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

Comparative Safety and Metabolic Efficacy of Endoscopic Versus Laparoscopic Sleeve Procedures: A Propensity-Matched Real-World Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Safety and Metabolic Efficacy of Endoscopic Versus Laparoscopic Sleeve Procedures: A Propensity-Matched Real-World Study Ali Osman, Ahmed Dirweesh, Stuart Amateau This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6928841/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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. Endoscopic sleeve gastroplasty laparoscopic sleeve gastrectomy obesity metabolic outcomes safety propensity matching Figures Figure 1 Figure 2 Key Points ESG showed a 0% complication rate versus 17.2% for LSG in matched real-world cohorts. LSG resulted in greater weight and BMI reduction, while ESG led to better lipid improvements. ESG may be a safer, less invasive alternative for select patients with morbid obesity. Introduction The global burden of obesity is rising rapidly. In 2022, the WHO reported that one in eight people worldwide had obesity. That year, 2.5 billion adults ≥ 18 years were overweight, including 890 million with obesity. In 2024, an estimated 35 million children under five were overweight. ¹ Obesity is linked to increased all-cause mortality, premature death, hypertension, type 2 diabetes, stroke, and cardiovascular disease. It also drives healthcare costs due to more hospitalizations, longer stays, more outpatient visits, and higher medication use. ² Sustained weight loss remains a key goal in obesity care, reducing comorbidity risk and improving survival.³ Management typically follows a stepwise approach: lifestyle changes (diet, exercise, behavioral therapy) first, then pharmacotherapy if needed.⁴ The 2013 AHA/ACC/TOS guidelines recommend medications or bariatric referral for patients with BMI ≥ 27 kg/m² and related comorbidities not responding to lifestyle changes.⁵ A systematic review showed average weight loss of 5–8.5 kg in the first 6 months, plateauing thereafter. Long-term (up to 48 months) losses were 3–6%, highlighting the difficulty of maintaining weight loss. ⁶ Leading diabetes societies recommend considering metabolic surgery for type 2 diabetes patients with BMI 30–34.9 kg/m² when glycemic control remains poor despite optimal therapy. ⁷ Laparoscopic sleeve gastrectomy (LSG), which removes ~ 70–80% of the stomach, is one of the most common bariatric surgeries due to its efficacy and simplicity. However, it carries risks: the 5-year mortality rate is ~ 4.27% per ACS-NSQIP data. ⁸ Other complications include staple line leak, stenosis, bleeding, and GERD. ⁹–¹¹ Endoscopic sleeve gastroplasty (ESG) is a less invasive, transoral procedure using full-thickness sutures to reduce stomach volume and mimic a sleeve (Figure-1). It achieves ~ 18.2% ± 10% total body weight loss at 12 months, with a ~ 2% adverse event rate, mostly mild. ¹² Despite studies on ESG and LSG, many suffer from small samples, short follow-up, or lack of robust methods, especially propensity matching. Thus, real-world comparative data on their safety and metabolic outcomes remain limited. Using the TriNetX global federated network, we conducted a retrospective, propensity-matched comparison of ESG and LSG, assessing safety and metabolic outcomes including BMI, body weight, HbA1c, lipid profile, and blood pressure. Methods We utilized TriNetX, a global federated health research network providing access to de-identified electronic medical records from 147 healthcare organizations (HCOs) at the time of analysis. Two cohorts were identified: patients who underwent endoscopic sleeve gastroplasty (ESG) and those who underwent laparoscopic sleeve gastrectomy (LSG). Before propensity score matching, the ESG cohort included 62 patients, and the LSG cohort 75,169. After matching, each group had 62 patients for comparative analysis. Inclusion criteria were age ≥ 18 years, a diagnosis of overweight or obesity (ICD-10: E66.01), and procedural documentation: ESG by HCPCS C9784, LSG by CPT 43775. The index event was the earliest date both the procedure and diagnosis were recorded. The observation window extended from Day 1 post-index through 365 days. We calculated risk differences (RDs), risk ratios (RRs), odds ratios (ORs), event frequencies, and conducted Kaplan–Meier survival analysis. Patients with pre-index outcomes were excluded from safety and lab analyses. Laboratory data were limited to those without pre-index abnormalities. Safety Analysis A composite endpoint was defined as any of the following within 12 months: Gastrointestinal hemorrhage Acute gastric ulcer with hemorrhage Intestinal perforation Postprocedural infection Protein-calorie malnutrition Vomiting Propensity score matching was based on age, gender, race, ethnicity, and diagnostic history (including gastric ulcer). Post-match balance was confirmed (Table-1). Table 1 Baseline Characteristics: ESG vs LSG (Before and After Propensity Score Matching) Characteristic ESG (Before Matching) LSG (Before Matching) p-value (Before Matching) ESG (After Matching) LSG (After Matching) p-value (After Matching) N 62 75,169 – 62 62 – Age at Index (mean ± SD) 49.4 ± 12.4 43.0 ± 12.3 < 0.001 49.4 ± 12.4 49.4 ± 12.4 1 Female (%) 80.60% 77.00% 0.49 80.60% 80.60% 1 White (%) 67.70% 59.50% 0.184 67.70% 67.70% 1 Black or African American (%) 24.20% 23.10% 0.839 24.20% 24.20% 1 Other Race (%) 16.10% 4.70% < 0.001 16.10% 16.10% 1 Not Hispanic or Latino (%) 91.90% 66.60% < 0.001 91.90% 91.90% 1 Hispanic or Latino (%) 16.10% 14.10% 0.64 16.10% 16.10% 1 Metabolic Efficacy Analysis Metabolic outcomes—including BMI, weight, HbA1c, lipid profile (LDL, HDL, total cholesterol, triglycerides), and blood pressure (SBP, DBP)—were evaluated by comparing baseline values with those from 1 month to 1-year post-procedure. Analyses were conducted within unmatched cohorts. For each parameter, mean change ± SD from baseline to follow-up was calculated. Results Safety Outcomes In the ESG cohort, none of the 56 patients experienced an event from the predefined composite safety outcome (0.0%). In contrast, ≤ 10 of the 58 LSG patients (17.2%) experienced at least one event. The risk difference was − 17.2% (95% CI: − 27.0% to − 7.5%), which was statistically significant (p = 0.001). Ten patients from each cohort were excluded due to events occurring prior to the index date. Although 62 patients were initially included in each matched cohort, the final number of patients contributing to the outcome analysis varied slightly. This discrepancy resulted from TriNetX’s platform excluding patients with missing data or inadequate follow-up for specific variables, leading to analytic sample sizes of 56 for ESG and 58 for LSG. The mean follow-up time post-index was 217.2 ± 132.9 days for ESG and 329.97 ± 92.2 days for LSG. Median follow-up was 240.5 days for ESG and 365 days for LSG. Kaplan–Meier survival analysis revealed a 100% event-free survival probability in the ESG group and 98.2% in the LSG group by Day 365. However, the log-rank test showed no statistically significant difference between the groups (p = 0.360), which may be attributed to the low number and temporally concentrated nature of events, along with potential limitations in event capture and time resolution due to TriNetX’s data privacy constraints. Metabolic Outcomes Metabolic outcomes following ESG and LSG are summarized in Tables 2 and 3 . Both procedures were associated with improvements in body weight, BMI, and cardiometabolic parameters over a follow-up period of one month to one year. As shown in Table 2 , the ESG cohort experienced a reduction in BMI from 40.7 ± 6.4 to 35.6 ± 6.5 kg/m² and in body weight from 250 ± 39 to 213 ± 39 lbs., corresponding to a 12.53% and 14.80% decrease, respectively (Table 3 ). In comparison, LSG produced greater reductions in BMI (46.0 ± 7.1 to 36.2 ± 7.4 kg/m²) and weight (282 ± 55 to 222 ± 53 lbs.), reflecting percentage decreases of 21.30% and 21.28%, respectively. HbA1c levels declined in both groups, with a greater relative reduction observed in the LSG cohort (–7.33%) compared to ESG (–2.57%). Notably, LDL cholesterol and total cholesterol improved more in the ESG group, with LDL decreasing by 12.17% and total cholesterol by 7.10%, compared to modest reductions of 1.89% and 2.22% in the LSG group. Conversely, LSG was associated with a substantial 24.83% reduction in triglycerides, whereas ESG showed a 9.86% increase. HDL cholesterol increased modestly in ESG (+ 1.13%) and more substantially in LSG (+ 8.51%). Blood pressure improvements were observed in both cohorts, with ESG demonstrating a greater decline in diastolic BP (–9.10% vs. − 4.51%) and LSG showing a slightly greater reduction in systolic BP (–6.06% vs. − 5.26%). See figure-2 for visual comparison of mean metabolic parameters before and after ESG and LSG. Table 2 Metabolic outcomes before and after ESG and LSG. Values shown as mean Parameter ESG (Baseline → Follow-up) LSG (Baseline → Follow-up) BMI (kg/m²) 40.7 ± 6.4 → 35.6 ± 6.5 46.0 ± 7.1 → 36.2 ± 7.4 Weight (lbs) 250 ± 39 → 213 ± 39 282 ± 55 → 222 ± 53 HbA1c (%) 5.8 ± 0.8 → 5.7 ± 0.7 6.0 ± 1.2 → 5.6 ± 1.0 Systolic BP (mmHg) 133 ± 18 → 126 ± 15 132 ± 17 → 124 ± 16 Diastolic BP (mmHg) 82 ± 11 → 75 ± 9 80 ± 11 → 76 ± 11 LDL (mg/dL) 106 ± 32 → 93 ± 33 106 ± 33 → 104 ± 34 HDL (mg/dL) 53 ± 14 → 54 ± 14 47 ± 14 → 51 ± 15 Total Cholesterol (mg/dL) 183 ± 35 → 170 ± 39 180 ± 39 → 176 ± 39 Triglycerides (mg/dL) 142 ± 93 → 156 ± 203 145 ± 96 → 109 ± 61 Table 3 Percentage Change in Metabolic Parameters 1 Year Before vs. After ESG and LSG Parameter ESG (% Change) LSG (% Change) BMI -12.53% -21.30% Total Body Weight -14.80% -21.28% Total Cholesterol -7.10% -2.22% LDL -12.17% -1.89% Triglycerides + 9.86% -24.83% HDL + 1.13% + 8.51% HbA1c -2.57% -7.33% Systolic BP -5.26% -6.06% Diastolic BP -9.10% -4.51% Discussion The primary composite safety outcome in this study included gastrointestinal hemorrhage, acute gastric ulcer with hemorrhage, intestinal perforation, postprocedural infection, protein-calorie malnutrition, and vomiting. Following propensity score matching, the incidence of composite adverse events was 0% in the ESG group (0/56) and 17.2% in the LSG group (10/58), yielding a risk difference of − 17.2% (95% CI: − 27.0% to − 7.5%; p = 0.001). These results suggest ESG may offer a more favorable short-term safety profile compared to LSG. It is important to acknowledge that the TriNetX platform rounds event counts below 10 up to 10 to protect patient privacy. While this may overestimate the event rate in the LSG group, the complete absence of adverse events in ESG remains clinically reassuring. This difference in safety outcomes is also consistent with procedural characteristics. LSG involves gastric resection, stapling, and suturing, increasing the risk of bleeding, perforation, malnutrition, and other complications. In contrast, ESG is a minimally invasive endoscopic procedure that reduces gastric volume through full-thickness suturing while preserving stomach anatomy, which likely contributes to its favorable safety profile. Although nausea and vomiting are common post-ESG, their absence in this dataset may reflect underreporting or incomplete coding rather than a true absence. Prior retrospective studies and meta-analyses report that ESG-related adverse events are generally mild and self-limiting. In large comparative studies, serious adverse events after ESG occur in 0.5–2.2% of cases, with gastrointestinal bleeding in fewer than 1%. 13–16 The most reported minor events include abdominal pain, nausea, vomiting, and GERD, typically occurring within five months post-procedure and managed conservatively. A prospective multicenter randomized trial of ESG in class I and II obesity reported only three serious adverse events among 131 patients, with no mortality, no surgical intervention, and no ICU admissions. These included an endoscopically managed abscess, conservatively treated GI bleeding, and a reversible case of malnutrition. 17 These findings reinforce the rarity and manageability of serious complications from ESG. Regarding efficacy, our data from a large, multicenter international database indicate that LSG achieved greater weight reduction than ESG. LSG resulted in a 21.28% reduction in total body weight and 21.3% in BMI, while ESG showed reductions of 14.8% and 12.5%, respectively. These outcomes were assessed over a 1-month to 1-year post-procedure window, with mean follow-up durations of approximately 7 to 11 months. These results align with existing literature showing LSG’s superior short-term weight loss efficacy, while ESG still provides meaningful benefit. Despite this, ESG was associated with greater improvements in LDL (–12.17% vs. − 1.89%) and total cholesterol (–7.10% vs. − 2.22%). In contrast, LSG showed greater reductions in triglycerides (–24.83% vs. +9.86%) and greater HDL increases (+ 8.51% vs. +1.13%). The observed triglyceride increase in ESG may reflect dataset limitations, as TriNetX reports mean lab values across the follow-up period rather than true longitudinal trends. Inconsistent testing or transient factors such as diet or medication changes may skew average values. Other metabolic parameters showed broadly similar trends. A1c declined by 2.57% in ESG and 7.33% in LSG. Diastolic blood pressure dropped by 9.1% with ESG and 4.5% with LSG, while systolic blood pressure decreased by 5.3% with ESG and 6.0% with LSG. While LSG showed greater improvements in some parameters (e.g., weight, A1c, HDL, triglycerides), ESG showed greater improvements in others (e.g., LDL, total cholesterol, DBP). These trends suggest comparable overall metabolic benefit between procedures, though differences should be interpreted cautiously given dataset limitations. These findings are consistent with prior studies showing LSG achieves greater total body weight loss and comparable metabolic improvements, while ESG provides clinically meaningful benefit with a more favorable safety profile.13–16 From a clinical perspective, ESG may be preferable for select patients seeking a less invasive, lower-risk, and potentially lower-cost approach. The absence of gastric resection, reduced complication rates, and meaningful metabolic improvement make ESG an attractive option for patients who prioritize safety or may not be candidates for surgery. This study has several strengths. It uses a large, multicenter federated EHR network, improving generalizability across healthcare settings. It also includes a direct propensity score–matched comparison for safety outcomes between ESG and LSG—a relatively rare approach in the current literature. Finally, it evaluates key metabolic parameters beyond weight, offering a more complete view of the procedures’ effects. However, several limitations must be acknowledged. The retrospective design introduces potential selection bias, incomplete data, and residual confounding despite matching. Event counts below 10 are rounded to 10, which may overestimate rare outcomes such as the 17.2% event rate in LSG. Changes in metabolic outcomes were analyzed within each cohort due to limitations in TriNetX, which does not support within-cohort propensity score matching. Therefore, comparisons between ESG and LSG may be affected by residual confounding, such as lipid lowering medications Moreover, the LSG cohort (n = 75,169) was substantially larger than the ESG cohort (n = 62), introducing further imbalance. The small sample size after matching (n = 62 per group) may limit power to detect differences beyond safety outcomes. Finally, metabolic outcomes were unmatched due to platform restrictions. These limitations highlight the need for prospective studies to validate findings. Future research should include head-to-head cohort studies with structured follow-up to allow precise measurement of outcomes such as lipid profile, blood pressure, and glycemic control. Cost-effectiveness, quality of life, and patient satisfaction outcomes should also be assessed, especially since LSG, while more effective for weight loss, carries greater risk of serious complications, which may impact long-term satisfaction and health outcomes. Declarations Ethics Approval and Consent to Participate This retrospective cohort study was conducted using de-identified data from the TriNetX research network. The use of this data complies with the Health Insurance Portability and Accountability Act (HIPAA) and meets ethical standards for research involving human participants. Institutional Review Board (IRB) approval was not required due to the de-identified nature of the data. Consent for Publication Not applicable. Funding None. Conflict of Interest Statement One of the authors declares no conflict of interest related to this work. Outside the submitted work, this author serves as a consultant for several medical device companies and as an advisor for industry partners. All other authors declare no conflict of interest. Author Contributions All authors contributed to the conception, design, data interpretation, drafting, and critical revision of the manuscript. All authors approved the final version of the manuscript. Data Availability The data that support the findings of this study are available from the TriNetX network, but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available. References World Health Organization. Obesity and overweight. Geneva: WHO; 2023. Accessed June 4, 2025. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight Centers for Disease Control and Prevention. Health Effects of Overweight and Obesity. Atlanta (GA): CDC; 2023. Accessed June 4, 2025. Available from: https://www.cdc.gov/obesity/basics/health-effects.html Pi-Sunyer X. The Look AHEAD Trial: a review and discussion of its outcomes. Curr Nutr Rep. 2014;3(4):387–91. doi: 10.1007/s13668-014-0099-x . PMID: 25729633; PMCID: PMC4339027 Sombra LRS, Anastasopoulou C. Pharmacologic therapy for obesity. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. Updated 2024 Feb 12. Accessed June 4, 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562269/ Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129(25 Suppl 2):S102–38. doi: 10.1161/01.cir.0000437739.71477.ee Franz MJ, VanWormer JJ, Crain AL, et al. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc. 2007;107(10):1755–67. doi: 10.1016/j.jada.2007.07.017 Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations. Diabetes Care. 2016;39(6):861–77. doi: 10.2337/dc16-0236 Guerrier JB, Dietch ZC, Schirmer BD, Hallowell PT. Laparoscopic sleeve gastrectomy is associated with lower 30-day morbidity versus laparoscopic gastric bypass: an analysis of the American College of Surgeons NSQIP. Obes Surg. 2018;28(11):3567–72. doi: 10.1007/s11695-018-3396-4 Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–20. doi: 10.1097/SLA.0b013e31822c9dac Kumar SB, Hamilton BC, Wood SG, et al. Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? A comparison of 30-day complications using the MBSAQIP data registry. Surg Obes Relat Dis. 2018;14(3):264–9. doi: 10.1016/j.soard.2017.12.011 Zellmer JD, Mathiason MA, Kallies KJ, Kothari SN. Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis. Am J Surg. 2014;208(6):903–10. doi: 10.1016/j.amjsurg.2014.08.002 Abu Dayyeh BK, Edmundowicz S, Thompson CC. Clinical practice update: expert review on endoscopic bariatric therapies. Gastroenterology. 2017;152(4):716–29. doi: 10.1053/j.gastro.2017.01.035 Ortiz Silva C, Delgado Mosquera MP, Zuluaga Peña JR, Costa Barney VA. Endoscopic sleeve gastroplasty: a retrospective cohort study of 90 patients in Colombia. Obes Surg. 2025. doi: 10.1007/s11695-025-07945-y Beran A, Matar R, Jaruvongvanich V, et al. Comparative effectiveness and safety between endoscopic sleeve gastroplasty and laparoscopic sleeve gastrectomy: a meta-analysis of 6775 individuals with obesity. Obes Surg. 2022;32(11):3504–12. doi: 10.1007/s11695-022-06254-y Alqahtani AR, Elahmedi M, Aldarwish A, et al. Endoscopic gastroplasty versus laparoscopic sleeve gastrectomy: a noninferiority propensity score-matched comparative study. Gastrointest Endosc. 2022;96(1):44–50. doi: 10.1016/j.gie.2022.02.050 Fayad L, Adam A, Schweitzer M, et al. Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study. Gastrointest Endosc. 2019;89(4):782–8. doi: 10.1016/j.gie.2018.08.030 Abu Dayyeh BK, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet. 2022;400(10350):441–51. doi: 10.1016/S0140-6736(22)01280-6 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6928841","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477649659,"identity":"5ff416b9-f50d-4e1f-b4ba-384a09b38888","order_by":0,"name":"Ali Osman","email":"","orcid":"","institution":"Washington University in St. Louis","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Osman","suffix":""},{"id":477649660,"identity":"086fd583-cefc-4981-9fe5-dec1cc57f25d","order_by":1,"name":"Ahmed Dirweesh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAs0lEQVRIiWNgGAWjYBACe2YQaSDBww/hMxPWYtgMIitsZCQbiNVicABEnkmzgTCI0nKc95nEx7bDPMY3stMeMFRYJzYQ1HKY3UxyJlCL2Y3c7QYMZ9KJ0cLGdpsXomWbBGPbYSK1/AU5bAZIyz9itQC9z2MgAdLSQIQWw2Y29p89FTY8EmfebpNIOJZuTFCLPf8xZoMfBhL2/O1AWz7UWMsS1IIKEkhTPgpGwSgYBaMAFwAAIY88xF3kK9cAAAAASUVORK5CYII=","orcid":"","institution":"University of Minnesota","correspondingAuthor":true,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Dirweesh","suffix":""},{"id":477649661,"identity":"125803a5-98f0-44c2-b335-b5575be937d9","order_by":2,"name":"Stuart Amateau","email":"","orcid":"","institution":"University of Minnesota","correspondingAuthor":false,"prefix":"","firstName":"Stuart","middleName":"","lastName":"Amateau","suffix":""}],"badges":[],"createdAt":"2025-06-19 08:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6928841/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6928841/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85852174,"identity":"cf425b60-9df5-44bb-a6ae-ee8d76000df7","added_by":"auto","created_at":"2025-07-02 10:28:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1415250,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of LSG and ESG. LSG involves stomach resection; ESG reduces volume via endoscopic suturing.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6928841/v1/cf8c665b3425a6f7fd6a269d.png"},{"id":85850428,"identity":"b43be8a0-3fe3-440a-b832-e497f5b32ec5","added_by":"auto","created_at":"2025-07-02 10:12:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92241,"visible":true,"origin":"","legend":"\u003cp\u003eMean metabolic parameters before and after ESG and LSG.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6928841/v1/2561795b915268868b19541c.png"},{"id":93035484,"identity":"5fcff497-cd52-47f9-b09b-8533bcd83cfb","added_by":"auto","created_at":"2025-10-08 11:02:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2087897,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6928841/v1/be93a557-ee2b-429f-9961-723d09a1574e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eComparative Safety and Metabolic Efficacy of Endoscopic Versus Laparoscopic Sleeve Procedures: A Propensity-Matched Real-World Study\u003c/p\u003e","fulltext":[{"header":"Key Points","content":"\u003cp\u003eESG showed a 0% complication rate versus 17.2% for LSG in matched real-world cohorts.\u003c/p\u003e\u003cp\u003eLSG resulted in greater weight and BMI reduction, while ESG led to better lipid improvements.\u003c/p\u003e\u003cp\u003eESG may be a safer, less invasive alternative for select patients with morbid obesity.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe global burden of obesity is rising rapidly. In 2022, the WHO reported that one in eight people worldwide had obesity. That year, 2.5\u0026nbsp;billion adults\u0026thinsp;\u0026ge;\u0026thinsp;18 years were overweight, including 890\u0026nbsp;million with obesity. In 2024, an estimated 35\u0026nbsp;million children under five were overweight. \u0026sup1;\u003c/p\u003e \u003cp\u003eObesity is linked to increased all-cause mortality, premature death, hypertension, type 2 diabetes, stroke, and cardiovascular disease. It also drives healthcare costs due to more hospitalizations, longer stays, more outpatient visits, and higher medication use. \u0026sup2;\u003c/p\u003e \u003cp\u003e Sustained weight loss remains a key goal in obesity care, reducing comorbidity risk and improving survival.\u0026sup3; Management typically follows a stepwise approach: lifestyle changes (diet, exercise, behavioral therapy) first, then pharmacotherapy if needed.⁴ The 2013 AHA/ACC/TOS guidelines recommend medications or bariatric referral for patients with BMI\u0026thinsp;\u0026ge;\u0026thinsp;27 kg/m\u0026sup2; and related comorbidities not responding to lifestyle changes.⁵\u003c/p\u003e \u003cp\u003eA systematic review showed average weight loss of 5\u0026ndash;8.5 kg in the first 6 months, plateauing thereafter. Long-term (up to 48 months) losses were 3\u0026ndash;6%, highlighting the difficulty of maintaining weight loss. ⁶ Leading diabetes societies recommend considering metabolic surgery for type 2 diabetes patients with BMI 30\u0026ndash;34.9 kg/m\u0026sup2; when glycemic control remains poor despite optimal therapy. ⁷\u003c/p\u003e \u003cp\u003eLaparoscopic sleeve gastrectomy (LSG), which removes\u0026thinsp;~\u0026thinsp;70\u0026ndash;80% of the stomach, is one of the most common bariatric surgeries due to its efficacy and simplicity. However, it carries risks: the 5-year mortality rate is ~\u0026thinsp;4.27% per ACS-NSQIP data. ⁸ Other complications include staple line leak, stenosis, bleeding, and GERD. ⁹\u0026ndash;\u0026sup1;\u0026sup1;\u003c/p\u003e \u003cp\u003eEndoscopic sleeve gastroplasty (ESG) is a less invasive, transoral procedure using full-thickness sutures to reduce stomach volume and mimic a sleeve (Figure-1). It achieves\u0026thinsp;~\u0026thinsp;18.2% \u0026plusmn; 10% total body weight loss at 12 months, with a\u0026thinsp;~\u0026thinsp;2% adverse event rate, mostly mild. \u0026sup1;\u0026sup2;\u003c/p\u003e \u003cp\u003eDespite studies on ESG and LSG, many suffer from small samples, short follow-up, or lack of robust methods, especially propensity matching. Thus, real-world comparative data on their safety and metabolic outcomes remain limited. Using the TriNetX global federated network, we conducted a retrospective, propensity-matched comparison of ESG and LSG, assessing safety and metabolic outcomes including BMI, body weight, HbA1c, lipid profile, and blood pressure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe utilized TriNetX, a global federated health research network providing access to de-identified electronic medical records from 147 healthcare organizations (HCOs) at the time of analysis. Two cohorts were identified: patients who underwent endoscopic sleeve gastroplasty (ESG) and those who underwent laparoscopic sleeve gastrectomy (LSG). Before propensity score matching, the ESG cohort included 62 patients, and the LSG cohort 75,169. After matching, each group had 62 patients for comparative analysis.\u003c/p\u003e \u003cp\u003eInclusion criteria were age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, a diagnosis of overweight or obesity (ICD-10: E66.01), and procedural documentation: ESG by HCPCS C9784, LSG by CPT 43775. The index event was the earliest date both the procedure and diagnosis were recorded. The observation window extended from Day 1 post-index through 365 days.\u003c/p\u003e \u003cp\u003eWe calculated risk differences (RDs), risk ratios (RRs), odds ratios (ORs), event frequencies, and conducted Kaplan\u0026ndash;Meier survival analysis. Patients with pre-index outcomes were excluded from safety and lab analyses. Laboratory data were limited to those without pre-index abnormalities.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSafety Analysis\u003c/h2\u003e \u003cp\u003eA composite endpoint was defined as any of the following within 12 months:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eGastrointestinal hemorrhage\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAcute gastric ulcer with hemorrhage\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntestinal perforation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePostprocedural infection\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProtein-calorie malnutrition\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003ePropensity score matching was based on age, gender, race, ethnicity, and diagnostic history (including gastric ulcer). Post-match balance was confirmed (Table-1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics: ESG vs LSG (Before and After Propensity Score Matching)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESG\u003c/p\u003e \u003cp\u003e(Before Matching)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLSG\u003c/p\u003e \u003cp\u003e(Before Matching)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(Before Matching)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eESG\u003c/p\u003e \u003cp\u003e(After Matching)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLSG\u003c/p\u003e \u003cp\u003e(After Matching)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003cp\u003e(After Matching)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75,169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at Index (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Race (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.70%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Hispanic or Latino (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91.90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91.90%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic or Latino (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMetabolic Efficacy Analysis\u003c/h3\u003e\n\u003cp\u003eMetabolic outcomes\u0026mdash;including BMI, weight, HbA1c, lipid profile (LDL, HDL, total cholesterol, triglycerides), and blood pressure (SBP, DBP)\u0026mdash;were evaluated by comparing baseline values with those from 1 month to 1-year post-procedure. Analyses were conducted within unmatched cohorts. For each parameter, mean change\u0026thinsp;\u0026plusmn;\u0026thinsp;SD from baseline to follow-up was calculated.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSafety Outcomes\u003c/h2\u003e \u003cp\u003eIn the ESG cohort, none of the 56 patients experienced an event from the predefined composite safety outcome (0.0%). In contrast, \u0026le;\u0026thinsp;10 of the 58 LSG patients (17.2%) experienced at least one event. The risk difference was \u0026minus;\u0026thinsp;17.2% (95% CI: \u0026minus;\u0026thinsp;27.0% to \u0026minus;\u0026thinsp;7.5%), which was statistically significant (p\u0026thinsp;=\u0026thinsp;0.001). Ten patients from each cohort were excluded due to events occurring prior to the index date. Although 62 patients were initially included in each matched cohort, the final number of patients contributing to the outcome analysis varied slightly. This discrepancy resulted from TriNetX\u0026rsquo;s platform excluding patients with missing data or inadequate follow-up for specific variables, leading to analytic sample sizes of 56 for ESG and 58 for LSG.\u003c/p\u003e \u003cp\u003eThe mean follow-up time post-index was 217.2\u0026thinsp;\u0026plusmn;\u0026thinsp;132.9 days for ESG and 329.97\u0026thinsp;\u0026plusmn;\u0026thinsp;92.2 days for LSG. Median follow-up was 240.5 days for ESG and 365 days for LSG.\u003c/p\u003e \u003cp\u003eKaplan\u0026ndash;Meier survival analysis revealed a 100% event-free survival probability in the ESG group and 98.2% in the LSG group by Day 365. However, the log-rank test showed no statistically significant difference between the groups (p\u0026thinsp;=\u0026thinsp;0.360), which may be attributed to the low number and temporally concentrated nature of events, along with potential limitations in event capture and time resolution due to TriNetX\u0026rsquo;s data privacy constraints.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMetabolic Outcomes\u003c/h3\u003e\n\u003cp\u003eMetabolic outcomes following ESG and LSG are summarized in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Both procedures were associated with improvements in body weight, BMI, and cardiometabolic parameters over a follow-up period of one month to one year. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the ESG cohort experienced a reduction in BMI from 40.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4 to 35.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5 kg/m\u0026sup2; and in body weight from 250\u0026thinsp;\u0026plusmn;\u0026thinsp;39 to 213\u0026thinsp;\u0026plusmn;\u0026thinsp;39 lbs., corresponding to a 12.53% and 14.80% decrease, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In comparison, LSG produced greater reductions in BMI (46.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 to 36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 kg/m\u0026sup2;) and weight (282\u0026thinsp;\u0026plusmn;\u0026thinsp;55 to 222\u0026thinsp;\u0026plusmn;\u0026thinsp;53 lbs.), reflecting percentage decreases of 21.30% and 21.28%, respectively. HbA1c levels declined in both groups, with a greater relative reduction observed in the LSG cohort (\u0026ndash;7.33%) compared to ESG (\u0026ndash;2.57%). Notably, LDL cholesterol and total cholesterol improved more in the ESG group, with LDL decreasing by 12.17% and total cholesterol by 7.10%, compared to modest reductions of 1.89% and 2.22% in the LSG group. Conversely, LSG was associated with a substantial 24.83% reduction in triglycerides, whereas ESG showed a 9.86% increase. HDL cholesterol increased modestly in ESG (+\u0026thinsp;1.13%) and more substantially in LSG (+\u0026thinsp;8.51%). Blood pressure improvements were observed in both cohorts, with ESG demonstrating a greater decline in diastolic BP (\u0026ndash;9.10% vs. \u0026minus;\u0026thinsp;4.51%) and LSG showing a slightly greater reduction in systolic BP (\u0026ndash;6.06% vs. \u0026minus;\u0026thinsp;5.26%). See figure-2 for visual comparison of mean metabolic parameters before and after ESG and LSG.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMetabolic outcomes before and after ESG and LSG. Values shown as mean\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESG (Baseline \u0026rarr; Follow-up)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLSG (Baseline \u0026rarr; Follow-up)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4 \u0026rarr; 35.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e46.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 \u0026rarr; 36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (lbs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e250\u0026thinsp;\u0026plusmn;\u0026thinsp;39 \u0026rarr; 213\u0026thinsp;\u0026plusmn;\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e282\u0026thinsp;\u0026plusmn;\u0026thinsp;55 \u0026rarr; 222\u0026thinsp;\u0026plusmn;\u0026thinsp;53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 \u0026rarr; 5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 \u0026rarr; 5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic BP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e133\u0026thinsp;\u0026plusmn;\u0026thinsp;18 \u0026rarr; 126\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e132\u0026thinsp;\u0026plusmn;\u0026thinsp;17 \u0026rarr; 124\u0026thinsp;\u0026plusmn;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiastolic BP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e82\u0026thinsp;\u0026plusmn;\u0026thinsp;11 \u0026rarr; 75\u0026thinsp;\u0026plusmn;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e80\u0026thinsp;\u0026plusmn;\u0026thinsp;11 \u0026rarr; 76\u0026thinsp;\u0026plusmn;\u0026thinsp;11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDL (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e106\u0026thinsp;\u0026plusmn;\u0026thinsp;32 \u0026rarr; 93\u0026thinsp;\u0026plusmn;\u0026thinsp;33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e106\u0026thinsp;\u0026plusmn;\u0026thinsp;33 \u0026rarr; 104\u0026thinsp;\u0026plusmn;\u0026thinsp;34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDL (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e53\u0026thinsp;\u0026plusmn;\u0026thinsp;14 \u0026rarr; 54\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e47\u0026thinsp;\u0026plusmn;\u0026thinsp;14 \u0026rarr; 51\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Cholesterol (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e183\u0026thinsp;\u0026plusmn;\u0026thinsp;35 \u0026rarr; 170\u0026thinsp;\u0026plusmn;\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e180\u0026thinsp;\u0026plusmn;\u0026thinsp;39 \u0026rarr; 176\u0026thinsp;\u0026plusmn;\u0026thinsp;39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e142\u0026thinsp;\u0026plusmn;\u0026thinsp;93 \u0026rarr; 156\u0026thinsp;\u0026plusmn;\u0026thinsp;203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e145\u0026thinsp;\u0026plusmn;\u0026thinsp;96 \u0026rarr; 109\u0026thinsp;\u0026plusmn;\u0026thinsp;61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePercentage Change in Metabolic Parameters 1 Year Before vs. After ESG and LSG\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESG (% Change)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLSG (% Change)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-12.53%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-21.30%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Body Weight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-14.80%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-21.28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Cholesterol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-7.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-2.22%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-12.17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.89%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriglycerides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e+\u0026thinsp;9.86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-24.83%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHDL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e+\u0026thinsp;1.13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e+\u0026thinsp;8.51%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-2.57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-7.33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic BP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-5.26%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-6.06%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiastolic BP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-9.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-4.51%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary composite safety outcome in this study included gastrointestinal hemorrhage, acute gastric ulcer with hemorrhage, intestinal perforation, postprocedural infection, protein-calorie malnutrition, and vomiting. Following propensity score matching, the incidence of composite adverse events was 0% in the ESG group (0/56) and 17.2% in the LSG group (10/58), yielding a risk difference of \u0026minus;\u0026thinsp;17.2% (95% CI: \u0026minus;\u0026thinsp;27.0% to \u0026minus;\u0026thinsp;7.5%; p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThese results suggest ESG may offer a more favorable short-term safety profile compared to LSG. It is important to acknowledge that the TriNetX platform rounds event counts below 10 up to 10 to protect patient privacy. While this may overestimate the event rate in the LSG group, the complete absence of adverse events in ESG remains clinically reassuring.\u003c/p\u003e \u003cp\u003eThis difference in safety outcomes is also consistent with procedural characteristics. LSG involves gastric resection, stapling, and suturing, increasing the risk of bleeding, perforation, malnutrition, and other complications. In contrast, ESG is a minimally invasive endoscopic procedure that reduces gastric volume through full-thickness suturing while preserving stomach anatomy, which likely contributes to its favorable safety profile.\u003c/p\u003e \u003cp\u003eAlthough nausea and vomiting are common post-ESG, their absence in this dataset may reflect underreporting or incomplete coding rather than a true absence. Prior retrospective studies and meta-analyses report that ESG-related adverse events are generally mild and self-limiting. In large comparative studies, serious adverse events after ESG occur in 0.5\u0026ndash;2.2% of cases, with gastrointestinal bleeding in fewer than 1%.\u003csup\u003e13\u0026ndash;16\u003c/sup\u003e The most reported minor events include abdominal pain, nausea, vomiting, and GERD, typically occurring within five months post-procedure and managed conservatively.\u003c/p\u003e \u003cp\u003eA prospective multicenter randomized trial of ESG in class I and II obesity reported only three serious adverse events among 131 patients, with no mortality, no surgical intervention, and no ICU admissions. These included an endoscopically managed abscess, conservatively treated GI bleeding, and a reversible case of malnutrition.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e These findings reinforce the rarity and manageability of serious complications from ESG.\u003c/p\u003e \u003cp\u003eRegarding efficacy, our data from a large, multicenter international database indicate that LSG achieved greater weight reduction than ESG. LSG resulted in a 21.28% reduction in total body weight and 21.3% in BMI, while ESG showed reductions of 14.8% and 12.5%, respectively. These outcomes were assessed over a 1-month to 1-year post-procedure window, with mean follow-up durations of approximately 7 to 11 months. These results align with existing literature showing LSG\u0026rsquo;s superior short-term weight loss efficacy, while ESG still provides meaningful benefit.\u003c/p\u003e \u003cp\u003eDespite this, ESG was associated with greater improvements in LDL (\u0026ndash;12.17% vs. \u0026minus;\u0026thinsp;1.89%) and total cholesterol (\u0026ndash;7.10% vs. \u0026minus;\u0026thinsp;2.22%). In contrast, LSG showed greater reductions in triglycerides (\u0026ndash;24.83% vs. +9.86%) and greater HDL increases (+\u0026thinsp;8.51% vs. +1.13%). The observed triglyceride increase in ESG may reflect dataset limitations, as TriNetX reports mean lab values across the follow-up period rather than true longitudinal trends. Inconsistent testing or transient factors such as diet or medication changes may skew average values.\u003c/p\u003e \u003cp\u003eOther metabolic parameters showed broadly similar trends. A1c declined by 2.57% in ESG and 7.33% in LSG. Diastolic blood pressure dropped by 9.1% with ESG and 4.5% with LSG, while systolic blood pressure decreased by 5.3% with ESG and 6.0% with LSG. While LSG showed greater improvements in some parameters (e.g., weight, A1c, HDL, triglycerides), ESG showed greater improvements in others (e.g., LDL, total cholesterol, DBP). These trends suggest comparable overall metabolic benefit between procedures, though differences should be interpreted cautiously given dataset limitations.\u003c/p\u003e \u003cp\u003eThese findings are consistent with prior studies showing LSG achieves greater total body weight loss and comparable metabolic improvements, while ESG provides clinically meaningful benefit with a more favorable safety profile.13\u0026ndash;16 From a clinical perspective, ESG may be preferable for select patients seeking a less invasive, lower-risk, and potentially lower-cost approach. The absence of gastric resection, reduced complication rates, and meaningful metabolic improvement make ESG an attractive option for patients who prioritize safety or may not be candidates for surgery.\u003c/p\u003e \u003cp\u003eThis study has several strengths. It uses a large, multicenter federated EHR network, improving generalizability across healthcare settings. It also includes a direct propensity score\u0026ndash;matched comparison for safety outcomes between ESG and LSG\u0026mdash;a relatively rare approach in the current literature. Finally, it evaluates key metabolic parameters beyond weight, offering a more complete view of the procedures\u0026rsquo; effects.\u003c/p\u003e \u003cp\u003eHowever, several limitations must be acknowledged. The retrospective design introduces potential selection bias, incomplete data, and residual confounding despite matching. Event counts below 10 are rounded to 10, which may overestimate rare outcomes such as the 17.2% event rate in LSG. Changes in metabolic outcomes were analyzed within each cohort due to limitations in TriNetX, which does not support within-cohort propensity score matching. Therefore, comparisons between ESG and LSG may be affected by residual confounding, such as lipid lowering medications Moreover, the LSG cohort (n\u0026thinsp;=\u0026thinsp;75,169) was substantially larger than the ESG cohort (n\u0026thinsp;=\u0026thinsp;62), introducing further imbalance. The small sample size after matching (n\u0026thinsp;=\u0026thinsp;62 per group) may limit power to detect differences beyond safety outcomes. Finally, metabolic outcomes were unmatched due to platform restrictions.\u003c/p\u003e \u003cp\u003eThese limitations highlight the need for prospective studies to validate findings. Future research should include head-to-head cohort studies with structured follow-up to allow precise measurement of outcomes such as lipid profile, blood pressure, and glycemic control. Cost-effectiveness, quality of life, and patient satisfaction outcomes should also be assessed, especially since LSG, while more effective for weight loss, carries greater risk of serious complications, which may impact long-term satisfaction and health outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study was conducted using de-identified data from the TriNetX research network. The use of this data complies with the Health Insurance Portability and Accountability Act (HIPAA) and meets ethical standards for research involving human participants. Institutional Review Board (IRB) approval was not required due to the de-identified nature of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the authors declares no conflict of interest related to this work. Outside the submitted work, this author serves as a consultant for several medical device companies and as an advisor for industry partners. All other authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception, design, data interpretation, drafting, and critical revision of the manuscript. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the TriNetX network, but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Obesity and overweight. Geneva: WHO; 2023. Accessed June 4, 2025. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Health Effects of Overweight and Obesity. Atlanta (GA): CDC; 2023. Accessed June 4, 2025. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/obesity/basics/health-effects.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/obesity/basics/health-effects.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePi-Sunyer X. 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Obes Surg. 2022;32(11):3504\u0026ndash;12. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11695-022-06254-y\u003c/span\u003e\u003cspan address=\"10.1007/s11695-022-06254-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlqahtani AR, Elahmedi M, Aldarwish A, et al. Endoscopic gastroplasty versus laparoscopic sleeve gastrectomy: a noninferiority propensity score-matched comparative study. Gastrointest Endosc. 2022;96(1):44\u0026ndash;50. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gie.2022.02.050\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2022.02.050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFayad L, Adam A, Schweitzer M, et al. Endoscopic sleeve gastroplasty versus laparoscopic sleeve gastrectomy: a case-matched study. Gastrointest Endosc. 2019;89(4):782\u0026ndash;8. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gie.2018.08.030\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2018.08.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbu Dayyeh BK, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet. 2022;400(10350):441\u0026ndash;51. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(22)01280-6\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(22)01280-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endoscopic sleeve gastroplasty, laparoscopic sleeve gastrectomy, obesity, metabolic outcomes, safety, propensity matching","lastPublishedDoi":"10.21203/rs.3.rs-6928841/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6928841/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eEndoscopic 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.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eAdults aged\u0026thinsp;\u0026ge;\u0026thinsp;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\u0026ndash;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.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003ePost-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\u0026thinsp;=\u0026thinsp;0.001). Event-free survival did not differ significantly (p\u0026thinsp;=\u0026thinsp;0.36). Both procedures improved BMI, HbA1c, and blood pressure. ESG showed greater reductions in total cholesterol (\u0026minus;\u0026thinsp;7.1% vs. \u0026minus;2.2%) and LDL (\u0026minus;\u0026thinsp;12.2% vs. \u0026minus;1.9%), while LSG led to greater reductions in weight (\u0026minus;\u0026thinsp;21.3% vs. \u0026minus;14.8%) and triglycerides (\u0026minus;\u0026thinsp;24.8% vs. +9.9%).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eIn 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.\u003c/p\u003e","manuscriptTitle":"Comparative Safety and Metabolic Efficacy of Endoscopic Versus Laparoscopic Sleeve Procedures: A Propensity-Matched Real-World Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 10:04:47","doi":"10.21203/rs.3.rs-6928841/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c7f5e72-7a69-41e0-bc43-f2d7ebb2e2bd","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-08T10:53:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-02 10:04:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6928841","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6928841","identity":"rs-6928841","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}