Surgery for Sustained Weight Loss

There have been numerous fad-type treatments promising easy, quick, low-risk, non-surgical treatment over the years, offered for the treatment of obesity. HCG injection, Phen-fen, Lap band, Orlistat (Xenical), Gastric balloon, GLP-1, and now endoscopic gastroplasty. The one thing they all have in common is the reported short-term outcome comparable to the long-term outcome of the surgery. Surgery has the longest history for sustained weight loss with data going back decades showing long term comorbidity resolution.

GLP-1, GIP class of medication reports the outcome 1-2-3 years compared to the 15-30 years outcome of the weight loss surgical procedures. These articles also fail to emphasize the high cost and comprehensive long-term risk with injections or pills taken daily or weekly.

Now to the latest fad: The results of the endoscopic gastroplasty are reported to be in the form of a 3-5-year interval. What these alternative low-risk treatments also have in common is the emphasis placed on short-term resolution of comorbidities and weight loss. The 5-year weight-loss rate is a dismal 11.8% (Total Body Weight Loss, %TBWL) (Lahooti et al., 2025). A 300-lb. person with gastroplasty will be down 34 lbs. in 5 years – compared to 100 lbs. following sleeve gastrectomy. Not surprisingly, the Endoscopic gastroplasty was found to have a 2.6% rate of serious adverse events (SEA) (Singh et al., 2019). Yet, the patients are under the impression that since gastroplasty is not a surgical procedure and no incisions are made, there are no serious risks.

One of the original first studies (Abu Dayyeh et al., 2022) also presented a set of data that one has to read the detailed findings to appreciate how poor the performance of the procedure is:

“Findings: Between Dec 20, 2017, and June 14, 2019, 209 participants were randomly assigned to ESG (n=85) or to control (n=124). At 52 weeks, the primary endpoint of mean percentage of EWL was 49·2% (SD 32·0) for the ESG group and 3·2% (18·6) for the control group (p<0·0001). Mean percentage of total bodyweight loss was 13·6% (8·0) for the ESG group and 0·8% (5·0) for the control group (p<0·0001), and 59 (77%) of 77 participants in the ESG group reached 25% or more of EWL at 52 weeks compared with 13 (12%) of 110 in the control group (p<0·0001). At 52 weeks, 41 (80%) of 51 participants in the ESG group had an improvement in one or more metabolic comorbidities, whereas six (12%) worsened, compared with the control group, in which 28 (45%) of 62 participants had similar improvement, whereas 31 (50%) worsened. At 104 weeks, 41 (68%) of 60 participants in the ESG group maintained 25% or more of EWL. ESG-related serious adverse events occurred in three (2%) of 131 participants, without mortality or need for intensive care or surgery.”

1-This study is about 85 patients having the endoscopic gastroplasty and 124 patient only being on diet (they compared the endoscopic gastroplasty (ESG) to diet and exercise, not sleeve gastrectomy)

2-at one year, the ESG group had lost 49.2% of the EWL (if needed to lose 100 lbs, only lost 49.2lbs)

These are examples of how patients need to educate and inform themselves beyond the headlines and ask the tough questions.

GLP-1/GIP class of medication has been promoted for everything under the sun (a little exaggeration here to make the point). Even though it may be true that many comorbidities resolve with any form of weight loss, we also know from weight-loss surgical data that many of these comorbidities return with weight gain. Which is why, in my opinion, it is deceptive to talk about the resolution of comorbidities with very little weight loss from alternative procedures such as lap band, gastric balloon, or endoscopic gastroplasty, when we know the comorbidities are resolved only when the weight loss is maintained long term.

Weight loss is maintained by Lap band adjustment (with the associated cost- and hopefully not having complications such as slipped band or continuous nausea and vomiting) or by replacing the gastric balloon every 6 months (how does that make sense), or by having the daily or weekly injection or pills of GLP-1, GIP class of medications with the risk of side-effects and the costs associated with these medications. All of this in the backdrop of near-certain weight gain when the lap band must be removed, or the gastric balloon is not reinserted, or the GLP-1 GIP medication is stopped (primarily because of the complication)

Weight-loss surgical procedures, such as Duodenal Switch, gastric sleeve, and Gastric bypass, are not risk-free. However, they have continually been shown to deliver sustained weight loss over decades.

As a surgeon with decades of experience with operating on patients with failed lap bands, endoscopic gastroplasties, GLP-1-GIP medications, and gastric balloons, one thing is common that patients say is how little they knew about their options. Patients who consider only the short-term outcome and perceive the least risk will require secondary treatment, which will deliver a more definitive result.

References

Abu Dayyeh, B. K., Bazerbachi, F., Vargas, E. J., Sharaiha, R. Z., Thompson, C. C., Thaemert, B. C., Teixeira, A. F., Chapman, C. G., Kumbhari, V., Ujiki, M. B., Ahrens, J., Day, C., Acosta, A. J., Badurdeen, D., Buttar, N. S., Clark, M. M., Eaton, L., Ghanem, O., Grothe, K., … Wilson, E. B. (2022). Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet (London, England), 400(10350), 441–451. https://doi.org/10.1016/S0140-6736(22)01280-6

Lahooti, A., Westerveld, D., Johnson, K., Aneke-Nash, C., Baig, M. U., Akagbosu, C., Hanscom, M., Buckholz, A., Newberry, C., Herr, A., Schwartz, R., Yeung, M., Sampath, K., Mahadev, S., Kumar, S., Carr-Locke, D., Aronne, L., Shukla, A., & Sharaiha, R. Z. (2025). Improvement in obesity-related comorbidities 5 years after endoscopic sleeve gastroplasty: a prospective cohort study. Gastrointestinal Endoscopy, 102(1), 26–36. https://doi.org/10.1016/J.GIE.2024.12.017

Singh, S., Hourneaux de Moura, D. T., Khan, A., Bilal, M., Ryan, M. B., & Thompson, C. C. (2019). Safety and Efficacy of Endoscopic Sleeve Gastroplasty Worldwide for Treatment of Obesity: A Systematic Review and Meta-analysis. Surgery for Obesity and Related Diseases : Official Journal of the American Society for Bariatric Surgery, 16(2), 340. https://doi.org/10.1016/J.SOARD.2019.11.012