Introduction: Endoscopic sleeve gastroplasty (ESG) is a promising bariatric intervention designed to emulate sleeve gastrectomy (SG), the most commonly performed bariatric operation. Comparative studies are limited and there is a lack of large-scale population-based data. Additionally, no studies have examined the impact of race on outcomes after ESG. This is the largest study yet to compare short-term safety and efficacy of ESG to SG, and the first to evaluate the impact of race on short-term outcomes after ESG. Methods: We analyzed 600,000 patients who underwent ESG or SG from 2016-2020 across over 800 hospitals in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Patients who underwent ESG were propensity matched to SG patients. We primarily compared occurrences of adverse events (AE), readmissions, reoperations, and reinterventions within 30-days. Secondary outcomes measured at 30 days included total body weight loss (TBWL), outpatient treatments for dehydration, and emergency room (ER) visits. Multivariate regression evaluated the impact of patient characteristics, including race, on AE. Results: 6,054 patients underwent ESG and 597,463 underwent SG. Propensity matching in a 1:5 ratio compared all ESG cases to 30,270 SG cases. ESG had shorter procedural time (62.9 min vs 72.4, p < .05) and length of stay (0.87 days vs 1.45, p< 0.05). AE were low after both procedures (SG: 1.1% vs ESG: 1.4%, p > 0.05). However, patients undergoing ESG had more readmissions (3.8% vs 2.6%), reoperations (1.4% vs 0.8%), and reinterventions (2.8% vs 0.7%) within 30 days (p < 0.05). SG cohort had more outpatient treatments for dehydration (3.3% vs 2.4%, p< 0.05) and ER visits not resulting in admission (5.9% vs 4.9%, p< 0.05). SG also resulted in greater mean %TBWL compared to ESG (5.4% vs 4.0%, p< 0.05). The greatest odds of increasing AE after both ESG and SG were attributed to the presence of renal insufficiency (ESG: OR 10.0, SG: OR 1.95) and therapeutic anticoagulation (ESG: OR 3.73, SG: OR 1.80). Race was not significantly associated with AE after ESG, while black race was associated with higher risk of AE after SG (OR 1.23, 95% CI: 1.13-1.35). (Table) Conclusion: ESG demonstrates comparable safety to SG with shorter procedure time and LOS. Clinicians may have been more inclined to readmit and intervene in ESG patients as compared to SG patients with similar complaints. Race did not impact short-term AE after ESG. Further prospective comparative studies are needed. Table 1. - Comparison of Short-Term Outcomes (30 Days) after Endoscopic Sleeve Gastroplasty versus Sleeve Gastrectomy Endoscopic Sleeve Gastroplasty (n = 6,053) Sleeve Gastrectomy (n=30,270) P-value Mean Pre-Procedure BMI (kg/m2) (SD) 40.5 (8.6) 42.8 (6.2) < 0.001 Mean Change in BMI After Procedure (kg/m2) (SD) -1.8 (2.9) -2.4 (1.8) < 0.001 Mean % Total Body Weight Loss (% TBWL) (SD) 4.0 (6.7) 5.4 (4.3) < 0.001 Major Adverse Event, n (%) 86 (1.4) 340 (1.1) 0.058 Reoperation, n (%) † 86 (1.4) 238 (0.8) < 0.001 Readmission, n (%) ‡ 231 (3.8) 794 (2.6) < 0.001 Re-Intervention, n (%) § 171 (2.8) 209 (0.7) < 0.001 Mean Number of Days from Procedure to Discharge (SD) 0.87 (2.18) 1.44 (0.97) < 0.001 Mean Procedure Length, minutes (SD) 62.90 (46.99) 71.69 (37.14) < 0.001 Received Treatment for Dehydration Outpatient, n (%) 147 (2.4) 993 (3.3) 0.001 Emergency Department Visit Not Resulting in Admission, n (%) 294 (4.9) 1786 (5.9) 0.002 †Abdominal re-exploration was the most commonly performed re-operation after both ESG and SG. The most common reason for re-operation after ESG included obstruction or gastrointestinal perforation, whereas gastrointestinal bleeding and staple line leak were the most common reasons after SG.‡Most common etiologies for readmission after ESG and SG were nausea, vomiting, fluid/electrolyte disturbance, and abdominal pain.§Most common re-intervention after ESG and SG was therapeutic endoscopy, with stent placement or dilatation representing the most common endoscopic interventions.