A propensity-matched cohort study of nearly 90,000 patients per group found that bariatric surgery—especially sleeve gastrectomy—carries significantly higher five-year esophageal complications than GLP-1 RA therapy for weight loss. Surgery patients experienced approximately double the risk of de novo reflux esophagitis (0.7% vs 0.4%), GERD (16.9% vs 9.8%), and Barrett esophagus (0.5% vs 0.2%) compared with GLP-1 RA users. Surgical patients also required more EGDs (8.8% vs 3.7%) and acid-suppression therapy, with PPI initiation in 29.4% versus 20.8%. Among interventions, sleeve gastrectomy showed the highest GERD rate (19.1%) while tirzepatide had the lowest (6.4%), suggesting GLP-1 RA therapy may offer a safer esophageal profile for appropriate candidates seeking medical weight management.