Endoscopic sleeve gastroplasty (ESG) has emerged as a minimally invasive, organ-sparing alternative to surgical bariatric procedures in the treatment of obesity. Initially developed to mimic the restrictive effect of surgical sleeve gastrectomy without requiring gastric resection, ESG has evolved through major technical refinements—including improved suture patterns and device platforms that enhance sleeve durability and procedural safety. Supported by growing clinical evidence, including randomized trials such as the MERIT study and data from large multicenter cohorts, ESG has demonstrated sustained weight loss, favorable metabolic outcomes, and a low complication profile. Its indications have expanded to include high-risk surgical candidates, lower BMI populations, and patients needing revisional or rescue intervention. Additionally, ESG’s integration with pharmacologic therapies and the exploration of novel technologies such as argon plasma coagulation and magnetic compression anastomosis continue to broaden its clinical utility. As global experience increases and new innovations emerge, ESG is solidifying its role as a safe, adaptable, and effective tool within the multidisciplinary management of obesity.