Endoscopic sleeve gastroplasty versus intragastric balloon insertion as bridge-to-surgery procedures for patients with BMI ≥50 kg/m 2 or contraindications to primary metabolic bariatric surgery

Background Metabolic bariatric surgery is the most effective obesity treatment, but high body mass index (BMI) and associated medical problems often pose surgical risks. Objectives This study compares the safety, feasibility, and efficacy of endoscopic sleeve gastroplasty (ESG) versus intragastric balloon (IGB) as bridge-to-surgery (BTS) procedures in patients with BMI ≥50 kg/m 2 and/or contraindications to primary metabolic bariatric surgery. Design A retrospective analysis (2017 – 2024) included patients with BMI ≥50 kg/m 2 undergoing ESG or IGB as a BTS procedure in a two-step approach at two German centers. Methods The primary outcome was total body weight loss (TBWL, %) at 6 months. Secondary outcomes included absolute weight loss, BMI reduction, excess body weight loss (EBWL, %), and adverse events between the two BTS procedures. Results Fourteen patients underwent ESG, 15 underwent IGB insertion as an intended BTS procedure. At 6 months, median %TBWL and %EBWL were significantly higher in the ESG group (17.8% (IQR, 14.5 – 22.1) vs. 8.99% (IQR, 4.6 – 14.0), p = 0.018; and 28.0% (IQR, 22.8 – 40.0) vs. 16.7% (IQR, 10.8 – 22.4), p = 0.035, respectively). IGB insertion was performed significantly faster (25 (IQR, 20.0 – 30.0) minutes (min) vs. 76 (IQR, 63.2 – 80.8) min; p < 0.01) but was associated with more mild-to-moderate adverse events (60.0% vs. 0%; p < 0.01). Conclusion In this retrospective cohort, ESG was associated with greater short-term weight loss and fewer mild-to-moderate adverse events than IGB as a BTS procedure for patients with BMI ≥50 kg/m 2 and/or contraindications to primary metabolic bariatric surgery (MBS).