Target Trial Emulation of 6-Month Weight Change after Endoscopic Sleeve Gastroplasty and Sleeve Gastrectomy: A Retrospective Cohort Study

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) offers a less invasive alternative to sleeve gastrectomy (SG) while preserving gastric anatomy; however, comparative effectiveness data from large real-world cohorts remain limited. Using the 2023 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) follow-up file, we compared short-term weight-loss and clinical outcomes after ESG and SG. STUDY DESIGN: ESG and SG cases were identified from the 2023 MBSAQIP follow-up file. Using target trial emulation methodology, patients underwent 1:8 nearest-neighbor matching on age, sex, race, diabetes, hypertension, cardiovascular comorbidity, and highest preoperative body mass index. The primary outcome was percent weight change (%WC) from highest preoperative weight to 6 months. The primary analysis used inverse probability of censoring weighting regression to account for missing 6-month weights. Secondary outcomes included 30-day adverse events and 6-month comorbidity and laboratory outcomes. RESULTS: The matched cohort included 3,753 patients (ESG, 417; SG, 3,336). At 6 months, SG achieved greater weight loss than ESG (-18.51% ± 7.98 vs -12.33% ± 6.96; p<0.001). In inverse probability of censoring weighting regression, SG remained associated with greater %WC (ESG coefficient +7.40; 95% CI, 6.59-8.21). Absolute adverse-event rates were low in both groups. SG demonstrated more favorable comorbidity outcomes, whereas ESG was associated with higher 30-day and 6-month readmission (3.8% vs 1.6%) and reoperation (1.0% vs 0.3%) rates. CONCLUSIONS: In this target trial emulation of a national bariatric registry, SG was associated with greater 6-month weight loss and more favorable short-term comorbidity outcomes than ESG. Although ESG produced clinically meaningful weight reduction with low absolute adverse-event rates, its higher readmission and reoperation rates should be considered during procedure selection and patient counseling.