Endoscopic sleeve beat the semaglutide pill at six months, then the gap closed by one year

Two obesity treatments that patients often weigh against each other have now been compared head to head in the same clinic. A retrospective study published in the journal Endoscopy on August 24, 2026 tracked 150 adults treated with either endoscopic sleeve gastroplasty or the daily semaglutide pill, and followed them for a year.

Endoscopic sleeve gastroplasty, usually shortened to ESG, is a procedure done through the mouth rather than through incisions in the abdomen. A doctor passes a flexible tube into the stomach and places rows of stitches that fold the stomach inward, making it smaller. Nothing is cut out and nothing is rerouted. Oral semaglutide is a tablet taken every day. Semaglutide belongs to the GLP-1 class, medicines that mimic a gut hormone and reduce appetite. The study used the 14 mg daily dose.

Six-month weight loss was 12.72% with the procedure and 8.67% with the pill

Patients were adults aged 18 to 65 with a BMI of 30 or higher, or 27 or higher with an obesity-related condition. Fifty had ESG and 100 took oral semaglutide. The main measure was percentage total body weight loss, meaning the share of starting weight lost.

At six months, the ESG group had lost an average of 12.72% of body weight, with a standard deviation of 5.67. The semaglutide group had lost 8.67%, standard deviation 3.84. The difference held up after the researchers adjusted for age, sex, starting BMI and diabetes, and after two further statistical methods designed to make the two groups more comparable.

The share of patients reaching common treatment targets also differed. Seventy percent of ESG patients lost at least 10% of body weight, against 43% on semaglutide. For at least 15% weight loss, the figures were 36% and 7%. The researchers reported no major adverse events in either group.

At twelve months the two groups were statistically indistinguishable

The one-year numbers tell a different story. Average total body weight loss was 11.92% for ESG and 10.91% for semaglutide, and that difference was not statistically significant. In plain terms, the early advantage for the procedure had largely disappeared by the end of the first year.

Two details sit underneath that convergence. Eighteen of the 100 semaglutide patients stopped the drug during follow-up, and five ESG patients started semaglutide. Both movements make the twelve-month comparison harder to read, because the groups at one year are not quite the groups that started.

The authors' own conclusion is measured. They write that ESG was associated with greater short-term weight loss and higher responder rates, that weight loss was sustained in both groups at twelve months without a significant difference between them, and that the findings are preliminary and should be interpreted with caution in the absence of a randomized trial.

Fifty procedures against 100 prescriptions, chosen by doctors and patients rather than at random

This was not a randomized trial. Patients and their doctors decided which treatment to use, and the reasons behind those decisions may also affect how much weight someone loses. Cost, fear of a procedure, tolerance for daily medication and insurance all steer that choice, and none of them are captured in a weight number.

The sample is small. Fifty ESG patients is a modest base for the responder percentages, where a handful of people moves the figure by several points. All patients came from one center, and the medication arm used oral semaglutide at 14 mg, so the results say nothing about injectable semaglutide, tirzepatide, or any other GLP-1 medicine at any other dose.

One year is also early. ESG stitches can loosen over time and medication effects depend on whether a person keeps taking the drug, so neither result here speaks to what happens at three or five years.