Comparative Efficacy and Safety of Bariatric Surgery and Bariatric Endoscopy for Obesity Management: A Network Meta-Analysis

Background and aims: While bariatric surgery has proven effective for obesity management, its high cost and associated risks have led to increasing interest in alternatives such as bariatric endoscopy. We compared the efficacy and safety of bariatric surgery and bariatric endoscopy for obesity management in adults with and without type 2 diabetes mellitus (T2DM). Methods: A comprehensive database search identified randomized controlled trials comparing bariatric surgery and endoscopy in adults with a BMI of 30–45 kg/m² and at least 52 weeks of follow-up. The primary endpoint was percentage total body weight loss (%TBWL). Secondary endpoints included HbA1c reduction, T2DM remission, and safety. A frequentist network meta-analysis with a random-effects model was conducted. Results: 15 RCTs comprising 1,548 adults were included. We included four bariatric surgeries [Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), greater curvature plication (GCP), and laparoscopic adjustable gastric banding (LAGB)] and three bariatric endoscopies [endoscopic sleeve gastroplasty (ESG), primary obesity surgery endoluminal (POSE) and intragastric balloon (IGB)]. RYGB resulted in the greatest %TBWL (-19.39%), followed by LSG (-12.63%), ESG (7.74%), and POSE (5.62%). RYGB, LSG, and ESG were associated with significant reductions in HbA1c, while ESG and RYGB also achieved significant T2DM remission. Bariatric endoscopy, particularly ESG (OR 4.65; 95% CI: 0.49 to 44.47) and POSE (OR 1.06; 95% CI: 0.48 to 2.34), demonstrated a favorable safety profile, with fewer serious adverse events compared to bariatric surgery (OR 8.40; 95% CI: 1.29 to 54.78). However, overlap in the 95% confidence intervals for both efficacy and safety outcomes limits the certainty of comparative conclusions across interventions. Conclusions: Bariatric endoscopy offers a favorable safety profile and clinically meaningful weight loss, representing a minimally invasive treatment option for obesity management and metabolic improvement.