the present and future of Endoscopic Sleeve Gastroplasty. The session demonstrates how advances in therapeutic endoscopy are creating new possibilities for obesity management while also emphasizing that continued clinical research is necessary to define the long-term role of the technique.

For doctors, gastroenterologists, bariatric surgeons, endoscopists, and postgraduate trainees, the presentation offers valuable insight into endoscopic gastric remodeling, advanced suturing techniques, patient selection, metabolic outcomes, postoperative care, and emerging technologies. It is particularly relevant for professionals interested in the intersection of therapeutic endoscopy and metabolic medicine.

The future of ESG is likely to be shaped by several factors simultaneously: improved devices, better procedural standardization, patient-specific selection, combination with medical therapy, artificial intelligence, multidisciplinary follow-up, and stronger long-term evidence. Rather than focusing solely on the technical procedure, modern ESG research is increasingly concerned with the entire patient journey and sustainable metabolic health.

Dr. Prabu Doss's discussion at WALS 2025 captures this evolving landscape and provides an educational framework for understanding where Endoscopic Sleeve Gastroplasty currently stands and what areas may shape its future. As endoscopic therapies continue to expand, ESG remains an important example of how minimally invasive technology can contribute to the multidisciplinary management of obesity.

This lecture is a useful educational resource for anyone following developments in advanced endoscopy, bariatric endoscopy, metabolic medicine, and minimally invasive obesity treatment. It highlights both the opportunities and the unanswered questions surrounding ESG and demonstrates why continued innovation must be accompanied by careful clinical evaluation, appropriate training, and long-term patient follow-up.