Endoscopic Sleeve Gastroplasty Versus Laparoscopic Sleeve Gastrectomy: A Retrospective Cohort Study of 12-Month Outcomes

Background and Objectives: The primary objective was to compare 12-month percentage total body weight loss (%TBWL) after endoscopic sleeve gastroplasty (ESG) and laparoscopic sleeve gastrectomy (LSG); secondary objectives were to compare metabolic, safety, and reflux outcomes, and an exploratory objective was to describe early predictors of suboptimal response. Materials and Methods: This retrospective single-center cohort included 28 ESG and 31 LSG patients treated between January 2019 and December 2022. The primary outcome was %TBWL at 12 months. Because the groups overlapped only within a limited body mass index (BMI) range, the adjusted comparison was repeated in patients with a BMI of 35–44.9 kg/m2, in whom both procedures were performed. Results: Baseline BMI was lower in the ESG group (36.8 versus 44.2 kg/m2), and class III obesity was present in 14.3% of ESG and 77.4% of LSG patients. Twelve-month %TBWL was 17.1% after ESG and 30.6% after LSG. The multiple-imputation adjusted difference favored LSG by 14.9 percentage points (95% confidence interval [CI] 11.0–18.8; p < 0.001) and 13.9 points (95% CI 9.2–18.6) in the BMI-overlap subset. Inverse probability weighting retained only 25 patients with residual imbalance and is reported solely as a supplementary sensitivity analysis. In secondary analyses, LSG was associated with larger reductions in glycated hemoglobin and alanine aminotransferase. Median hospital stay was shorter after ESG (1.2 versus 2.9 days). New-onset or worsened reflux occurred in 14.3% and 32.3%, respectively (log-rank p = 0.140; unadjusted hazard ratio 2.33, 95% CI 0.73–7.45; exploratory covariate-adjusted and Firth-penalized estimates were imprecise). Serious adverse events occurred in 3.6% and 6.5%. In an exploratory, internally validated model, 3-month weight loss was associated with suboptimal 12-month response (optimism-corrected area under the curve 0.878). Conclusions: LSG was associated with greater weight loss and selected metabolic improvements, whereas ESG was associated with shorter hospitalization. Because the groups differed substantially at baseline, overlapped only within a narrow BMI range, and were small, the ESG–LSG comparison is exploratory: these associations apply to that overlap zone, should not be interpreted as comparative-effectiveness estimates, and provide limited evidence for clinical procedure selection. Reflux comparisons and the prediction model are exploratory and require confirmation in larger cohorts.