S807 Minimally Invasive Solutions for Obesity: A Real-World Comparison of Endoscopic and Laparoscopic Sleeve Procedures

Introduction: Endoscopic sleeve gastroplasty (ESG) and laparoscopic sleeve gastrectomy (LSG) are both established interventions for the treatment of morbid obesity. While LSG remains more commonly performed, ESG has gained attention as a minimally invasive alternative. However, comparative real-world data on their safety and metabolic outcomes are limited. We aimed to compare the safety and metabolic efficacy of ESG and LSG using a propensity score–matched real-world cohort derived from a federated electronic health record database. Methods: Adults (≥18 years) with morbid obesity (ICD-10: E66.01) who underwent ESG (HCPCS: C9784) or LSG (CPT: 43775) were identified from the TriNetX Global Collaborative Network. A 1:1 propensity score–matched analysis was conducted based on age, sex, race, and comorbidities. The primary safety endpoint was a composite of gastrointestinal bleeding, gastric ulcer with hemorrhage, perforation, postoperative infection, severe malnutrition, and vomiting. Metabolic efficacy outcomes included 1-year changes in body mass index, weight, HbA1c, lipids, and blood pressure. Statistical analyses included risk differences, Kaplan-Meier survival analysis, and comparisons of mean changes in laboratory and vital sign parameters. Results: After matching, 62 patients were included in each group. ESG was associated with a significantly lower incidence of the composite safety outcome compared to LSG (0% vs < 17.2%, P = 0.001). However, due to TriNetX’s data obfuscation policy, the exact number of events in the LSG group is not disclosed when fewer than 10 events are present; thus, the reported 17.2% represents an upper-bound estimate. Event-free survival did not differ significantly between groups (P = 0.36). Both ESG and LSG led to meaningful improvements in BMI, HbA1c, and blood pressure. ESG showed greater reductions in total cholesterol (−7.1% vs −2.2%) and LDL (−12.2% vs −1.9%), while LSG resulted in more pronounced reductions in total body weight (−21.3% vs −14.8%) and triglycerides (−24.8% vs +9.9%). Conclusion: In this matched real-world cohort, ESG demonstrated superior short-term safety and comparable metabolic improvements to LSG, with distinct effects on lipid profiles. ESG may represent a safer, less invasive alternative to LSG for appropriately selected patients with morbid obesity.