Faster, then level. Endoscopic sleeve gastroplasty (ESG) takes weight off sooner than a GLP-1 drug. In the two direct comparisons with twelve months of data, the drug had caught up by the end of the year. In a cohort of 150 adults, ESG led oral semaglutide 12.72% to 8.67% at six months [1]. At twelve months the figures were 11.92% and 10.91%, with a P value of 0.41.
ESG is an endoscopic procedure, done through the mouth, that stitches the stomach smaller. It is neither a drug nor a full operation. How it compares with surgery and with the drugs on cost is in when the drug starts to cost more than an operation. How it ranks among every option is in which weight-loss treatment works best.
The six-month lead
The procedure’s early advantage is consistent. In the 150-patient cohort, it held after covariate adjustment, inverse probability weighting and propensity matching [1]. Of the procedure group, 70% reached 10% weight loss, against 43% on the tablet. At the 15% mark it was 36% against 7%.
A small randomized trial found the same shape against liraglutide. Forty-three patients with class I or II obesity were assigned to ESG or the drug [2]. Weight loss was greater after the procedure at three and six months, P = 0.001.
Why the curves cross
The trajectories differ, not just the endpoints. In the cohort, the procedure group went from 12.72% to 11.92%. The tablet group went from 8.67% to 10.91% [1]. The randomized trial’s authors describe the same pattern: some weight regain after ESG, and slower but more consistent loss on liraglutide [2].
A titrated drug takes months to reach its maintenance dose. A comparison that stops before a year measures the dosing schedule as much as the treatment. The same caution applies to early response figures on any GLP-1.
After a sleeve gastrectomy
One comparison looked at a narrower group: people regaining weight after a surgical sleeve gastrectomy [4]. Twenty-two had a revisional ESG and 68 took semaglutide or tirzepatide. The procedure led at three and six months. At twelve months it was 13.4% against 9.2%, P = .07.
The drug average hides a split. Tirzepatide reached 13.2% at twelve months, level with the procedure. Semaglutide reached 8.1%. The authors note the drugs were underdosed, and refills were difficult for 41.3% of patients. The wider evidence on drugs after surgery is in rescue therapy after bariatric surgery.
What each costs over five years
A procedure is paid for once. A drug is paid for monthly. One Markov model compared ESG with semaglutide over five years in class II obesity [3]. ESG added 0.06 QALYs and cost $33,583 less in total.
The model priced semaglutide at $13,618 a year. It would need to fall to $3,591 for the drug to stop being dominated, meaning cheaper and worse. That is a threefold price cut. What cash sellers charge a month is in what a GLP-1 costs per month. In the model, ESG also sustained more weight loss over five years, BMI 31.7 against 33.0.
A five-year comparison also depends on how long people stay on the drug. About two thirds of people taking a GLP-1 for weight without diabetes are off it within a year, as persistence data show. Stopping changes both the cost and the weight.
What this evidence cannot settle
Three limits apply. Only one comparison was randomized, and it had 43 patients. The 150-patient cohort was not randomized, so whatever led people to choose a procedure is in the result. Its crossover also ran one way: 18 tablet patients stopped the drug, and 5 procedure patients started it [1].
The drugs tested were not the strongest ones. Oral semaglutide 14 mg is a diabetes dose. It is not the injection, and it is not the higher oral weight-loss dose. What the tablet costs against the injection is covered in whether the pill is cheaper. Liraglutide is an older daily injection. None of the comparisons here set ESG against injected semaglutide or tirzepatide in people who had not already had surgery.