Surgeries and Endoscopic Procedures Offer Different Benefits for MASLD

As cases of metabolic dysfunction–associated steatotic liver disease (MASLD) rise alongside global obesity rates, evidence continues to show that bariatric surgery offers the most durable improvements in liver health, especially for patients with advanced disease.¹ Yet for individuals who are unable or unwilling to undergo surgery, emerging endoscopic techniques are becoming increasingly viable alternatives, with short- to medium-term benefits in reducing liver fat and improving fibrosis.

A comprehensive review published in the Journal of Clinical Medicine compared the effectiveness of multiple surgical and endoscopic interventions on hepatic outcomes in patients with MASLD and its more severe form, metabolic dysfunction–associated steatohepatitis (MASH). Although Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) remain the gold standards, according to the authors, the data affirm that less invasive options like endoscopic sleeve gastroplasty (ESG), intragastric balloons (IGBs), and duodenal mucosal resurfacing (DMR) can also yield clinically meaningful liver benefits.

Bypass and Sleeve Gastrectomy Lead in Long-Term Gains

Bariatric surgery has long been associated with improvements in cardiometabolic health, including long-term hypertension improvement in patients with obesity, but this review reinforced their impact on liver health as well.^2,3 In the review, RYGB led to steatosis remission in 89% to 95% of patients, with long-term reductions in liver fat, inflammation, and fibrosis.¹ Patients with moderate to severe baseline steatosis, defined as grades 2 and 3, especially saw these benefits. VSG demonstrated comparable efficacy, with about 50% to 60% of patients having substantial histological and clinical improvement or resolution of MASLD within 1 to 3 years after the operation; between 56% and 68% achieved remission.

In contrast, adjustable gastric banding (AGB) offered more modest results, improving steatosis in roughly 42% of cases compared with 76% with RYGB. Although the more aggressive biliopancreatic diversion with duodenal switch (BPD-DS) showed profound hepatic improvements—35% reduction in fatty liver after 1 year and 60% reduction after 3 years—it came with higher nutritional risks, limiting its routine use.

Protein–calorie malnutrition and deficiencies in fat-soluble vitamins are known complications of BPD-DS, and in rare cases, the procedure has been linked to acute liver failure.⁴ Some patients experiencing severe malabsorptive effects have required revisional surgeries, such as lengthening the common channel or converting to gastric bypass, to prevent worsening liver dysfunction. These concerns, alongside the procedure's technical complexity, have limited its broader clinical use despite its superior metabolic outcomes.¹

Endoscopic Procedures Offer Viable, Less Invasive Alternatives

Though not as powerful as surgery, endoscopic therapies have expanded treatment options for MASLD, particularly for those with contraindications to surgical procedures. IGBs demonstrated rapid steatosis reduction, with 1 study showing liver fat dropped from 52% to 4% in just 6 months (P < .0001) .⁵ ESG and DMR also showed promise, especially when paired with meaningful weight loss.¹

“Additionally, DMR exhibited insulin-sensitizing and lipid-lowering effects independent of weight loss or glycemic control, making it a promising intervention for MASLD and MASH,” the authors said. “Further studies are needed to establish its long-term role in metabolic and liver disease management.”

The duodenal-jejunal bypass liner (DJBL; EndoBarrier) is an endoscopic device designed to mimic the effects of gastric bypass surgery by reducing nutrient absorption. Clinical studies have shown that DJBL can lead to significant short-term weight loss, improved metabolic markers, and reductions in hepatic steatosis and liver stiffness, but fibrosis outcomes remain uncertain. Though promising, DJBL’s long-term safety and efficacy for MASLD and MASH will require further validation through ongoing trials like the RESET study (NCT04101669) expected to conclude in 2026.⁶

Early clinical data also suggest the Magnetic Anastomosis System (MAS)—a minimally invasive bariatric technique that connects 2 parts of the small intestine without surgical incisions—may lead to significant weight loss, improved blood sugar control, and reduced reliance on cardiometabolic medications, especially when combined with VSG.¹ Although initial findings are promising, larger trials are needed to confirm MAS’s long-term safety and potential benefits for liver outcomes in MASLD and MASH.

“Optimal procedural selection should consider patient-specific clinical factors, hepatic severity, and long-term therapeutic objectives,” the authors wrote. “Continued research through well-designed longitudinal studies will be critical to refine and optimize MASLD management strategies.”

References

1. Tasabehji D, Saleh S, Mokadem M. Impact of bariatric surgery and endoscopic therapies on liver health in metabolic dysfunction-associated steatotic liver disease: a review. J Clin Med. 2025;14(12):4012. doi:10.3390/jcm14124012
2. Bonavitacola J. Weight loss surgery associated with blood pressure control. AJMC^®. September 5, 2024. Accessed July 1, 2025. https://www.ajmc.com/view/weight-loss-surgery-associated-with-blood-pressure-control
3. Kaltwasser J. Bariatric surgery leads to long-term hypertension improvement in patients with obesity. AJMC. February 5, 2024. Accessed July 1, 2025. https://www.ajmc.com/view/bariatric-surgery-leads-to-long-term-hypertension-improvement-in-patients-with-obesity
4. Côté M, Pelletier L, Nadeau M, et al. Micronutrient status 2 years after bariatric surgery: a prospective nutritional assessment. Front Nutr. 2024;11:1385510. doi:10.3389/fnut.2024.1385510
5. Forlano R, Ippolito AM, Iacobellis A, et al. Effect of the BioEnterics intragastric balloon on weight, insulin resistance, and liver steatosis in obese patients. Gastrointest Endosc. 2010;71(6):927-933. doi:10.1016/j.gie.2009.06.036
6. RESET system pivotal trial (rev F) (STEP-1). ClinicalTrials.gov. Updated July 18, 2024. Accessed July 1, 2025. https://clinicaltrials.gov/study/NCT04101669