Comparative Safety of Endoscopic Sleeve Gastroplasty Versus Laparoscopic Sleeve Gastrectomy: A Meta-Analysis of over 1.1 Million Patients

Background: Endoscopic Sleeve Gastroplasty (ESG) has emerged as a less invasive bariatric option compared to Laparoscopic Sleeve Gastrectomy (LSG). However, direct comparisons of their safety profiles remain limited. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA and MOOSE guidelines. Comparative studies evaluating short-term (≤ 30 days) safety outcomes of ESG versus LSG in adults with obesity were included. Primary outcomes were major and overall adverse events. Secondary outcomes included procedure-related complications, readmission, mortality, and organ-specific adverse events. Results: Eleven observational studies encompassing 1,117,309 patients (ESG: 11,890; LSG: 1,105,419) were included. Major adverse events showed no significant difference between ESG and LSG (RR = 1.11; 95% CI: 0.94–1.31; p = 0.22). ESG was associated with significantly lower risk of gastric leak (RR = 0.06; 95% CI: 0.01–0.47; p = 0.007), GERD (RR = 0.10; 95% CI: 0.02–0.53; p = 0.006), and hospital stay (MD = − 0.90 days; 95% CI: −0.93 to − 0.87; p < 0.00001). However, ESG had a higher risk of sepsis (RR = 2.49; 95% CI: 1.21–5.13; p = 0.01) and readmission (RR = 1.37; 95% CI: 1.22–1.53; p < 0.00001). Mortality did not differ significantly. Conclusion: ESG demonstrates a comparable short-term safety profile to LSG, with advantages in reduced gastric leak, GERD, and length of hospital stay. ESG may serve as a viable, less invasive alternative to LSG in appropriately selected patients. Further randomized studies are warranted to assess long-term outcomes.