Endoscopic Sleeve Gastroplasty: a Proposal for a Minimal Invasive Endoscopic Approach to Adolescent Obesity

Adolescent obesity is a growing global health concern, often refractory to conventional interventions. While bariatric surgery remains the most effective treatment, its invasiveness and long-term implications limit its use in pediatric patients. Endoscopic sleeve gastroplasty (ESG) has recently emerged as a minimally invasive alternative. This narrative review aims to provide a comprehensive overview of ESG in adolescents, addressing efficacy, safety, mechanisms of action, comparisons with other therapies, and current guideline recommendations. We conducted a narrative review of studies on ESG in individuals under 21 years of age. Literature searches were performed using PubMed, Scopus, EMBASE, and Web of Science for English-language articles published up to April 2025. Studies were included if they reported on ESG outcomes, safety, mechanisms, indications, or expert consensus. Available pediatric data, primarily from a single-center cohort of 109 adolescents, show a total body weight loss (TBWL) of 14.4% at 6 months, 16.2% at 12 months, and 13.7% at 24 months. ESG demonstrated a favorable safety profile, with minor adverse events (abdominal pain, nausea) in 2-3% and no severe complications or growth impairment. Mechanistically, ESG induces weight loss via gastric restriction and delayed gastric emptying, without altering nutrient absorption or appetite-regulating hormones. Comparisons with other modalities show ESG outperforms lifestyle therapy and pharmacotherapy in TBWL, with fewer complications than laparoscopic sleeve gastrectomy. ESG is cost-effective in class II obesity and may be reversible or combined with medical therapies. Despite promising results, ESG remains supported by Level IV evidence and is recognized in only a few pediatric guidelines. ESG offers a safe, anatomy-preserving, and moderately effective treatment option for adolescents with moderate-to-severe obesity. It may serve as a valuable bridge between conservative therapy and surgery. However, long-term data and randomized controlled trials are needed to define its role within standardized pediatric obesity care pathways.