Published online Oct 27, 2025. doi: 10.4240/wjgs.v17.i10.111290
Revised: July 22, 2025
Accepted: August 29, 2025
Published online: October 27, 2025
Processing time: 119 Days and 17.8 Hours
Obesity impacts 42% of United States adults and results in an estimated economic burden of nearly 1.4 trillion dollars annually. Endoscopic sleeve gastroplasty (ESG) is a United States Food and Drug Administration authorized procedure with an excellent safety, efficacy, and durability profile. The cost-effectiveness of ESG compared to lifestyle modification (LM) in real-world patients with class I-III obesity represents a critical knowledge gap.
To approximate the cost-effectiveness of ESG vs LM using a real-world dataset of 860 United States adults with class I-III obesity undergoing ESG.
A 6-state Markov model was employed, including healthy weight, overweight, class I-III obesity, and death. The LM control group was built using transition states previously described in the literature, supplemented by expert opinion. Cycles lasted six-months in the model’s first year and twelve-months thereafter. Existing literature informed approximations of each health state utility, adverse event disutility, and incidence of obesity-associated comorbidities. One-way sensitivity and probabilistic sensitivity analyses were performed.
The base-case incremental cost-effectiveness ratio (ICER) for ESG vs LM was 5904 dollars per quality-adjusted life year (QALY). In a one-way sensitivity analysis, the utilities assigned to the three obesity classes most greatly influenced the ICER. Probabilistic sensitivity analysis estimated an increase in upper-bound ICER of 8038 dollars per QALY, well under the generally cited United States willingness to pay ratio of 100000 dollars per QALY.
The results of this model support that ESG is overwhelmingly cost-effective compared to LM across all obesity classes. Payors should consider expanding coverage for their members.
Core Tip: Endoscopic sleeve gastroplasty (ESG) is an endoscopic bariatric tool that offers patients a non-surgical option for weight loss. However, the cost effectiveness of ESG as compared to conventional lifestyle modification (LM) in real world patients needs further investigation. In this study, we aimed to estimate the cost-effectiveness of ESG vs LM. Our results showed that the base-case incremental cost-effectiveness ratio for ESG vs LM was 5904 dollars per quality-adjusted life year, suggesting that ESG is cost effective across all classes of obesity.