Non-alcoholic fatty liver disease: Is surgery the best current option and can novel endoscopy play a role in the future?

Abstract

Over the last decade, non-alcoholic fatty liver disease (NAFLD) has overtaken alcohol as the leading cause of cirrhosis in the Western world. There remains to be a licensed pharmacological treatment for NAFLD. Weight loss is advised for all patients with NAFLD. Many patients however, struggle to lose the recommended weight with lifestyle modification alone. Many drugs have either failed to show significant improvement of steatosis or are poorly tolerated. Bariatric surgery has been shown to reduce liver steatosis and regress liver fibrosis. The pathophysiology is not fully understood, however recent evidence has pointed towards changes in the gut microbiome following surgery. Novel endoscopic treatment options provide a minimally invasive alternative for weight loss. Randomised controlled trials are now required for further clarification.

Keywords: Obesity; Metabolic associated fatty liver disease; Non-alcoholic fatty liver disease; Non-alcoholic steatohepatitis; Bariatric endoscopy; Bariatric surgery

Core Tip: The overstitch endoscopic suturing system (Overstitch; Apollo Endosurgery, Austin, Tex) which was first reported in 2013, allows sleeve gastropexy to be performed by placing full-thickness sutures through the gastric wall from the pre-pyloric antrum to the gastro-oesophageal junction. Performed using flexible endoscopy, it has the advantage of being less invasive with no permanent visible scar and evidence suggestive of fewer complications compared to laparoscopic sleeve gastrectomy. There is now mounting evidence not only showing benefits in terms of weight loss but also improvements in other metabolic markers including Hemoglobin A1c, blood pressure and alanine aminotransferase, making endoscopic sleeve gastroplasty potentially a viable treatment option for non-alcoholic fatty liver disease in the future.