During EBL, the application of ligatures along the gastric body has been touted as a new well-tolerated and technically feasible approach for inducing weight loss in patients with obesity. The procedure started at the distal gastric body where five parallel rows of bands were created, totaling 20–30 bands, with the final row being positioned at the proximal gastric body containing the ligatures, which induced the formation of linear scars within the healed ulcer in the gastric body, thereby causing marginal narrowing of the lumen. EBL triggered subsequent weight loss similar to that observed with other endoscopic bariatric methods. Specifically, none of the patients had manifestations of gastroparesis, and there were no significant increases in the GCSI subscale scores for nausea/vomiting, bloating, and distention, whereas the GCSI subscale score for fullness and early satiety showed a subsequent increase among the participants.

In the present study, the mean percent excess weight loss and total weight loss 1 month after EBL were 22.3% ± 9.9% and 7.8% ± 2.5%, respectively. In one study comparing intragastric balloon insertion, which limits food breakdown by concentrating on the second phase of digestion, with endoscopic sleeve gastroplasty, intragastric balloon insertion led to a total weight loss of 2.6% in 47 patients, whereas endoscopic sleeve gastroplasty led to a total weight loss of 2.4% in 58 patients 1 month after the procedure [11]. However, despite the achievement of weight loss with intragastric balloon insertion, 17% of the patients reported serious adverse effects. In another study, severe adverse effects resulting in early balloon removal were reported by 28.2% and 10.5% of the patients who underwent intragastric balloon insertion and endoscopic sleeve gastroplasty, respectively [12]; the adverse effects of endoscopic sleeve gastroplasty were more severe and required medical management.

Laparoscopic sleeve gastrectomy induces weight loss through the reduction of stomach capacity with a focus on enhancing satiety and early fullness. Fayed et al. [13] observed a mean weight loss of 8.0% after 1 month. However, the development of postoperative gastroesophageal reflux is a major disadvantage, and endoscopic sleeve gastroplasty is a safer alternative to laparoscopic sleeve gastrectomy. EBL does not appear to induce GERD, although longer and more specific studies are required to confirm this. Additionally, Hadi et al. [14] reported a total weight loss of 5% after 1 month in a cohort of 90 patients who underwent endoscopic sleeve gastroplasty or laparoscopic sleeve gastrectomy, with no significant independent association between the procedure type and total weight loss.

Compared with bariatric surgical approaches, our approach promoted improved weight loss at the end of the first month [15,16,17]. This finding could have been attributed to the less invasiveness, shorter operative time, fewer adverse events, and technical feasibility of EBL.

In the present study, the patients experienced milder complications compared to those reported for other obesity treatment modalities. Importantly, we did not observe immediate complications during EBL, illustrating its safety. In the present study, the patients complained of nausea, vomiting, and epigastric pain, which were controlled with medical treatment and resolved over 2 days, in contrast to the longer duration of 3–7 days reported by patients who intragastric balloon replacement [18].

Other immediate adverse events, such as upper gastrointestinal bleeding, extragastric hemorrhage, pulmonary embolism, and pneumoperitoneum, were previously reported in patients undergoing laparoscopic sleeve gastrectomy and ESG. However, recent ESG meta-analyses have shown that these AEs are very scarce (< 2%) [19, 20]. Patients with intragastric balloons reported complications such as balloon intolerance requiring early removal, balloon rupture, gastric outlet obstruction, and gastric perforation [16]. EBL did not appear to lead to these complications.

This study was conducted on a small number of patients without a control group and for a short duration of 1 month for assessing safety and efficacy parameters.