Shaping the Future of Restrictive Bariatric Surgery: Clinical, Economic, and Long-Term Perspectives on Endoscopic and Laparoscopic Sleeve

Background: Restrictive bariatric procedures such as Laparoscopic Sleeve Gastrectomy (LSG) and Endoscopic Sleeve Gastroplasty (ESG) are increasingly utilized to address obesity and its comorbidities. LSG is a well-established and widely adopted bariatric procedure, whereas ESG, supported by recent technological advancements, is increasingly being utilized as a treatment option for obesity. Comparative evaluation of their outcomes is essential to guide clinical decision-making. Objective: To systematically review and synthesize evidence from randomized controlled trials (RCTs), meta-analyses, and registry data comparing ESG and LSG in terms of weight loss efficacy, safety, recovery time, economic impact, and impact on obesity-related comorbidities. Methods: A systematic search was conducted across PubMed, Embase, Scopus, and Cochrane Library for studies published between January 2020 and July 2025. Inclusion criteria were RCTs, meta-analyses, and registry-based studies reporting comparative outcomes for ESG and LSG. Data extraction focused on total body weight loss (TBWL), excess weight loss (EWL), complication rates, recovery time, economic implications, and hormonal/metabolic changes. Risk of bias was assessed using Cochrane RoB 2, and certainty of evidence was graded using GRADE methodology. Results: LSG demonstrated superior long-term EWL (60–70%) and TBWL (25–30%) at 2–5 years (1–3). ESG showed moderate efficacy with TBWL of 13–16% and EWL of 35–45% at 12 months, sustained up to 3 years (4,9). ESG had lower serious adverse event rates (<2%) and faster recovery (2–3 days) compared to LSG (5–10% adverse events; 2–6 weeks recovery) (1,3,13). Both procedures improved glycaemic control, hypertension, and NAFLD, with LSG showing greater metabolic remission (2,6,13). Hormonal analyses revealed distinct patterns: LSG reduced ghrelin and increased PYY and adiponectin; ESG preserved ghrelin levels and improved insulin secretory dynamics (9,10,11). Conclusion: ESG offers a safe, outpatient alternative to LSG with moderate efficacy, rapid recovery and potential short-term economic benefits . LSG remains superior in long-term weight loss and metabolic impact. ESG may serve as a complementary option in tiered obesity management. Further head-to-head trials and mechanistic studies are warranted.