ESGE 2026
Endoscopic gastroplasty outpaces oral GLP-1 for weight loss
Clinical Takeaway: When patients are weighing a one-time procedure against a daily GLP-1 pill, ESG may deliver faster and larger short-term weight loss. Consider it earlier in the conversation for patients who struggle with daily medication adherence or want a less-invasive procedural option.
Patients with obesity increasingly face a choice between a growing list of procedure and medication options, but head-to-head real-world data remain scarce. This retrospective cohort study compared endoscopic sleeve gastroplasty (ESG), a minimally invasive endoscopic procedure that reduces gastric volume, with the most commonly available oral GLP-1 receptor agonist at the time of the study.
ESG outperformed oral semaglutide on every weight-loss measure assessed. At six months, patients who underwent ESG lost an average of 12.7% of total body weight, compared with 8.7% in those taking 14 mg of oral semaglutide, the standard diabetes dose. The mean difference of about 4 percentage points held after adjustment for age, sex, BMI, and diabetes status. FDA has approved a higher 25 mg dose of oral semaglutide specifically for chronic weight management, which was not assessed here.
Clinically meaningful weight loss was also more common in the ESG group: 70% achieved at least 10% total body weight loss compared with 43% on semaglutide, and 36% achieved at least 15% loss compared with 7%. Adverse event rates were comparable between groups and were largely mild gastrointestinal symptoms, with no serious complications or deaths reported.
Prior studies reported sustained weight loss of around 15% to 18% at 18 to 24 months after ESG, with most weight loss occurring in the first six months followed by modest regain thereafter. Comparable real-world durability data for oral semaglutide are still limited, though pivotal trials of injectable semaglutide show that weight loss is generally sustained as long as the drug is continued and regained when stopped — a key difference between the two modalities that may shape long-term treatment selection.
The study included 150 patients treated in routine clinical practice and was presented at ESGE Days 2026 in Milan, but has not yet been peer-reviewed. The researchers note ESG is a one-time intervention while semaglutide requires sustained daily adherence, a practical difference that may shape patient choice independent of efficacy.
"In real-world practice, patients often ask whether they should choose a procedure or a medicine, but there has been very little comparative data to guide that decision," said Nitin G. Jagtap, MD, of AIG Hospitals in Hyderabad, India. "A daily oral therapy requires sustained commitment, whereas ESG is a one-time intervention associated with more rapid weight loss. These approaches should be viewed as complementary."
Source: Jagtap N. ESGE Days 2026. Endoscopic Sleeve Gastroplasty Versus Oral Semaglutide for Obesity: A Real-World Comparative Study