Individual randomized controlled trials (RCTs) and pairwise meta-analyses do not compare all commercially available endoscopic bariatric therapies (EBTs) head-to-head. Therefore, the choice among them is currently made by inference or indirect data. We therefore assessed the comparative efficacy and safety of EBTs through a network meta-analysis.

We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception for intragastric balloons (IGBs) and from 2013 for endoscopic sleeve gastroplasty (ESG) until May 2023. Only RCTs comparing any of the currently commercially available EBTs with controls were considered eligible. Outcomes included percentage of total weight loss (%TWL), serious adverse events (SAEs), and intolerability.

We identified 821 citations, of which 10 and 8 were eligible for the qualitative and quantitative analysis, respectively. Considering %TWL at the time of IGB removal, all EBTs were associated with statistically higher %TWL than controls. There were no significant differences among EBTs. However, considering the %TWL at the follow-up closest to 12 months, both ESG and the Spatz3 gastric balloon (Spatz Medical, Fort Lauderdale, Fla, USA) were more effective than the Orbera gastric balloon (Apollo Endosurgery, Austin, Tex, USA), with no statistical difference between ESG and Spatz3. For both outcomes, P score and ranking score suggested that ESG was probably associated with a greater weight loss (.889272 and .899469, respectively), followed by Spatz3 (.822894 and .842773, respectively), and Orbera (.536968 and .507165, respectively).

All currently available EBTs approved by the U.S. Food and Drug Administration are more effective than both diet plus lifestyle intervention and sham procedures with an acceptable safety profile. ESG seems the most effective and may be prioritized for patients fit for both ESG and IGBs. Direct controlled trials between EBTs are warranted to confirm these findings.