Mapping the continuum of procedural bariatric care: real-world weight loss after endoscopic and surgical...

Obesity is a chronic, relapsing disease for which lifestyle and pharmacologic therapies, including glucagon-like peptide-1 receptor agonists, can achieve meaningful weight loss but are often limited by tolerability, access, and weight recurrence after discontinuation. Consequently, metabolic and bariatric interventions play a central role in the management of moderate to severe obesity. However, real-world comparative data spanning endoscopic and multiple surgical modalities remain limited.

We performed a retrospective cohort study of consecutive adults undergoing endoscopic sleeve gastroplasty (ESG), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion with duodenal switch (BPD-DS) at a single tertiary academic center. Patients with concurrent anti-obesity pharmacotherapy were excluded. The primary outcome was percent total body weight loss (TBWL%) at 12 months (± 2 months). Secondary outcomes included categorical TBWL thresholds (> 10%, > 15%, > 20%, > 25%, > 30%) and percent excess weight loss (EWL%). Multivariable linear regression was used to identify independent predictors of TBWL.

Among 2,825 patients (79.3% female; mean age 47.5 ± 11.9 years; mean baseline BMI 45.6 ± 7.9 kg/m²), 183 underwent ESG, 699 SG, 1,813 RYGB, and 130 BPD-DS. Mean 12-month TBWL differed significantly by procedure (p < 0.001): ESG 14.1 ± 9.3%, SG 23.6 ± 9.4%, RYGB 31.0 ± 8.3%, and BPD-DS 36.8 ± 8.7%. The likelihood of achieving higher categorical TBWL increased with procedural intensity, whereas EWL values demonstrated less pronounced separation, particularly between RYGB and BPD-DS. In adjusted analyses, procedure type was the strongest independent predictor of TBWL (p < 0.001), with younger age, female sex, absence of diabetes, and lower baseline BMI also associated with greater weight loss.

Endoscopic and surgical bariatric interventions are associated with distinct yet overlapping weight loss profiles at one year, reflecting differences in mechanism, invasiveness, and patient selection. While absolute TBWL varies across modalities, convergence in EWL highlights the influence of baseline adiposity and the importance of metric selection. These findings provide practical benchmarks to support individualized, patient-centered decision-making across the full continuum of metabolic therapies.