Endoscopic sleeve gastroplasty (ESG) is an endoscopic metabolic intervention that achieves clinically meaningful weight loss at short- and early mid-term follow-up. Considerable variation persists in patient selection, procedural technique, and post-procedure management. To harmonize practice and define priorities for future research, an international multidisciplinary consensus was developed under the International Federation for Surgery and Other Therapies for Obesity (IFSO).

A modified Delphi process was conducted among 23 international experts in metabolic bariatric surgery, bariatric endoscopy, endocrinology, and nutrition. Statements derived from a structured literature review were refined through three rounds of anonymous voting. Agreement was defined as ≥ 80% of votes within the 7–9 range on a 9-point Likert scale. Consensus strength was graded A (≥ 90%), B (80–89%), or C (70–79%).

Twenty-eight statements were finalized across three domains: (1) indications and patient selection (2), technical and procedural considerations, and (3) post-procedure management. Twenty-three statements reached grade A or A+, four grade B, and one grade C. Strong agreement supported multidisciplinary evaluation before ESG, standardized full-thickness suturing along the greater curvature, and selective use of adjunct pharmacotherapy in patients with suboptimal initial clinical response.

This international consensus provides a framework for current best practices in ESG, supporting standardization of indications and techniques, safety, and integration within standard pathways for the treatment of obesity.