For the estimated hundreds of millions of adults living with obesity, the choice between a surgical and an endoscopic stomach-reduction procedure involves a genuine trade-off that clinicians have long debated without robust pooled evidence. A new meta-analysis now quantifies that trade-off with enough precision to meaningfully inform shared clinical decision-making.
Drawing on nine non-randomized comparative studies encompassing 7,468 patients, the analysis found that endoscopic sleeve gastroplasty (ESG) produced substantially less total body weight loss than laparoscopic sleeve gastrectomy (LSG) at every measured time point: roughly 8 percentage points less at six months, 12.5 points less at one year, and 10 points less at two years. The gap in excess weight loss was even more striking—18 percentage points at 12 months. On the safety side, ESG was associated with nearly 37 fewer hours of hospitalization on average, while rates of readmission, bleeding complications, and operative duration were statistically indistinguishable between the two approaches.
This meta-analysis fits into a rapidly evolving landscape of endoluminal bariatric procedures, where the appeal of avoiding permanent anatomical alteration and general-anesthesia risk is significant, particularly for patients who are poor surgical candidates or who prefer reversibility. However, the approximately 12-point annualized weight-loss deficit for ESG is clinically meaningful: that difference can determine whether a patient achieves thresholds associated with remission of type 2 diabetes or resolution of sleep apnea. The exclusive reliance on non-randomized studies—assessed via the ROBINS-I tool—is a notable limitation, as selection bias likely channels lower-BMI or lower-risk patients toward ESG, potentially flattering its safety profile. No randomized controlled trials were available, which means causal interpretation must remain cautious. For now, ESG appears best positioned as a bridge procedure or an option for patients ineligible for or unwilling to undergo surgery, rather than a universal equivalent to LSG.