Comparing Minimally Invasive Bariatric Techniques: A Systematic Review of Robotic Sleeve Gastrectomy vs. Endoscopic Sleeve Gastroplasty

doi:10.21203/rs.3.rs-5040568/v1

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Research Article

Comparing Minimally Invasive Bariatric Techniques: A Systematic Review of Robotic Sleeve Gastrectomy vs. Endoscopic Sleeve Gastroplasty

https://doi.org/10.21203/rs.3.rs-5040568/v1

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Background

Within bariatric surgery, endoscopic sleeve gastroplasty (ESG) and robotic sleeve gastrectomy (RSG) have emerged as minimally invasive procedures for weight loss and metabolic management. While both offer benefits for obesity, the comparative effects in terms of weight loss, efficacy, and safety remain uncertain.

Methods

A systematic search of PubMed/MEDLINE, and Cochrane Library was conducted to collect both prospective and retrospective studies assessing the effectiveness and safety of RSG and ESG in treating morbid obesity. Regression analysis was performed.

Results

We collected eleven studies (1182 patients) evaluating RSG and fourteen studies (3077 patients) evaluating ESG. Average patient ages for RSG were 42.79±11.31 years (63.9% females) with preoperative Body Mass Index of 47.81+8.00 and 38.52±9.69 years (86.1% females) with BMI of 35.20±4.29 for ESG. Mean operation time was 104.93 minutes for RSG, and 68.4 for ESG. RSG yielded a Estimated Weight Loss % (%EWL) of 51.26% at 18 months, while ESG yielded 73.01%. Complication rates were 2.71% (32/1182) for RSG and 8.88% (273/3077) for ESG, while reoperation rates were 0.59% for RSG and 1.34% for ESG. Average hospital stays were 2.71 days for RSG and 0.68 days for ESG.

Conclusion

The long-term clinical results of RSG and ESG for morbid obesity show similarly favorable outcomes. ESG has shorter operative times and hospital stays, but more complications. Additional research with larger cohorts and randomized trials is needed to determine the preferred procedure.

Bariatric surgery

Endoscopic sleeve gastroplasty (ESG)

Robotic sleeve gastrectomy (RSG)

EWL

As obesity escalates into a global crisis, research increasingly points to bariatric surgery as a more effective intervention than traditional treatment methods, including lifestyle changes and pharmacotherapy.¹ Bariatric surgery began in 1954 with a simple small bowel bypass to reduce the absorptive capacity of the stomach.² During the 1970s, the evolution from earlier forms of bariatric surgery pioneered by Kremen to stomach stapling marked a significant shift towards techniques more akin to those used in contemporary procedures. The advent of the BioEnterics® Lap-Band ® system, quickly pushed the laparoscopic technique to the forefront of bariatric surgery.³

While laparoscopic techniques are still the standard for bariatric procedures, the use of robotic-assisted surgery has become increasingly popular. These robotic surgeries, typically done with the da Vinci Surgical System, allow for minimally invasive procedures that provide improved precision and visualization for the surgeon.⁴ One of the more prominent robotic procedures to treat obesity is the robotic sleeve gastrectomy (RSG). Like the laparoscopic sleeve gastrectomy, RSG reduces the stomach size by ~ 80% to limit the amount of food a patient can hold as well as alter stomach hormones to decrease appetite and increase satiety, promoting weight loss for the patient.

Endoscopic bariatric treatments have developed within the last decade, boasting higher patient acceptance due to the minimally invasive and anatomic-preserving nature of the procedures.⁵ The most commonly practiced endoscopic bariatric treatments are intragastric balloons, endoscopic duodenal-jejunal bypass liners, and endoscopic sleeve gastroplasty (ESG). The pathophysiological mechanisms of endoscopic procedures are similar to those of surgical bariatric surgeries by limiting gastric capacity, reducing nutrient absorption, and facilitating the non-absorbed discharge of gastric contents.⁶ In this study, we aim to summarize the existing literature and compare surgical outcomes for RSG and ESG.

Literature Search

The article selection process was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement in order to retrieve all the relevant articles within the known literature⁷. The following keywords were used in every possible combination within Google Scholar, Pubmed/Medline, and Cochrane Library: “endoscopic sleeve gastroplasty,” “robotic sleeve gastrectomy,” and “sleeve gastrectomy”. All the studies were searched before October 23, 2023 and search queries were limited to only display articles written in the English language. Duplicate articles were identified and removed from our system.

Inclusion and Exclusion Criteria

To be eligible for selection within this systematic review, articles were required to meet the following criteria: (1) assessing the efficacy and safety of RSG and ESG in the treatment of morbid obesity, (2) prospective or retrospective studies, (3) published from 2010 to 2023, and (4) published in the English language. We excluded articles that met the following criteria: (1) large database studies, (2) individual case series, (3) abstracts, letters, or reviews without original data, and (4) studies with no reported outcomes of interest.

The primary objective endpoints were %EWL (excess weight loss), operative time, length of stay, reoperation, complications, and conversion to open surgery.

Data Extraction

Eligible articles were reassessed by two independent reviewers to confirm all inclusion criteria were met. If any disagreement or discrepancy occurred in the studies, the two reviewers consulted the guarantor author. For each article, the following data was recorded: demographics (including number of patients, mean age, sex, comorbidities, and preoperative body mass index (BMI)); mean operative time; estimated blood loss; length of stay; reoperation; intraoperative and post-operative complications; conversion to open surgery; %EWL (excess weight loss) after 1, 3, 6, 12, 18 months; and comorbidity relief. For continuous outcomes, the mean, standard deviation, and number of patients were recorded. We calculated standard deviation using available data when it was not provided. Three independent reviewers ensured accurate data extraction.

Statistical Analysis

Regarding the categorical outcomes, the odds ratio (OR) and 95% confidence interval (CI) were calculated, based on the extracted data, by means of a fixed-effects model (Mantel-Haenszel statistical method), where the number of studies providing data was sufficient. OR < 1 denoted that outcome was more frequent in the RSG group. Continuous outcomes were evaluated by means of weighted mean difference (WMD) with its 95% CI, using fixed-effects and random-effects (inverse variance statistical method) models, appropriately to calculate pooled effect estimates. In cases where WMD < 0, values in the RSG group were higher. Between studies, heterogeneity was assessed using Cochran’s Q statistic and by estimation.

Article Selection Results

Our literature review selected twenty-four studies from various countries including the United States, Brazil, India, Spain, Greece, Portugal, Saudi Arabia, and France, spanning from 2010 to October 2023. The key details of these articles are summarized in Table 1. The article selection process is shown below in Fig. 1.⁸

Table 1

Characteristics of included studies
First author, Year	Journal	Country
Robotic Sleeve Gastrectomy
Ayloo, 2011 ⁹	J Laparoendosc Adv Surg Tech A	United States
Diamantis, 2010 ¹¹	Obes Surg	Greece
Ecker, 2016 ¹²	Surg Obes Relat Dis	United States
Elli, 2014 ¹³	Obes Surg	United States
Kannan, 2015 ¹⁴	Surg Obes Relat Dis	United States
Moon, 2016 ¹⁵	Obes Surg	United States
Pepper, 2016 ¹⁶	Obes Surg	United States
Romero, 2013 ¹⁷	Obes Surg	United States
Schraibman, 2014 ¹⁸	Obes Surg	Brazil
Vilallonga, 2013 ¹⁹	Obes Surg	Spain
Endoscopic Sleeve Gastroplasty
Abu Dayyeh, 2022 ²⁰	Lancet	United States
Abu Dayyeh, 2017 ²¹	Clin Gastroenterol Hepatol	United States
Alexandre, 2023 ²²	J Visc Surg	France
Alqahtani, 2023 ²³	Am J Gastroenterol	Saudi Arabia
Alqahtani, 2019 ²⁴	Clin Endosc	Saudi Arabia
Barrichello, 2019 ²⁵	Clin Endosc	Brazil, United States
Correia, 2023 ²⁶	Surg Endosc	Portugal
Fayad, 2019 ²⁷	Clin Endosc	United States
Lopez-Nava, 2017 ²⁸	Arq Bras Cir Dig	Spain
Maselli, 2023 ²⁹	WGJE	Brazil/United States
Maselli, 2021 ³⁰	Clin Endosc	United States, UAE, Saudi Arabia, Brazil
Morales, 2018 ³¹	Surg Endosc	Spain
Sartoretto, 2018 ³²	Obes Surg	Australia/United States

Figure 1. PRISMA diagram

Table 1. Characteristics of included studies

Patient Demographics

This systematic review synthesized data from 24 studies, encompassing a total of 5259 patients, with 1182 undergoing Robotic Sleeve Gastrectomy (RSG) and 4077 undergoing Endoscopic Sleeve Gastroplasty (ESG). The demographic breakdown indicated 991 females and 4268 males, with ESG and RSG procedures being performed on 565 females and 3512 males, and 426 females and 755 males, respectively. The average age of patients was 37.49 ± 9.64 years for ESG and 42.79 ± 11.38 years for RSG. Furthermore, the average preoperative BMI was 34.74 ± 4.3 for ESG patients and 47.81 ± 8.08 for RSG patients. Detailed patient demographics and intraoperative parameters for each individual study are displayed in Table 2, while aggregated data across all studies are presented in Table 3, offering a comprehensive overview of patient profiles and procedural specifics within this comparative analysis.

Table 2

Intraoperative parameters of each study ^9–32
First author, Year	Number of Patients	Female (%)	Mean age	Mean pre-op BMI	Length of stay (days)	Mean operative time (min)	Intraoperativecomplication rate (%)	Conversion rate (%)
Robotic Sleeve Gastrectomy
Ayloo, 2011	30	96.7	38 ± 9.1	57	2.6 ± 1.2	135 ± 28	0	0
Bhatia, 2014	35	42.9	41.7 ± 3.43	48.17	3.36 ± .37	116.6 ± 48.8	0	0
Diamantis, 2010	19	89.5	39.4 ± 10.9	48.2	4	95.5 ± 11.5	0	0
Ecker, 2016	415	74.0	43.6 ± 11.2	48.7	3	96.4 ± 24.9	1	.24
Elli, 2014	105	90.5	41 ± 10.2	49	2.44 ± 0.746	110.6 ± 48.27	0	0
Kannan, 2015	46	60.9	46	48.69 ± 9.59	4.2 ± 0.9	110	0	0
Moon, 2016	268	29.1	43.4 ± 11.9	46.7 ± 7.7	1.7 ± 1.8	N/A	0	0
Pepper, 2016	14	85.7	17	43	2.8125	131.5	0	0
Romero, 2013	134	66.4	43 ± 12.6	45	2.2 ± 0.6	106.6 ± 48.8	0	0
Schraibman, 2014	16	37.5	43 ± 16	41.3	3	148	0	0
Vilallonga, 2013	100	79.0	44 ± 11	48	4 ± 3	108 ± 18	5	0
Endoscopic Sleeve Gastroplasty
Abu Dayyeh, 2022	77	88.3	47.3 ± 9.3	35.5 ± 2.6	N/A	N/A	0	0
Abu Dayyeh, 2017	25	84.0	47.6 ± 10	35.5 ± 2.6	N/A	N/A	0	0
Alexandre, 2023	99	74.7	45 ± 12.7	42.7 ± 7.8	1	38 ± 2.95	0	0
Alqahtani, 2023	656	93.9	33.6 ± 9	28.9 ± 0.8	N/A	51 ± 18	0
Alqahtani, 2019	1000	89.7	34.4 ± 9.5	33.3 ± 4.5	0.5	82 ± 20	0	0
Barrichello, 2019	193	76.7	42.3 ± 9.6	34.11 ± 2.97	0.5	76 ± 24	0	0
Correia, 2023	73	83.6	49.2 ± 9.7	38.60 ± 3.51	2	83 ± 20	0	1.4
Fayad, 2019	54	57.4	N/A	43.07 ± 0	.34 ± .73	N/A	0	0
Lopez-Nava, 2017	154	70.1	44.9 ± 9.5	38.3 ± 5.5	1	N/A	0	0
Maselli, 2023	404	78.5	42.9	44.8 ± 4.7	N/A	42 ± 9	0	0
Maselli, 2021	82	92.7	42.8 ± 10.4	37.2 ± 5.7	0.5	48.3 ± 20.5	0	0
Morales, 2018	148	81.8	41.52 ± 10	35.11 ± 5.5	1	45 ± 60	2	0
Sartoretto, 2018	112	68.8	45.1 ± 11.7	37.9 ± 6.7	1	N/A	0	0

Table 3

Patient characteristics across all studies
Perioperative data	ESG	RSG
Patients	3077	1182
Age	38.52 ± 9.69	42.79 ± 11.31
Female/Male	565/3512	426/755
Pre-op BMI	35.20 ± 4.29	47.81 ± 8.00
Major Comorbidities Diabetes Hypertension GERD Sleep Apnea Other	235 Patients 361 Patients 87 Patients 90 Patients 285 Patients	304 Patients 462 Patients 11 Patients 405 Patients 390 Patients
Operation Time (minutes)	63.10 ± 22.58	104.93 ± 32.43
Length of Stay (days)	0.68	2.71 ± 1.89

Table 2. Intraoperative parameters of each study ^9–32

Table 3. Patient characteristics across all studies

The review also focused on major comorbidities, including diabetes, hypertension, Gastroesophageal Reflux Disease (GERD), and sleep apnea, although not all studies provided details on these conditions. In total, among the patients with disclosed comorbidities, 539 had diabetes, 823 had hypertension, 98 had GERD, 495 had sleep apnea, and 675 had other comorbidities. Specifically, for ESG, among 1058 patients with known comorbidities, 22% were diagnosed with diabetes, 34% with hypertension, 8% with GERD, 9% with sleep apnea, and 27% with other conditions. For RSG, among 1572 patients with disclosed comorbidities, 19% had diabetes, 29% had hypertension, 1% had GERD, 26% had sleep apnea, and 25% had other comorbidities.

Clinical Outcomes

In this systematic review, we evaluated five critical factors to discern the differences between ESG and RSG: percent excess weight loss (%EWL) over time, postoperative complication rates, reoperation rates, rates of conversion to open surgery, average hospital length of stay, and mean operative times. The %EWL observed in ESG patients at 1, 3, 6, 12, and 18 months post-procedure were 36.29 ± 31.60, 42.58 ± 35.02, 58.32 ± 39.80, 67.21 ± 44.50, and 65.63 ± 54.81, respectively. Conversely, RSG patients reported %EWL of 16.56 ± 8.67, 25.21 ± 10.73, 43.96 ± 8.04, 65.51 ± 23.50, and 51.26 at corresponding intervals, showing that ESG patients consistently achieved higher %EWL at all monitored stages.

A total of 330 postoperative complications were documented, with 288 occurring in ESG patients and 42 in RSG patients. The ESG cohort had a reoperation rate of 1.35% and a conversion rate to open surgery of 0.025%, while the RSG cohort exhibited a reoperation rate of 0.76% and a conversion rate to open surgery of 0.085%. Furthermore, the average hospital stay was significantly shorter for ESG patients at 0.97 ± 0.73 days, compared to 2.71 ± 1.89 days for RSG patients, emphasizing ESG's minimally invasive approach.

An important operational distinction was found in the mean operative times: ESG procedures averaged 68.4 ± 18.66 minutes, while RSG procedures took longer, with an average of 104.93 ± 33.66 minutes. This indicates that overall, the RSG procedure is more time-consuming, reflecting the complexity and technical demands of robotic surgery compared to the more streamlined ESG process.

The detailed post-operative outcomes for each individual study are compiled in Table 4, while a comprehensive overview of outcomes across all analyzed studies is presented in Table 5. This structured presentation of data provides a transparent comparison of the efficacy, safety, and operational efficiencies of ESG and RSG, contributing to a nuanced understanding of their relative benefits and challenges in managing obesity.

Table 4

Post-operative outcomes of each study ^9–32
First Author, Year	Follow-up period (months)	%EWL (3 month)	%EWL (6 month)	%EWL (12 month)	%EWL (24 month)	Reoperation Rate (%)	Postoperative complications (%)
Robotic Sleeve Gastrectomy
Ayloo, 2011	12	N/A	N/A	N/A	N/A	3.33	0
Bhatia, 2014	6	N/A	42.8 ± 3.6	N/A	N/A	0	0
Diamantis, 2010	1 (n = 19) 3 (n = 19) 6 (n = 16) 12 (n = 16)	1.3 ± 7.5	4.1 ± 13.2	65.5 ± 25.6	N/A	0	0
Ecker, 2016	N/A	N/A	N/A	N/A	N/A	5.06	7.22
Elli, 2014	3 (n = 71), 6 (n = 69), 9 (n = 44), 12 (n = 38), 18 (n = 23), 24 (n = 23), 36 (n = 15), > 36 (n = 11)	22.49	44.52	48.89	43.44	0	0
Kannan, 2015	3 (n = 43), 6 (n = 30), 12 (n = 26)	27 ± 11.03	39.0 ± 12.0	57.0 ± 20.4	N/A	15.2	2.17
Moon, 2016	1	N/A	N/A	N/A	N/A	1.87	.75
Pepper, 2016	1	N/A	N/A	N/A	N/A	21.4	0
Romero, 2013	12	N/A	N/A	71.5	N/A	7.46	2.99
Schraibman, 2014	12	N/A	N/A	N/A	N/A	0	0
Vilallonga, 2013	12	N/A	N/A	66	N/A	1	1
Endoscopic Sleeve Gastroplasty
Abu Dayyeh, 2022	24	N/A	N/A	N/A	41.0% ± 32.0	11.7	3.90
Abu Dayyeh, 2017	20	N/A	N/A	N/A	N/A	100	0
Alexandre, 2023	12	N/A	N/A	42.9 ± 25.6%	N/A	0	0
Alqahtani, 2023	6 n = 443 12 n = 377 24 n = 197 36 n = 163	N/A	67.5 ± 31.9	88.0 ± 27.8	87.3 ± 24.5	25.2	2.59
Alqahtani, 2019	1 n = 814 3 n = 689 6 n = 369 9 n = 291 12 n = 216 18 n = 54	49.3 ± 42.5	64.3 ± 56.2	67.5 ± 52.3	N/A	2.70	1.60
Barrichello, 2019	12	N/A	N/A	59.41% ± 25.69%	N/A	2.07	1.55
Correia, 2023	1 n = 73 3 n = 52	36.3 ± 11.35%"	N/A	N/A	N/A	20.5	0
Fayad, 2019	6	N/A	N/A	N/A	N/A	5.56	0
Lopez-Nava, 2017	1 (n = 143) 6 (n = 133) 12 (n = 64) 24 (n = 28)	N/A	47.8 ± 29.4	52.6 ± 31.3	60.4 ± 31.1	0	0
Maselli, 2023	3 n = 312 6 n = 233 12 n = 151 15 n = 112 24 n = 112 36 n = 15	29.5 ± 9.6	39.2 ± 12.7	49.6 ± 15.1	49.4 ± 16.7	.50	0
Maselli, 2021	12	N/A	N/A	47.6% ± 26.6%	N/A	11.0	0
Morales, 2018	12 n = 148 18 n = 72	N/A	N/A	75.4 ± 85	N/A	1.35	0
Sartoretto, 2018	1(n = 93) 3(n = 82 6(n = 52)	39.9 ± 17.3	50.3 ± 22.4	N/A	N/A	2.68	0

Table 5

%EWL at different intervals.
	Preop BMI	1 month post op %EWL	3 months post op %EWL	6 months post op %EWL	12 months post op %EWL	18 months post op %EWL
ESG mean ± SD	35.20 ± 4.29	36.29 ± 30.94	42.58 ± 33.9	58.32 ± 38.2	67.21 ± 41.58	73.01 ± 48.7
RSG mean ± SD	47.81 + 8.00	16.56 ± 8.6	25.21 ± 10.08	42.97 ± 9.67	65.51 ± 22.52	51.26

Table 4. Post-operative outcomes of each study ^9–32

Table 5. %EWL at different intervals.

Table 6. P-values for RSG.

Table 6

P-values for RSG.
	Preop BMI	Diabetes (1 or 2)	Hypertension	Sleep Apnea
P-value	0.93	0.16	0.06	0.53

Statistical Analysis Results

Due to inconsistencies across studies, mainly variable increments of post-op follow up time, we focused on initial %EWL values for our statistical analysis as a success indicator. Using a multiple regression model with %EWL as the dependent variable and pre-operative BMI and comorbidities as independent variables, RSG studies showed no significant correlations between pre-operative BMI and comorbidities affecting %EWL at an alpha level of 0.05, as depicted in Fig. 3. However, at a 0.1 alpha level, a minor correlation between %EWL and hypertension emerged with a p-value of 0.06 (Fig. 2). In contrast, ESG studies revealed a significant correlation between pre-operative BMI and %EWL, with a p-value of 0.03, shown in Fig. 4. No correlation was found when comparing hospital stay, operative time, and complication rate.

Figure 2. %EWL vs hypertension correlation for RSG

Figure 3. %EWL vs pre-operative BMI correlation for RSG

Figure 4. %EWL vs pre-operative BMI correlation for ESG

This systematic review and comparison has shown that both RSG and ESG are effective and safe bariatric procedures. The %EWL for RSG patients was higher than ESG patients with each postoperative month check, however this difference was not statistically significant. Additionally, the variability in weight loss outcomes was more pronounced in ESG patients, as indicated by the larger standard deviation for %EWL across all time points.

A significant difference between the two procedures lies in hospital stay, with ESG patients benefiting from considerably shorter hospital stays. Fayad et al. reported the shortest hospital stay with a length of only 0.34 days. This disparity primarily stems from ESG's minimally invasive nature, which eliminates the need for hospitalization. By avoiding the complexities of inpatient hospitalization, ESG simplifies the postoperative care process, allowing patients to commence their recovery with minimal hospital oversight. This aspect of ESG not only underscores its efficiency in facilitating patient recovery, but also highlights its potential to reduce healthcare costs associated with prolonged hospital stays.^33,34 Furthermore, the expedited discharge process associated with ESG can significantly enhance patient satisfaction by allowing individuals to return to their daily routines sooner.

In our statistical analysis, the ESG studies showed a significant correlation between pre-operative BMI and %EWL, with a p-value of 0.03. Conversely, RSG studies revealed no significant correlation, indicated by a p-value of 0.93. This raises questions about the influence of pre-operative BMI on success rates between the two procedures. Although correlation does not imply causation, the variance might be attributed to operational differences: RSG typically involves a single surgeon, potentially leading to more consistent outcomes, unlike ESG, which often involves multiple surgeons, gastroenterologists, and assistants, possibly introducing variability in procedural success.

Additionally, patients that underwent RSG exhibited a higher average preoperative BMI compared to those who underwent ESG. This distinction likely stems from the lower-risk patient population that is given ESG treatment. Patients with lower BMIs and fewer comorbidities are oftentimes better candidates for ESG treatment than higher-risk patients. This observation is supported by Fayad et al., who found in their comparative review that ESG patients presented with significantly fewer comorbidities at baseline than those undergoing Laparoscopic Sleeve Gastrectomy.²⁷ Given that individuals with higher BMI are more susceptible to surgical complications, RSG, performed under complete anesthesia, emerges as a more suitable option for this demographic.^11,19,35 This rationale aligns with the observation from reviewed studies that RSG patients typically present with a greater number of comorbidities than their ESG counterparts.¹¹ The necessity of complete anesthesia for patients with comorbidities—deemed higher-risk—underscores the preference for RSG in such cases. Furthermore, the prevalence of comorbidities among RSG patients may be linked to the procedure's extensive anatomical modifications, potentially offering superior mitigation of these health issues compared to ESG. Thus, for patients on the higher end of the BMI scale, RSG is the preferred intervention, while ESG would be preferred for less extreme cases. The difference in BMI between the two groups, as indicated by the p-value obtained in this study, reinforces RSG's suitability for higher BMI patients.

However, it's important to note that recent studies have highlighted the efficacy of ESG even among high-BMI patients. Maselli et al. presented findings from a cohort of 404 class III obesity patients undergoing ESG, illustrating that with ongoing nutritional support, ESG could induce sustained weight loss in adults with severe obesity.⁵ Similarly, Lopez-Nava et al. documented a 20.5% total body weight loss (TBWL) at one year in a study involving 146 patients with morbid obesity treated with ESG.³⁶ These studies suggest that the initial year post-ESG sees the most significant weight loss, with subsequent years focusing on maintaining the achieved weight reduction.^5,36 This evidence underscores the potential of ESG as a viable option for managing obesity in patients across a broad spectrum of BMI categories, challenging the traditional preference for RSG in higher-risk individuals.

This systematic review faces several critical limitations. Firstly, the absence of randomized controlled trials introduces potential biases in data extraction, though retrospective, and prospective studies do offer valuable clinical insights. This study’s sample size may not have been large enough to produce robust data. Our selection criteria excluded studies published before 2010, large database analyses, and non-English language research, further limiting our study pool. Dependence on published data, without access to raw, individual-level details, also hindered our analysis. Additionally, inherent differences in study populations and methodologies introduced confounding variables that were difficult to control for in our comparative analysis. Finally, the limitations encountered in this comparative review mirror those inherent in the included studies.

Robotic Sleeve Gastrectomy and Endoscopic Sleeve Gastroplasty are both procedures that offer effective and safe options for the management of morbid obesity. Our analysis highlighted that while ESG typically results in shorter operative times and hospital stays, it is associated with a higher complication rate compared to RSG. Despite these differences, both procedures demonstrate significant potential in weight loss efficacy, underscoring the importance of patient-specific considerations in selecting the appropriate surgical intervention.

The findings from this review should be interpreted in light of its limitations, including the absence of randomized controlled trials and potential biases inherent in the included studies. Future research should focus on larger, randomized trials to provide more definitive evidence regarding the comparative efficacy and safety of these procedures. Such studies would greatly contribute to optimizing bariatric surgery strategies, enhancing patient outcomes, and broadening the options available to individuals struggling with obesity.

Funding

The authors declare that no external funding or financial support was received from any organization, institution, or individual for the research, authorship, or publication of this article. All work was conducted independently without any financial incentives or conflicts of interest.

Author Contribution

Y.A. conceptualized the study, curated data, conducted the investigation, developed the methodology, administered the project, supervised the work, validated the findings, and wrote the original draft. T.E. contributed to conceptualization, data curation, and writing of the original draft. R.R. performed data curation, conducted statistical analysis, and contributed to writing through review and editing. Y.S. was responsible for data curation and statistical analysis. R.P. contributed to data curation, investigation, and writing the original draft. F.S. contributed to data curation, investigation, and writing through review and editing. D.A. was involved in writing through review and editing. V.S. contributed to data curation and investigation. F.M. and A.T. provided validation and writing through review and editing. All authors reviewed the manuscript.

Acknowledgement

We would like to thank Temple University College of Science and Technology for their unwavering support and commitment to research.

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Comparing Minimally Invasive Bariatric Techniques: A Systematic Review of Robotic Sleeve Gastrectomy vs. Endoscopic Sleeve Gastroplasty

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