In a comprehensive analysis of clinical studies, researchers found that bariatric surgery leads to more substantial and lasting improvements in liver health than endoscopic procedures in patients with obesity-related liver disease.
Led by Dana Tasabehji of the University of Iowa, they examined the effectiveness of various weight-loss interventions in treating metabolic dysfunction-associated steatotic liver disease (MASLD), a condition that affects nearly 1 in 3 people worldwide.
Roux-en-Y gastric bypass (RYGB) was identified as the most effective intervention. Studies showed that RYGB resolved liver fat in up to 95% of patients. It also significantly reduced liver inflammation and fibrosis—the scarring that can progress to cirrhosis. Improvements were observed as early as 6 months postsurgery and persisted for up to 5 years. In one study, nearly half of the patients who underwent RYGB showed fibrosis regression. Levels of liver enzymes, including ALT and AST, declined by as much as 58% and 34%, respectively.
Vertical sleeve gastrectomy (VSG) showed similarly strong outcomes. Approximately 60% of patients achieved resolution of liver fat, a finding that was supported by improvements in imaging and biopsy findings. ALT and AST levels decreased by more than 60% in some cases. The procedure also led to improvements in metabolic conditions such as type 2 diabetes and hypertension.
Adjustable gastric banding (AGB), though less effective overall, still produced meaningful liver-related improvements. Around 42% of patients showed improvement in steatosis, and some had complete resolution of inflammation and fibrosis. AGB appeared particularly beneficial in adolescents, with reports of improved liver health alongside weight reduction.
Biliopancreatic diversion with duodenal switch (BPD-DS) also led to significant reductions in liver fat and resolution of steatohepatitis in about 70% of patients. However, some studies noted worsening fibrosis in a minority of cases. These adverse outcomes were possibly linked to rapid weight loss or nutritional deficiencies.
Endoscopic therapies, including intragastric balloon (IGB) and endoscopic sleeve gastroplasty (ESG), showed moderate hepatic benefits. IGB reduced liver fat in over 75% of patients within 6 months and lowered liver enzyme levels. ESG also improved markers of steatosis and fibrosis, and benefits were sustained for up to 2 years. However, both procedures produced less pronounced effects compared with surgical options and may be more suitable for patients who are not surgical candidates.
Emerging treatments such as duodenal mucosal resurfacing and duodenal-jejunal bypass liners demonstrated early benefits, including liver fat reduction and improved liver stiffness. However, long-term data are needed to establish their safety and effectiveness.
Overall, the evidence indicates that surgical interventions—especially RYGB and VSG—offer the most durable liver health improvements in patients with MASLD. Endoscopic approaches may serve as alternatives for those seeking less invasive treatments. Treatment selection should be based on clinical factors, liver disease severity, and patient preference.
The authors reported no conflicts of interest.
Source: Journal of Clinical Medicine