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Introduction Endoscopic sleeve gastroplasty (ESG) has gained traction as a minimally invasive intervention for obesity, delivering notable weight loss and metabolic benefits. However, its safety and efficacy in patients with compensated advanced chronic liver disease (cACLD) remain underexplored and these patients are often perceived as higher risk for procedures.Methods A retrospective review was conducted of patients with cACLD who underwent ESG at a tertiary hospital in Singapore. All procedures were performed by a single expert endoscopist employing a standardised U-shaped stitch pattern. Data on patient demographics, procedural safety, weight loss outcomes, and liver stiffness metrics were collected and analysed.Results Six patients with cACLD secondary to metabolic dysfunction-associated steatotic liver disease were included, with one patient presenting with clinically significant portal hypertension and varices documented on prior endoscopy. The cohort had a mean weight of 87.7 ± 16.8 kg and mean BMI of 32.7 ± 2.6 kg/m 2. No intraprocedural or postprocedural complications occurred. At 6 months, significant mean weight loss of 9.9 ± 4.1 kg was achieved (p < 0.05). FibroScan data available for four patients demonstrated significant reduction in liver stiffness (mean decrease: 4.2 ± 2.5 kPa, p < 0.05). A decrease in controlled attenuation parameter values was also observed (mean: 16.3 ± 22.3 dB/m), although this did not reach statistical significance (p > 0.05).Conclusions This single-centre experience suggests that ESG is a safe and feasible option for patients with cACLD, with no observed procedural complications. Preliminary data indicate potential benefits in weight loss and liver stiffness, underscoring the need for larger studies to validate these findings and further elucidate the metabolic and hepatic outcomes of ESG in this high-risk group.