Donnangelo L, Gadi SRV, Maselli D, Oneill F, Wooley C, Casey S, McGowan CE. Endoscopic sleeve gastroplasty vs lifestyle modification for weight loss: A real-world cost-effectiveness study. World J Gastrointest Surg 2025; 17(10): 111290 [PMID: 41178873 DOI: 10.4240/wjgs.v17.i10.111290]
Corresponding Author of This Article
Christopher E McGowan, MD, AGAF, FASGE, Department of Gastroenterology, True You Weight Loss, 2001 Weston Parkway, Cary, NC 27513, United States. christopher.e.mcgowan@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Surg. Oct 27, 2025; 17(10): 111290 Published online Oct 27, 2025. doi: 10.4240/wjgs.v17.i10.111290
Endoscopic sleeve gastroplasty vs lifestyle modification for weight loss: A real-world cost-effectiveness study
Lauren Donnangelo, Sanjay R V Gadi, Daniel Maselli, Frank Oneill, Chase Wooley, Shannon Casey, Christopher E McGowan
Lauren Donnangelo, Daniel Maselli, Christopher E McGowan, Department of Gastroenterology, True You Weight Loss, Cary, NC 27513, United States
Sanjay R V Gadi, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, United States
Frank Oneill, Department of Health Economics, Apollo Endosurgery, Austin, TX 78746, United States
Chase Wooley, Shannon Casey, Department of Clinical Research, True You Weight Loss, Cary, NC 27513, United States
Author contributions: Donnangelo L, Wooley C, and Casey S participated in study design, data collection and analysis; Donnangelo L and Gadi SRV prepared and edited the manuscript; Maselli D, Oneill F, and McGowan CE critically revised the manuscript; McGowan CE conceptualized and designed the study. All authors approved the final version to publish.
Institutional review board statement: The study was reviewed and approved for publication by WCG Institutional Review Board.
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrollment as part of undergoing the endoscopic sleeve gastroplasty at the institutions participating in this study.
Conflict-of-interest statement: Dr. McGowan reports personal fees from Boston Scientific, Intuitive Surgical, and Apollo Endosurgery, outside the submitted work.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author. Participants gave informed consent for data sharing, and presented data are anonymized and risk of identification is low.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Christopher E McGowan, MD, AGAF, FASGE, Department of Gastroenterology, True You Weight Loss, 2001 Weston Parkway, Cary, NC 27513, United States. christopher.e.mcgowan@gmail.com
Received: June 27, 2025 Revised: July 22, 2025 Accepted: August 29, 2025 Published online: October 27, 2025 Processing time: 119 Days and 17.8 Hours
Abstract
BACKGROUND
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.
AIM
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.
METHODS
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.
RESULTS
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.
CONCLUSION
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.
