Endoscopic sleeve gastroplasty (ESG) ‒ A semi-systematic review of current evidence, metabolic impact, special populations, and comparative strategies.

Obesity is a major global health challenge. Conventional lifestyle interventions or emerging anti-obesity medications often fail to achieve sustained long-term results. Metabolic and bariatric surgery (MBS) remains the gold-standard treatment for moderate-to-severe obesity and its comorbidities. However, concerns regarding operative risk, irreversibility, high cost, and patient refusing surgical option limit broader adoption. Endoscopic bariatric therapies (EBT) have emerged as a minimally invasive alternative bridging medical and surgical approaches. Endoscopic sleeve gastroplasty (ESG) has become the most widely adopted. First described in 2013, ESG has demonstrated feasibility, safety, and efficacy in obesity management. Large case series and meta-analyses report 15-20% total weight loss up to 24 months, emerging 5-year data, and 50-80% improvement in obesity-related comorbidities. Serious adverse events occur in less than 2.5% of cases. ESG is highly cost-effective compared with lifestyle intervention alone. Relative to laparoscopic sleeve gastrectomy, ESG offers lower procedural risk, faster recovery, and anatomical preservation, making it suitable for patients with mild-to-moderate obesity or elevated surgical risk. Emerging innovations in EBT include ESG technical improvements, robotic-assisted ESG, new suturing devices, combination therapy with GLP-1RAs, small-intestine metabolic interventions, and AI-assisted navigation. With ongoing advancements and expanding indications, ESG is poised to become a cornerstone of modern obesity management. This semi-systematic review summarizes recent global ESG evidence from 2020 to 2025, highlighting mechanisms and technical aspects, indications, efficacy in weight loss and metabolic improvement, special populations, safety, cost-effectiveness, and comparisons with diet alone, pharmacotherapy, and bariatric surgery.