Meta regression of endoscopic sleeve gastroplasty versus intragastric balloon investigating influence of duration and baseline body mass index

Endoscopic sleeve gastroplasty (ESG) and intragastric balloon (IGB) are established endoscopic bariatric therapies (EBTs) for obesity, but their comparative efficacy and safety remain uncertain. We conducted a systematic review and meta-analysis of comparative studies evaluating ESG versus IGB. The primary outcome was percentage of total body weight loss (%TBWL), assessed at the longest available follow-up and stratified timepoints (1, 3, 6, and 12 months). To explore temporal trends, we performed a meta-regression using follow-up duration as a continuous moderator. Secondary outcomes included a meta-regression based on baseline BMI differences and a pooled analysis of adverse events. Six comparative studies (n = 5330) were included. ESG was associated with significantly greater %TBWL than IGB (mean difference: 2.541; 95% CI 0.754 to 4.327; p = 0.005), with increasing benefit over time. Meta-regression confirmed a significant positive association between follow-up duration and treatment effect (p = 0.0006). A separate meta-regression revealed greater efficacy of ESG in patients with higher baseline BMI (p = 0.0001). Overall adverse event rates were comparable between the two groups (p = 0.20) ; however, IGB showed observed trends toward higher device intolerance and early removal rates in individual cohorts. Our findings suggest that ESG may offer a therapeutic advantage over IGB regarding weight loss efficacy, a trend that appears more pronounced in cohorts with higher obesity severity and across extended follow-up periods. ESG offers a comparable safety profile to IGB and may represent a more durable endoscopic bariatric option with potential advantages in procedural tolerability. Long-term trials are needed to validate its metabolic and clinical advantages beyond 12 months.