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

Restrictive bariatric procedures such as Laparoscopic Sleeve Gastrectomy (LSG) and Endoscopic Sleeve Gastroplasty (ESG) are increasingly utilised 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 utilised as a treatment option for obesity. Comparative evaluation of their outcomes is essential to guide clinical decision-making.

To systematically review and synthesise evidence from randomised 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.

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 the Cochrane RoB 2 and ROBINS-I tools.Certainty of evidence was graded using the GRADE methodology.

From 340 records, 24 studies were included (ESG n ≈ 3,800; LSG n ≈ 7,200); 18 contributed to pooled analyses.LSG demonstrated superior long-term EWL (60–70%) and TBWL (25–30%) at 2–5 years Beran et al. (Obes Surg. 32(9):3504–3512 2022); Joseph et al. (SurgEndosc. 38(9):5914–5921 2024); Marincola et al. (EndoscInt Open. 9(1):E87–E95 2021). ESG showed moderate efficacy with TBWL of 13–16% and EWL of 35–45% at 12 months, sustained up to 3 years Fehervari et al. (Obes Surg. 33(12):4567–4579, 2023); NICE (2024). 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) Beran et al. (Obes Surg. 32(9):3504–3512,2022); Marincola et al. (EndoscInt Open. 9(1):E87–E95, 2021); Salminen et al. (JAMA Surg. 157(8):656–666, 2022). Both procedures improved glycaemic control, hypertension, and NAFLD, with LSG showing greater metabolic remission Joseph et al. (SurgEndosc. 38(9):5914–5921, 2024); Salminen et al. (JAMA Surg. 157(8):656–666, 2022); Mocanu D, et al. (SurgEndosc. 2025). Hormonal analyses revealed distinct patterns: LSG reduced ghrelin and increased PYY and adiponectin; ESG preserved ghrelin levels and improved insulin secretory dynamics NICE (2024); Alhayo & Devadas (J Surg Case Rep.(12):rjz315,2019); López-Nava et al. (Obes Surg. 30(7):2640–2648, 2020).

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.