Is endoscopic sleeve gastroplasty as safe as laparoscopic sleeve gastrectomy? A propensity-matched analysis.

Introduction: Endoscopic sleeve gastroplasty (ESG) reduces gastric volume via endoscopic suturing, offering a less invasive alternative to laparoscopic sleeve gastrectomy (LSG). However, their comparative safety remains inadequately explored. This study evaluates 30-day postoperative outcomes between ESG and LSG using a national database.

Methods: A retrospective analysis of the MBSAQIP database (2020-2023) was conducted comparing primary ESG and LSG procedures. Propensity score matching (1:4) was performed for 16 baseline variables, including demographics, BMI, ASA class, and comorbidities. Major complications were defined as significant postoperative adverse events, including reoperation, reintervention, unplanned ICU admission, intubation, or severe organ dysfunction. Outcomes were analyzed using t-test/rank-sum and Chi-square/Fisher's exact tests. Risk factors for major complications in ESG patients were identified using LASSO regression and multivariate logistic regression.

Results: Among 207,984 patients, 1% underwent ESG and 99% LSG. ESG patients were older (45.0 vs. 41.8 years, p < 0.001), predominantly female (86% vs. 81%, p < 0.001), and had lower BMI (39.9 vs. 45.0 kg/m², p < 0.001). After matching (ESG: 2171; LSG: 7997), ESG was associated with longer operative times (81.3 vs. 56.1 min, p < 0.001), shorter hospital stays (0.2 vs. 1.2 days, p < 0.001), and higher 30-day readmission (3.0% vs. 1.7%, p = 0.001) and intervention rates (0.7% vs. 0.26%, p = 0.003). ESG had a significantly higher rate of major complications compared to LSG (2.1% vs. 1.4%, p = 0.019). Among five variables identified by LASSO (age, cardiovascular disease, COPD, sleep apnea, and therapeutic anticoagulation), only age (OR: 1.03; 95% CI: 1.00-1.06; p = 0.022) and cardiovascular disease (OR: 6.95; 95% CI: 2.47-19.61; p < 0.001) were associated with an increased risk of major complications in ESG patients.

Conclusion: While both procedures showed low overall 30-day adverse event rates, ESG was associated with a higher rate of major complications, readmissions, and interventions. Careful patient selection for ESG is warranted, particularly for older patients and those with cardiovascular disease.