Comparative Safety and Metabolic Efficacy of Endoscopic Versus Laparoscopic Sleeve Procedures: A Propensity-Matched Real-World Study

Background: Endoscopic Sleeve Gastroplasty (ESG) and Laparoscopic Sleeve Gastrectomy (LSG) are established interventions for morbid obesity. While LSG is more widely performed, ESG has emerged as a minimally invasive alternative. Comparative real-world data on safety and metabolic outcomes remain limited. This study compared ESG and LSG using a propensity-matched cohort from a federated electronic health record network. Methods: Adults aged ≥ 18 years with morbid obesity (ICD-10: E66.01) who underwent ESG (HCPCS: C9784) or LSG (CPT: 43775) were identified from the TriNetX Global Network. A 1:1 propensity score–matched analysis based on demographics and comorbidities was performed. The primary safety outcome was a composite of gastrointestinal bleeding, ulcer with hemorrhage, perforation, infection, malnutrition, and vomiting. Secondary metabolic outcomes included changes in body mass index (BMI), weight, hemoglobin A1c (HbA1c), lipid profile, and blood pressure from baseline to 1-year post-procedure. Analyses included risk differences and Kaplan-Meier survival. Results: Post-matching, 62 patients were included in each group. ESG had a significantly lower incidence of adverse events compared to LSG (0% vs. 17.2%, p = 0.001). Event-free survival did not differ significantly (p = 0.36). Both procedures improved 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 led to greater reductions in weight (− 21.3% vs. −14.8%) and triglycerides (− 24.8% vs. +9.9%). Conclusion: In this real-world analysis, ESG demonstrated superior short-term safety and comparable metabolic benefits to LSG. ESG may be a safer, less invasive option for select patients with morbid obesity.