Endoscopic Versus Surgical Bariatric Interventions for Obesity: A Systematic Review and Network Meta-Analysis

Abstract

Background: Laparoscopic sleeve gastrectomy (LSG) is the gold standard surgical intervention for obesity; however, it is underutilized because of patient reluctance and perioperative risks. Endoscopic sleeve gastroplasty (ESG) is a promising, minimally invasive alternative; however, comprehensive data comparing its efficacy and safety with those of the broader spectrum of bariatric interventions remain fragmented. This study aimed to evaluate the comparative effectiveness and safety of endoscopic and surgical bariatric modalities through a systematic review and network meta-analysis (NMA).

Methods: Major electronic databases (PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus) were searched from January 2010 to April 2026. Studies directly comparing endoscopic bariatric therapies (ESGs, intragastric balloons (IGBs)) with surgical interventions (LSG, laparoscopic greater curve plication (LGCP), and laparoscopic adjustable gastric banding (LAGB)) or lifestyle modifications (high-intensity diet and lifestyle therapy (HIDLT)) were included. The primary outcomes were the percentage total body weight loss (%TBWL) at 12 months and the incidence of serious adverse events (SAEs). Frequentist random-effects pairwise and NMAs were performed. The certainty of evidence was appraised using the GRADE framework.

Results: Seventeen studies (including matched cohorts and large national registries) met the inclusion criteria. In direct pairwise analysis, LSG achieved significantly greater 12-month %TBWL than ESG (mean differences (MD): –10.53%; 95% confidence interval (CI), –14.10 to –6.97, P < 0.0001). There was no statistically significant difference in SAEs between the ESG and LSG (risk ratio, 1.30; 95% CI, 0.97–1.73; P = 0.076). In the NMA, with LSG as the reference, all interventions yielded inferior weight loss: LGCP (MD: –2.18%), ESG (–11.33%), LAGB (–15.81%), HIDLT (–17.63%), and IGB (–19.00%). The treatment hierarchy rankings (P-scores) identified LSG as the most effective intervention (0.988), followed by LGCP (0.812) and ESG (0.600). The IGB ranked the lowest (0.089). Local node splitting revealed no significant inconsistencies between direct and indirect evidence.

Conclusions: LSG maintains definitive superiority in 12-month weight-loss efficacy. However, ESG has demonstrated robust clinical effectiveness, significantly outperforming legacy endoscopic devices (IGBs), and lifestyle interventions. Although data cannot confirm that ESG is as safe as LSG, it remains an anatomy-preserving option with a lower risk of reflux, making it an excellent alternative for patients averse to or ineligible for conventional bariatric surgery.