Background <p>Endoscopic sleeve gastroplasty (ESG) is increasingly utilized for treating obesity, but some patients may subsequently present for conversion to a surgical procedure. Foreign material or distorted anatomy may make conversion more challenging. The preoperative evaluation, intraoperative findings, and postoperative outcomes of converting ESG to bariatric surgery are not well described.</p> Methods <p>Bariatric surgery patients at a single center with history of ESG were identified by review of electronic medical records from 2016 to 2026. Background characteristics, preoperative imaging, endoscopic findings, intraoperative details, and outcomes were obtained by chart review. Intraoperative videos were obtained when possible.</p> Results <p>Twenty patients underwent conversion from ESG to laparoscopic sleeve gastrectomy (<i>n</i> = 11) or gastric bypass (<i>n</i> = 9) between 2021 and 2026. Prior ESG was performed at various centers locally and abroad. Mean pre-surgery BMI was 37.6&#xa0;kg/m². Most patients (19/20, 95%) underwent preoperative esophagram, which showed a tubularized stomach in half of cases (10/19, 53%) but no radiopaque materials precluding conversion to surgery. Preoperative endoscopy (<i>n</i> = 5) and intraoperative endoscopy (<i>n</i> = 3), when performed, revealed no apparent gastroplasty. Intraoperative findings included mild adhesions around the stomach, with sutures sometimes visible, but an otherwise native stomach not requiring any changes to the staple line. Mean total weight loss was 29.1% at 1&#xa0;year postoperatively. No stapler misfires occurred, and none of the postoperative complications were related to&#xa0;the&#xa0;gastric staple line. There were no gastric staple line leaks or bleeds.</p> Conclusion <p>In our experience, sleeve gastrectomy and gastric bypass were both technically feasible and relatively straightforward to perform in patients with a history of ESG.</p>