Endoscopic sleeve gastrectomy vs traditional bariatric surgery: A paradigm shift in managing metabolic dysfunction-associated steatohepatitis and cirrhosis?

Abstract

Metabolic dysfunction-associated steatohepatitis (MASH) has become a leading indication for liver transplantation. Bariatric surgery is a proven intervention for weight loss and metabolic improvement in MASH but concerns over surgical risk in patients with advanced liver disease has expanded interest in endoscopic sleeve gastroplasty (ESG) as a less invasive alternative. This review examine the efficacy, safety, and metabolic impact of ESG vs traditional bariatric surgery (Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy) in patients with MASH, with and without cirrhosis. We analyze current evidence on weight loss outcomes, histologic and biochemical improvements in MASH, resolution of metabolic syndrome, and perioperative risks associated with these procedures. Special attention is given to the feasibility of ESG in compensated cirrhosis (Child-Pugh A/B) and the potential role of bariatric interventions in delaying or avoiding liver transplantation. As the prevalence of MASH-related cirrhosis rises, refining bariatric strategies for this high-risk population is imperative. ESG may offer a lower procedural risk profile, but current data are largely limited to small, observational studies with short-term follow-up. A tailored, multidisciplinary approach is essential to optimize weight management and liver health in MASH patients, with future studies needed to clarify the long-term efficacy and safety of ESG in MASH.

Key Words: Obesity; Metabolic dysfunction-associated steatohepatitis; Liver cirrhosis; Endoscopic sleeve gastroplasty; Laparoscopic sleeve gastrectomy; Roux-en-Y gastric bypass

Core Tip: Endoscopic sleeve gastroplasty (ESG) is an emerging minimally invasive option for obesity and metabolic dysfunction-associated steatohepatitis (MASH), particularly in patients with advanced liver disease who are poor surgical candidates. This review explores ESG’s potential to improve weight loss, insulin resistance, and hepatic markers, with fewer complications than traditional bariatric surgery, though current evidence remains preliminary. As the global burden of MASH grows, ESG may represent a safer, more accessible intervention, especially where liver transplantation is not feasible, while ongoing trials and individualized strategies continue to clarify its long-term role in liver care.

INTRODUCTION

The global rise in obesity has led to a parallel surge in metabolic dysfunction-associated steatotic liver disease (MASLD), a condition now recognized as the most common chronic liver disease worldwide and a major contributor to cirrhosis and liver transplantation demand[1,2]. MASLD encompasses a spectrum from simple steatosis to the more aggressive form, nonalcoholic steatohepatitis (MASH), characterized by hepatocellular injury, inflammation, and fibrosis[1,3]. This progression increases the risk of cirrhosis, hepatocellular carcinoma (HCC), and liver failure, placing a growing burden on healthcare systems.

Weight loss remains the cornerstone of MASLD and MASH management. Clinical guidelines consistently emphasize that even modest reductions in body weight can lead to meaningful improvements in liver fat, inflammation, and fibrosis[2,4,5]. For many patients, however, achieving and sustaining weight loss through lifestyle modification alone is difficult. As a result, bariatric surgery, particularly Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG), has become a key treatment option for individuals with obesity and metabolic liver disease in the absence of decompensated cirrhosis, offering substantial and durable improvements in hepatic and metabolic parameters[4-6].

In recent years, endoscopic sleeve gastroplasty (ESG) has emerged as a minimally invasive alternative under investigation. ESG reduces gastric volume via endoscopic suturing, inducing weight loss without the need for surgical incisions or permanent anatomical changes[7,8]. Early studies suggest that ESG may be a lower-risk option for patients at elevated surgical risk, such as those with advanced liver disease or multiple comorbidities, while potentially conferring metabolic and hepatic benefits[7]. However, most available data are derived from small, observational, or single-center studies, and long-term outcomes remain to be clearly defined.

This narrative review synthesizes the current literature comparing ESG with traditional bariatric surgery in the treatment of MASLD and MASH. We examine their respective impacts on weight loss, liver histology, metabolic health, procedural safety, and perioperative risk. Special attention is given to applications in patients with cirrhosis, the potential role of endoscopic interventions in transplant eligibility, and evolving multidisciplinary approaches to care. Our goal is to provide clinicians with a practical, evidence-based framework for selecting optimal interventions in this complex and increasingly prevalent population. To support this synthesis, we conducted a focused literature review as outlined below.

A targeted search of PubMed, EMBASE, and Google Scholar was performed to identify articles published from inception to May 2025. The search was not limited by language, study design, or country of origin. Search terms included combinations of: “Endoscopic sleeve gastroplasty”, “laparoscopic sleeve gastrectomy”, “Roux-en-Y gastric bypass”, “bariatric surgery”, “MASLD”, “MASH”, “fibrosis”, and “cirrhosis”. Guidelines and position statements from American Association for the Study of Liver Disease (AASLD), American Society of Anesthesiologists (AGA), European Association for the Study of the Liver (EASL), American Society of Metabolic and Bariatric Surgery (ASMBS), and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) were also reviewed. Studies were selected based on relevance to MASLD, MASH, or cirrhosis and inclusion of hepatic or metabolic outcomes. Priority was given to randomized controlled trials, cohort studies, and meta-analyses published in peer-reviewed journals. Because this is not a systematic review, PRISMA guidelines were not followed, and no formal protocol was registered. GRADE criteria were also not formally applied. Findings were synthesized qualitatively based on clinical significance, recency, and overall quality of evidence.

PATHOPHYSIOLOGY OF MASH AND THE ROLE OF OBESITY

Background and epidemiology

MASH is a progressive form of MASLD characterized by hepatocyte ballooning, hepatic steatosis, lobular inflammation, and variable degrees of fibrosis[9,10].

As of 2023, MASLD was estimated to affect more than 30% of the global population, a rise from 25% in 2016[11]. The prevalence of MASH among individuals with MASLD is less precisely defined due to reliance on biopsy for diagnosis, but the best estimates suggest approximately 16%, with reported ranges from 3% to 50% depending on study design and patient population[11,12]. MASH has emerged as a leading cause of cirrhosis and HCC, and is now the most common cause of liver transplantation in the United States among females and those over age 65 years[13,14]. Recognizing and interrupting the progression from MASLD to MASH and cirrhosis offers an important opportunity to reduce liver-related morbidity and mortality.

Mechanisms of obesity, hepatic steatosis, and fibrosis

More than two-thirds of individuals with MASLD meet clinical criteria for obesity[15]. Adipose tissue functions as a metabolically active endocrine organ, comprising adipocytes, preadipocytes, macrophages, and stromal cells that regulate energy homeostasis, insulin sensitivity, and inflammatory signaling[15,16]. A significant portion of hepatic triglycerides-up to two-thirds-are derived from circulating free fatty acids (FFAs) released by adipose tissue[15].

Obesity induces adipose expansion through hypertrophy and hyperplasia, alongside activation of inflammatory pathways such as JNK, IKK/NF-κB, and TLR4[14,15]. These alterations lead to systemic insulin resistance, heightened hepatic de novo lipogenesis, and increased FFA flux to the liver[12]. The hepatic accumulation of lipotoxic species induces oxidative stress, mitochondrial dysfunction, and endoplasmic reticulum stress, setting the stage for hepatocellular injury and inflammation[15,17]. In response, hepatic stellate cells are activated and promote fibrogenesis[12,18]. Over time, persistent injury and maladaptive wound healing result in apoptosis, fibrosis, and genomic instability, increasing the risk of cirrhosis and HCC[12,18-20].

Obesity also contributes to a chronic low-grade inflammatory state via secretion of cytokines like tumor necrosis factor-alpha (TNF-α) and interleukin-6 from dysfunctional adipose tissue[12,21]. These converging metabolic and inflammatory insults can drive progression from simple steatosis to MASH. However, while obesity, insulin resistance, and hepatic steatosis are strongly associated with MASH, none of these factors alone reliably predict fibrosis progression[9,12]. Instead, disease evolution appears to hinge on the cumulative impact of metabolic stressors, genetic predispositions, and environmental factors.

The interplay between metabolic dysfunction, chronic inflammation, and fibrogenesis underscores the multifaceted pathophysiology of MASH[11,14]. Yet beyond these intrinsic mechanisms, external factors such as diet quality and gut microbial composition have gained increasing recognition for their role in modulating disease progression[5,21]. Exploring how these factors contribute to hepatic injury further enriches our understanding of MASH pathogenesis and lays the groundwork for evaluating targeted interventions, including bariatric surgery, that may influence both systemic and liver-specific metabolic pathways[2,5].

Gut microbiota and dietary factors: Diet quality and gut microbial composition are central to MASH pathogenesis. High-fat, low-fiber, and fructose-rich diets are associated with hepatic steatosis and inflammation[12]. In murine studies, healthy dietary interventions improved hepatocyte ballooning and attenuated MASH activity[22]. Similarly, a Mediterranean-style diet improved hepatic steatosis and insulin sensitivity in individuals with MASLD[12,23].

The gut-liver axis provides a mechanistic link: Microbial metabolites and endotoxins from the gut reach the liver via the portal vein, modulating hepatic inflammation and fibrogenesis[24]. Dysbiosis and increased intestinal permeability allow translocation of endotoxins such as lipopolysaccharides, which activate Kupffer and stellate cells through TLR4 signaling[24,25]. MASLD patients typically exhibit reduced gut microbial diversity and compositional shifts, including increases in Escherichia, Streptococcus, and Prevotella, and reductions in Coprococcus and Faecalibacterium, though heterogeneity limits diagnostic applications[26,27].

Weight loss and its impact on histologic and metabolic parameters

Intentional weight loss is one of the most effective strategies associated with improvement in the histological features of MASH. Clinical trials have demonstrated that achieving ≥ 7%-10% total body weight loss (TBWL) is linked to resolution of steatohepatitis and regression of fibrosis in a substantial proportion of patients[28-30]. In one study, patients following a low-fat, high-fiber diet rich in fruits and vegetables showed histological improvement in nearly half of cases, with those achieving ≥ 10% weight loss demonstrating consistent improvements across all histologic domains[28].

Beyond liver-specific effects, weight loss improves systemic insulin resistance, reduces alanine aminotransferase (ALT) levels, improves lipid profiles, and lowers systemic inflammation[29-31]. These findings underscore the central role of weight reduction in both the prevention and management of MASH.

TRADITIONAL BARIATRIC SURGERY: EFFICACY AND LIMITATIONS

Bariatric surgery has long been recognized as an effective intervention for achieving substantial and sustained weight loss, and mounting evidence supports its role in improving liver histology in patients with MASH[30-34]. Standard indications recommend bariatric surgery for individuals with body mass index (BMI) ≥ 40 kg/m², or ≥ 35 kg/m² with obesity-related comorbidities[15]. Among available surgical options, RYGB and LSG are the most commonly performed procedures[34-36]. RYGB combines restrictive and malabsorptive mechanisms by creating a small gastric pouch and rerouting a portion of the small intestine[35,36]. LSG, in contrast, is a purely restrictive intervention that involves the resection of approximately 80% of the stomach, promoting early satiety and reduced caloric intake[35-37].

Both surgeries yield metabolic improvements that extend beyond weight reduction, including enhanced insulin sensitivity and beneficial changes in gut-derived hormones such as ghrelin, glucagon-like peptide-1 (GLP-1), and peptide YY (PYY)[38,39]. In a pivotal prospective study, 84% of patients undergoing bariatric surgery experienced histological resolution of MASH without fibrosis progression after five years[32]. Moreover, a recent randomized controlled trial comparing bariatric surgery to lifestyle intervention found that significantly more patients in the surgical arms achieved MASH resolution without worsening fibrosis at one year-57% following LSG and 56% following RYGB-compared to just 16% in the lifestyle group[40]. These outcomes underscore the capacity of surgery to induce significant metabolic and hepatic benefits, likely reflecting the magnitude of weight loss achieved.

Nevertheless, bariatric surgery carries notable risks and limitations, particularly in individuals with advanced liver disease. Current guidelines recommend bariatric surgery for patients with obesity and MASH in the absence of cirrhosis, citing its benefits in halting disease progression and reversing fibrosis[4,41]. In cases of compensated cirrhosis, surgery may still be considered with appropriate patient selection and multidisciplinary coordination, and has been associated with histological and metabolic improvement when performed in experienced centers[4,36,41,42].

However, outcomes are heavily influenced by the degree of liver dysfunction. A large cohort study demonstrated that patients with compensated cirrhosis had twice the odds of postoperative mortality compared to non-cirrhotic individuals, while those with decompensated cirrhosis faced more than 21 times the odds of death following surgery[43]. Similarly, a meta-analysis confirmed that cirrhotic patients undergoing bariatric procedures had over twice the risk of surgical complications, though bariatric surgery was still associated with improvements in comorbidities and liver function when successful[44,45]. These findings emphasize the importance of a highly individualized, risk-stratified approach to surgical planning.

In patients with decompensated cirrhosis or clinically significant portal hypertension, bariatric surgery is generally contraindicated due to the elevated risk of postoperative hepatic decompensation and mortality[4,41]. Even in less advanced disease, perioperative complications—such as anastomotic leaks, surgical site infections, venous thromboembolism, and micronutrient deficiencies—remain concerns and require close monitoring[36,37].

Given these limitations, there is increasing interest in minimally invasive alternatives such as ESG, which may offer favorable safety profiles in select high-risk populations, though evidence regarding its metabolic and hepatic benefits remains preliminary and largely based on short-term, observational data.

ESG: A MINIMALLY INVASIVE ALTERNATIVE

ESG is a less invasive alternative to traditional bariatric surgery for patients seeking weight loss and metabolic improvement. This incisionless procedure employs a full-thickness endoscopic suturing system to reduce gastric volume, mimicking the restrictive mechanism of surgical sleeve gastrectomy without requiring resection or permanent anatomical alteration[46-48]. Its minimally invasive nature has been associated with fewer perioperative complications, reduced postoperative discomfort, and shorter recovery times compared to surgical approaches[49]. These procedural features are particularly relevant for patients with liver disease or elevated surgical risk.

Importantly, ESG does not involve intestinal bypass, thereby lowering the risk of nutrient malabsorption, a key consideration in patients with early-stage liver disease, where nutritional preservation is critical. This characteristic makes ESG a potential option for individuals who are not ideal surgical candidates due to comorbid conditions or compensated liver dysfunction[46]. As such, careful definition and application of selection criteria for ESG remain essential.

ESG is generally offered to patients with a BMI of 30-40 kg/m² or those with elevated surgical risk. While patients with MASH and BMI ≥ 35 kg/m² are often considered strong candidates for bariatric surgery due to the potential for histologic benefit, ESG has gained attention as a less invasive alternative in select cases[50]. Consensus statements suggest ESG is appropriate for patients with BMI > 30, or ≥ 27 with comorbidities[51]. However, robust comparative data are still limited, and outcomes should be interpreted in the context of evolving evidence.

Although ESG typically results in less weight loss than surgical procedures, early studies suggest it may still provide clinically relevant benefits. Reported TBWL at 12-24 months ranges from 15%-20%, along with improvements in metabolic parameters such as hemoglobin A1c, triglycerides, and liver enzymes[48,52,53]. A 2023 meta-analysis comparing ESG to LSG confirmed greater weight loss in the LSG group at all time points; however, ESG showed a lower incidence of adverse events[49]. While this difference did not initially reach statistical significance, a sensitivity analysis excluding a heterogeneity-driving study demonstrated a significant reduction in adverse events with ESG (relative risk: 0.39, 95%CI: 0.18-0.83, P = 0.01). These findings support ESG’s potential procedural safety advantages, although long-term data are still lacking.

Emerging evidence suggests ESG may lead to improvements in liver-related surrogate markers, but its long-term histological impact remains uncertain. A 2024 sham-controlled randomized trial reported reductions in liver stiffness and hepatic steatosis after ESG; however, changes in the non-alcoholic fatty liver disease activity score (NAS) and fibrosis stage were not observed unless patients achieved > 10% TBWL[54,55]. In this subgroup, improvements in NAS were noted, underscoring the critical role of weight loss magnitude in driving hepatic benefit. These findings align with broader analyses of biochemical and imaging-based markers but should not be interpreted as equivalent to biopsy-confirmed histologic resolution.

Further support comes from a 2023 meta-analysis documenting reduction in steatosis, fibrosis scores, and ALT levels following ESG[56]. The rate of severe adverse events remains low (about 2%), with the most common complications being transient nausea and abdominal pain[57]. Serious adverse events, including perigastric leak and gastrointestinal bleeding, are rare but underscore the need for experienced operators and careful monitoring.

Preliminary studies suggest ESG may be feasible in selected patients with compensated liver disease and has not been associated with worsening hepatic function in early reports[46]. It has also been explored in post-liver transplant recipients with obesity, although this evidence is still limited and largely descriptive[58]. ESG is currently not recommended for patients with decompensated cirrhosis due to insufficient safety and efficacy data. As such, patient selection remains a cornerstone of clinical decision-making.

Taken together, ESG represents a potential tool in the evolving treatment landscape for MASLD. While its minimally invasive profile and preliminary benefits are encouraging, more rigorous studies are needed to clarify its role. Until then, ESG should be considered on a case-by-case basis in multidisciplinary settings, with clear communication about its benefits, limitations, and evolving evidence base.

BARIATRIC INTERVENTIONS IN CIRRHOSIS: A HIGH-RISK POPULATION

Risk stratification: Compensated vs decompensated cirrhosis

Stratifying cirrhosis into compensated and decompensated stages is crucial to guide safe bariatric intervention. Compensated cirrhosis typically presents without major symptoms, while decompensated disease manifests with complications such as ascites, variceal bleeding, and/or hepatic encephalopathy. The Child-Turcotte-Pugh (CTP) score remains a widely used tool to assess surgical risk, classifying patients into Child A (5-6 points), B (7-9), or C (≥ 10). Postoperative mortality rises significantly across these classes, with estimates of about 10% for Child A, about 30% for Child B, and over 70% for Child C undergoing abdominal surgery[59,60]. Similarly, a model for end-stage liver disease (MELD) score > 20 is strongly associated with adverse perioperative outcomes[58].

When considering endoscopic ESG in patients with cirrhosis, additional hepatic-specific stratification is warranted. ESG is generally contraindicated in the presence of portal hypertension or gastroesophageal varices due to increased risk of bleeding and poor procedural tolerance. Coagulopathy is another commonly cited exclusion criterion, aimed at minimizing peri-procedural complications. Technical limitations such as large hiatal hernias (> 3-5 cm), active peptic ulcer disease, neoplastic lesions, or prior gastric surgery may also preclude ESG[8,46]. These criteria, along with severe psychiatric illness, pregnancy, active substance use, and advanced cardiopulmonary disease, are commonly applied to the general ESG population and are frequently considered absolute or relative contraindications regardless of liver status[48,51,58].

Although not uniformly assessed, sarcopenia may represent an important consideration given its association with poor post-procedural outcomes. Most protocols emphasize multidisciplinary evaluation, often involving hepatology, nutrition, psychology, and endocrinology[48,52]. Pre-procedural workup typically includes laboratory tests, abdominal imaging, and upper endoscopy to screen for active infection, decompensation, or unrecognized portal hypertension. ESG may be cautiously considered in well-compensated cirrhosis, provided there is no clinical or radiologic evidence of clinically significant portal hypertension.

Bariatric surgery is contraindicated in patients with decompensated cirrhosis unless performed in conjunction with liver transplantation[41,60,61]. In contrast, individuals with well-compensated disease (CTP A or MELD ≤ 15) may be considered for LSG or RYGB following comprehensive multidisciplinary evaluation[61]. Though these patients have higher perioperative mortality compared to non-cirrhotic populations, outcomes in high-volume centers are acceptable (< 1%) in carefully selected patients and may be offset by the benefits of metabolic and hepatic improvement[62]. However, delayed wound healing in the setting of high-dose prednisone and immunosuppression, as well as the critical need for nutrition post-transplantation, may limit the feasibility of routine simultaneous liver transplantation and bariatric surgery.

Pre-transplant optimization: Bariatric interventions as a bridge to transplant

Bariatric interventions are increasingly being explored to optimize obese patients with cirrhosis for liver transplantation. Minimally invasive strategies such as intragastric balloons (IGBs) and ESG offer potential lower-risk alternatives to surgery in this high-risk population. Small case series suggest that IGBs may enable sufficient weight loss to meet transplant eligibility criteria[62,63]. ESG has also been proposed as a possible “last resort” option for patients ineligible for surgery; however, prospective data supporting its safety and efficacy in this setting remain limited, and long-term outcomes are unknown[42,64].

Surgical approaches, particularly LSG, have demonstrated potential in carefully selected patients. In one cohort of 32 individuals with compensated cirrhosis (median MELD score of 12) undergoing LSG, there were no perioperative deaths or liver-related complications. Clinical improvements were observed in a subset of patients (seven experienced resolution of MASLD-related complications), and 14 ultimately underwent liver transplantation[42]. Nevertheless, follow-up analyses have raised concerns that prior bariatric surgery, especially RYGB, may increase the risk of waitlist dropout or post-transplant complications due to nutrient malabsorption and technical challenges during transplantation[42].

Complications and perioperative risks

Cirrhotic patients undergoing bariatric surgery face higher risks of complications than non-cirrhotic patients. National inpatient database analyses show that among bariatric surgery admissions, those with cirrhosis had increased rates of in-hospital mortality (about 1.8% vs 0.17%), postoperative bleeding (2.9% vs 1.1%), acute kidney injury (4.5% vs 1.2%), and surgical complications (2.0% vs 0.6%)[66]. Outcomes tend to be worse at low-volume centers (< 50 cases/year), where cirrhotic patients experienced 4-5 times higher mortality compared to non-cirrhotic individuals[65].

Common complications include wound infection, hepatic decompensation, renal injury, and portal vein thrombosis. Coagulopathy and portal hypertension can predispose patients to bleeding, even during laparoscopic approaches such as LSG[66]. Additionally, the physiologic stress of surgery may trigger decompensation in marginally stable individuals. These findings reinforce that while Child A patients often tolerate surgery reasonably well, those with Child B or C disease face exponentially greater risks[41,61].

Current recommendations advise that patients with decompensated cirrhosis (CTP C or MELD > 20) defer bariatric surgery unless undergoing simultaneous liver transplantation[41,60].

Simultaneous liver transplantation and sleeve gastrectomy

Some transplant centers have explored simultaneous liver transplantation and sleeve gastrectomy (LT-SG) as a combined strategy for managing obesity in patients with end-stage liver disease. Preliminary data from the Mayo Clinic (n is close to 7) suggest that the approach is technically feasible, resulting in sustained weight loss and metabolic improvements without prolonging hospital stay or increasing perioperative complications[42]. Complementing these findings, a prospective study from Italy evaluated 11 morbidly obese transplant candidates who underwent LT-SG. Most were transplanted for HCC, with over half receiving extended criteria donor organs. Although meaningful long-term weight loss was achieved, the study reported a high 90-day mortality rate (54.5%), with all deaths occurring in patients with multiple risk factors, including age > 60, BMI > 45, metabolic syndrome, MELD > 25, or a high donor risk index[67].

These findings underscore the complexity and high risk associated with LT-SG. While the procedure may offer metabolic advantages, its use should be restricted to carefully selected patients with favorable donor profiles and minimal additional comorbidities. Prognostic models such as the MELD and Pretransplant Survival Outcomes Following Liver Transplantation can help assess transplant candidacy, though only MELD has been widely validated and incorporated into clinical practice. For centers considering LT-SG, success depends on a coordinated, multidisciplinary approach involving transplant hepatologists, bariatric surgeons, anesthesiologists, and other specialists[67].

Although bariatric interventions show potential as a bridge to transplantation, particularly in the setting of severe obesity, the use of combined LT-SG should remain limited to experienced centers with robust multidisciplinary teams and well-defined patient selection protocols[42,68]. Ongoing multicenter studies are needed to refine candidate criteria and establish long-term safety and efficacy benchmarks.

Comparative procedures: ESG vs surgical options

Restrictive approaches are generally favored in cirrhotic patients due to a lower risk of malabsorption. LSG is often preferred over RYGB because it avoids intestinal rerouting and maintains endoscopic access to the biliary tree—an important consideration in transplant candidates[42]. Although RYGB typically yields greater weight loss, it is technically more complex and associated with a higher risk of malnutrition and sarcopenia, particularly in patients with cirrhosis[42].

ESG has been proposed as a less invasive alternative that involves no incisions, no intestinal bypass, and minimal anatomical disruption. Meta-analyses indicate that ESG achieves approximately 15%-20% TBWL, with reported complication rates of 2%-3%, compared to 10%-17% following LSG[69]. However, these comparisons are based on studies involving predominantly non-cirrhotic populations. Data specific to ESG in cirrhotic patients remain limited, and its safety profile in the presence of portal hypertension is not well established. While ESG avoids general anesthesia and may theoretically reduce surgical stress, it still involves full-thickness gastric suturing, which could pose bleeding risks in patients with elevated portal pressures[42].

At present, LSG remains the most evidence-supported bariatric option for patients with compensated cirrhosis. ESG may represent a potential alternative in selected cases, but further prospective studies are needed to confirm its safety and efficacy in this population.

Current guidelines and clinical decision pathways

Table 1 outlines current guideline-based approach to bariatric therapy in patients with cirrhosis. Major guidelines emphasize individualized care in patients with cirrhosis. The 2023 AASLD guidelines recommend that bariatric surgery be considered in compensated cirrhosis only after thorough multidisciplinary evaluation and explicitly advise against surgery in decompensated patients, except in the context of liver transplantation[41]. Similarly, the 2024 EASL-European Association for the Study of Diabetes-European Association for the Study of Obesity MASLD guidelines state that bariatric surgery may be considered in compensated advanced liver disease, particularly in the absence of clinically significant portal hypertension, but is contraindicated in patients with decompensated cirrhosis[4].

Table 1 Recommendations based on liver disease severity.

Liver disease severity	Guideline recommendation
No cirrhosis	Follow standard bariatric surgery guidelines
Compensated cirrhosis (Child-Pugh A)	LSG or ESG may be considered in high-volume centers with hepatology involvement
Clinically significant portal hypertension or Child-Pugh B	Proceed with extreme caution, with multidisciplinary evaluation
Decompensated cirrhosis (Child-Pugh C)	Avoid bariatric surgery outside of liver transplant settings

LSG: Laparoscopic sleeve gastrectomy; ESG: Endoscopic sleeve gastroplasty.

The ASMBS/IFSO 2022 statement highlights that obesity accelerates liver disease progression and supports the consideration of bariatric surgery in well-selected Child A or B patients when performed in experienced centers[62]. The presence of clinically significant portal hypertension may represent a critical threshold, requiring case-by-case assessment.

The AGA further endorses LSG as the preferred procedure in cirrhotic patients and reiterates that bariatric surgery should only be offered to individuals with decompensated liver disease in the context of liver transplantation[42].

The joint American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies in the management of obesity, which recommend individualized use of endoscopic bariatric therapies in patients with BMI > 30 or > 27 with at least one obesity-related comorbidity[70].

ESG VS TRADITIONAL SURGERY: COMPARATIVE OUTCOMES

To support clinical decision-making, Table 2 below summarizes key comparative outcomes of ESG, LSG, and RYGB[71-82]. These interventions differ in weight loss efficacy, metabolic impact, and hepatic outcomes, factors particularly relevant for patients with obesity and MASLD. Short-and long-term data across are reviewed across domains such as TBWL, MASH resolution, fibrosis regression, glycemic control, lipid profile, and liver inflammation.

Table 2 Endoscopic sleeve gastroplasty vs traditional surgery.

Category	RYGB	LSG	ESG	Ref.
Procedure type	Surgical (anatomic bypass)	Surgical (gastric volume reduction)	Endoscopic (gastric plication without resection)
Expected Weight Loss	Approximately 30%-35% TBWL at 1 year; approximately 55% excess weight loss at 7 years	Approximately 0% TBWL at 1 year; approximately 47% excess weight loss at 7 years	Approximately 17% TBWL at 1 year; approximately 18.5% at 2 years	[69-76]
Long-term efficacy	Sustained ≥ 7 years	Sustained ≥ 7 years	Plateaus earlier; modest long-term efficacy	[72,77]
MASH resolution	Approximately 84% resolution at 5 years; 56% fibrosis regression	Similar to RYGB; strong histological improvement	No histologic data yet; surrogate markers improving (fibrosis score, HSI)	[32,40,53,78-80]
Glycemic control	Rapid improvement (within days), even before weight loss; strongest incretin effect	Significant improvement via GLP-1 rise; slightly less immediate than RYGB	HOMA-IR drops seen within 1 week; continued glycemic benefit over 24 months	[78,80]
Lipid profile effects	↓ LDL, ↓ TGs, ↑ HDL (greater LDL reduction than LSG)	↓ LDL, ↓ TGs, ↑ HDL	Similar trends in small studies; larger cohorts needed	[81]
Liver inflammation	↓ ALT/AST/CRP	↓ ALT/AST/CRP	↓ hepatic steatosis indices (Approximately 4 pts/year), ↓ fibrosis scores	[78,80,82]
Benefits	Strongest metabolic effect; durable weight loss; histologic liver improvement	Well-studied; effective in BMI ≥ 40 and BMI 30-40; fewer nutritional complications than RYGB	Minimally invasive; fewer complications; outpatient; metabolic gains in lower BMI	[4,36,41,42,48-51]
Risks	Surgical risk; malabsorption; dumping syndrome; higher complication profile	Surgical risk; leak, bleeding; less malabsorption than RYGB	Less effective in BMI > 40; requires lifestyle commitment; no long-term histology data	[4,41,57,65,66]
Special considerations	Best in patients needing rapid metabolic reversal or with severe MASH	Balanced option for many patients, including those with cirrhosis	Emerging option for lower BMI (30-40); favorable for high-risk surgical patients	[4,32,42,50]
Contraindications	Advanced decompensated cirrhosis (unless in transplant setting); poor surgical candidates	Same as RYGB	Active gastric varices; significant portal hypertension without clearance	[41,60-62]

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMI: Body mass index; CRP: C-reactive protein; ESG: Endoscopic sleeve gastroplasty; GLP-1: Glucagon-like peptide-1; HDL: High-density lipoprotein; HOMA-IR: Homeostatic model assessment of insulin resistance; HSI: Hepatic steatosis index; LDL: Low-density lipoprotein; LSG: Laparoscopic sleeve gastrectomy; MASH: Metabolic dysfunction-associated steatohepatitis; RYGB: Roux-en-Y gastric bypass; TBWL: Total body weight loss; TGs: Triglycerides.

LIMITATIONS OF CURRENT EVIDENCE AND ONGOING TRIALS

Lack of long-term histological data with ESG

Bariatric surgery is supported by robust evidence demonstrating histologic resolution of MASH and improvement in fibrosis. Meta-analyses and prospective trials have reported MASH resolution rates of up to 85%, with significant fibrosis regression within the first year following surgery[4]. The BRAVES randomized controlled trial (NCT03524365) in Italy provided compelling data: Approximately 70% of patients undergoing LSG or RYGB achieved MASH resolution at one year, compared to only 16% of patients receiving lifestyle intervention alone[40].

In contrast, evidence for ESG remains limited, particularly regarding histologic endpoints. The only published randomized controlled trial evaluating ESG in biopsy-confirmed MASH, NASH-APOLLO (NCT03426111), demonstrated reductions in liver fat and stiffness but showed no statistically significant improvements in overall MASH or fibrosis scores unless patients achieved > 10% TBWL[55]. While ESG appears to improve hepatic steatosis and biochemical markers, its effect on histologic outcomes remains inadequately defined.

Heterogeneity in study populations and endpoints

Short study durations and methodological variability: Most ESG studies to date are single-center, observational, and limited in duration (typically less than two years). As highlighted in a recent National Institute for Health and Care Excellence (NICE, United Kingdom) review, the available evidence for ESG in metabolic liver disease is primarily based on non-randomized designs, introducing potential bias and limiting generalizability[83]. Aside from NASH-APOLLO, randomized data remain sparse.

Narrow inclusion criteria: Participants in ESG trials often differ meaningfully from those enrolled in bariatric surgery cohorts. ESG studies frequently include younger, predominantly female patients with class I or II obesity (BMI 30-40 kg/m²) and minimal liver dysfunction[83]. Patients with significant portal hypertension, coagulopathy, or ascites are typically excluded[84], limiting applicability to lower-risk populations with early-stage MASH. In contrast, bariatric surgical trials occasionally include patients with compensated cirrhosis, broadening their clinical relevance.

Non-standardized outcome measures: Endpoints across ESG studies vary widely, ranging from TBWL and liver stiffness scores to magnetic resonance imaging (MRI) fat fraction, liver enzyme panels, and histologic activity scores. Few trials incorporate paired liver biopsies. This heterogeneity complicates direct comparison with surgical outcomes. For example, while the NASH-APOLLO study reported improvements in steatosis and liver stiffness via elastography, no consistent changes in MASLD activity score or fibrosis stage were observed[55]. Table 3 provides an overview of Current Clinical Trials and Registries[40,84-86].

Table 3 Overview of current clinical trials and registries.

Trial/registry1	Design and population	Primary focus	Key findings/status	Notes	Ref.
NASH-APOLLO, NCT03426111	RCT, Spain; 40 patients with biopsy-confirmed MASH. ESG + lifestyle vs sham endoscopy + lifestyle	Weight loss and histological changes	ESG improved weight, liver stiffness, and steatosis; histologic gains only with > 10% TBWL	First RCT of ESG in MASH with histologic endpoints	[55]
TESLA-NASH, NCT04060368	RCT; 30 patients with MASH. ESG vs LSG	Histological resolution of MASH, all-cause mortality and liver-related outcomes in obese subjects with MASH	Ongoing	First head-to-head ESG vs LSG in MASLD/MASH	[85]
University of West Virginia NCT05507151	Single-arm prospective pilot; 30 patients with MASLD or MASH. Excludes cirrhosis/portal hypertension	ESG safety profile, quality of life assessment, anthropometric, metabolic, and biochemical changes in obese subjects with MASH	Ongoing	Focus on early-stage disease; reflects cautious ESG use in advanced liver disease	[84]
Mass general brigham, NCT04820036	Prospective study; 20 patients with MASH and advanced fibrosis. Includes EUS-guided liver biopsy and portal pressure monitoring	Effect of ESG on fibrosis and hemodynamics, insulin resistance, quality of life assessment	Ongoing	Unique data on portal pressure and advanced disease	[86]
BRAVES, NCT03524365	RCT; 288 participants with biopsy-proven MASH. Compared LSG and RYGB vs intensive medical therapy in MASH	Histological improvement and weight loss	LSG/RYGB superior to medical therapy in MASH resolution	Not ESG-specific, but remains benchmark for surgical outcomes in MASH	[40]
Surgical registries	MBSAQIP, Scandinavian Obesity Registry	Liver-related and metabolic outcomes post-bariatric surgery	Contributing real-world data on long-term outcomes	No ESG-specific global registry exists

¹NCT numbers correspond to ClinicalTrials.gov identifiers.

ESG: Endoscopic sleeve gastroplasty; EUS: Endoscopic ultrasound; LSG: Laparoscopic sleeve gastrectomy; MASH: Metabolic dysfunction-associated steatohepatitis; MASLD: Metabolic dysfunction-associated steatotic liver disease; MBSAQIP: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program; RCT: Randomized controlled trial; RYGB: Roux-en-Y gastric bypass; TBWL: Total body weight loss.

CLINICAL RECOMMENDATIONS AND PRACTICAL CONSIDERATIONS

Multidisciplinary approach to MASH and obesity

The management of MASH and obesity is intrinsically complex, requiring a coordinated, multidisciplinary framework that brings together expertise across gastroenterology, hepatology, endocrinology, bariatric surgery, nutrition, psychology, physical therapy, and specialized nursing care[1,2,4,5,33,34]. This integrative approach is essential to addressing the multifactorial interplay of metabolic, hepatic, and psychosocial drivers of disease progression. Clinical guidelines emphasize individualized risk stratification—accounting for fibrosis stage, metabolic comorbidities, and cardiovascular risk—to guide tailored therapeutic strategies[4].

A cornerstone of this model is the proactive assessment and management of psychological factors, including mood disorders, disordered eating, and body image disturbances. These issues are highly prevalent and can compromise long-term outcomes if left unaddressed[2,28,31,34,35]. Evidence supports that integrating behavioral health interventions with procedural therapies enhances adherence, supports sustained weight loss, and improves metabolic health[28,31,32].

Registered dietitians play a vital role in developing nutritional strategies that not only support caloric reduction but also meet liver-specific needs. These include optimizing protein intake to prevent sarcopenia, anticipating micronutrient deficiencies (especially after bariatric procedures), and promoting sustainable dietary patterns to improve hepatic and metabolic function[19,32,35]. In patients with advanced fibrosis or cirrhosis, dietary interventions must carefully balance nutritional adequacy with the need to prevent hepatic decompensation[36,38].

Physical activity is another essential pillar of care. Exercise physiologists and physical therapists design individualized plans that improve insulin sensitivity, reduce visceral adiposity, and target hepatic steatosis, key mechanisms in MASH pathogenesis[6,12,24]. In patients with cirrhosis or portal hypertension, exercise regimens should be adapted to ensure safety while maintaining therapeutic benefit[35,36].

Bariatric nurses and care coordinators serve as the operational hub of multidisciplinary teams, facilitating communication across disciplines, guiding patients through complex treatment pathways, and reinforcing adherence to perioperative and postoperative care[46,53]. The development of integrated bariatric endoscopy programs within hepatology and obesity clinics has further streamlined access to comprehensive care and improved continuity[46].

Interdisciplinary case conferences and shared decision-making models are increasingly recognized as best practice, particularly for high-risk patients with advanced fibrosis or compensated cirrhosis. These forums allow nuanced discussion of potential risks and benefits, and enable care plans to evolve in response to the patient's clinical trajectory[4,5,42,44].

Emerging data continue to support the combination of lifestyle interventions with procedural therapies, whether endoscopic or surgical, emphasizing the enduring importance of behavioral health, nutrition, and physical activity in sustaining clinical gains[28,31,32]. In parallel, precision medicine is beginning to reshape care by incorporating genetic, metabolic, and microbiome data to inform more personalized treatment pathways, with the goal of optimizing therapeutic selection and long-term outcomes[87-89].

The integration of pharmacologic adjuncts, particularly GLP-1 receptor agonists (GLP-1 RAs), with endoscopic therapies represents an important advance in multimodal care. These strategies require close collaboration between medical, surgical, and endoscopic teams, reflecting a growing emphasis on patient-centered, multimodal approaches[90,91]. When implemented effectively, this coordinated model may reduce perioperative complications, support long-term weight maintenance, and contribute to sustained improvements in liver-related outcomes, aligning with best-practice guidelines for the management of obesity and MASH[4,33,34,56].

Decision-making frameworks: ESG vs LSG/RYGB

Effective decision-making requires not only clinical acumen but also robust patient engagement. Decision aids and shared decision-making frameworks are essential for enhancing patient understanding, aligning interventions with individual values and expectations, and improving adherence and satisfaction[7,20,91]. Additionally, logistical considerations-including insurance coverage, institutional expertise, the availability of bariatric endoscopy programs, and long-term follow-up capacity—must be factored into therapeutic planning[36,46,87,89].

Emerging hybrid strategies, such as ESG combined with pharmacotherapy, are under active investigation as potential means to narrow the efficacy gap between ESG and surgical options[90-92]. Revisional pathways, such as ESG after failed LSG, or revisional bariatric surgery following ESG, further underscore the importance of flexible, long-term strategies tailored to evolving patient needs[2,11,18,58,93].

In summary, ESG may be best suited for patients seeking a less invasive intervention and willing to accept more modest weight loss and metabolic improvement, particularly in the context of elevated surgical risk. In contrast, LSG and RYGB remain the most evidence-supported options for achieving substantial and sustained weight loss and metabolic benefits in appropriately selected candidates. Multidisciplinary collaboration and individualized, patient-centered decision-making remain essential to optimize outcomes across this evolving therapeutic landscape.

Monitoring, follow-up, and post-procedural support

Sustained success after ESG, LSG, or RYGB hinges on comprehensive, long-term follow-up encompassing weight monitoring, metabolic assessments, liver health evaluation, and psychosocial support. Pre-procedural evaluation should include liver stiffness measurement (via transient elastography or MRI elastography), fibrosis staging using validated tools (e.g., FIB-4, MASLD fibrosis score), screening for portal hypertension, and full cardiometabolic profiling[4,8,35,36,38]. Psychosocial and nutritional assessments are equally important to establish baseline risk and optimize peri-procedural safety[9,35].

Guidelines recommend follow-up visits every 3-6 months during the first two years post-procedure, with intervals thereafter tailored to clinical needs and the type of intervention[4,5,33,53]. Monitoring should include serial hepatic panels, noninvasive fibrosis reassessment (e.g., FibroScan), and periodic imaging to track hepatic steatosis and fibrosis regression or progression[24,34,43,49,56]. Patients with cirrhosis require particular vigilance, including routine variceal surveillance, ongoing portal hypertension management, and close observation for hepatic decompensation, even in the context of significant weight loss[36,38,42,45,53].

Nutritional monitoring is essential—particularly for LSG and RYGB recipients, who are at risk for lifelong micronutrient deficiencies (e.g., iron, vitamin B12, calcium, vitamin D, and fat-soluble vitamins), necessitating regular supplementation and dietary counseling[11,19,33,35,36]. Although ESG is associated with a lower risk of malabsorption, patients still benefit from regular nutritional assessments to reinforce adherence, adjust dietary plans, and monitor for delayed complications[43,49,56].

Psychological support remains integral. Behavioral interventions targeting disordered eating, motivation, and body image can strengthen long-term adherence and reduce the risk of weight regain—an especially relevant challenge following ESG[28,33,93]. Adjunct pharmacologic therapies, particularly GLP-1 RA, are increasingly incorporated to enhance metabolic outcomes and support long-term weight maintenance[90,91].

Innovative digital health tools-including telemedicine platforms and app-based coaching—are expanding access to post-procedural care, enabling remote monitoring, real-time support, and greater patient engagement[9,20,94]. For those undergoing revisional procedures, robust multidisciplinary coordination remains essential to optimize outcomes and minimize procedural risk[2,18].

Ultimately, lifelong, integrated surveillance—anchored by collaboration among hepatologists, nutritionists, endocrinologists, psychologists, and bariatric specialists-remains the cornerstone of sustained clinical success in this high-risk population[4,5,33,36].

FUTURE DIRECTIONS

Need for head-to-head trials comparing ESG with surgical options

Direct comparisons between ESG and established surgical interventions such as LSG and RYGB remain limited. As previously discussed, existing meta-analyses suggest that ESG may result in meaningful weight loss and metabolic improvements relative to LSG in select populations[49,56]. However, its precise clinical role, particularly in patients with MASLD or MASH, remains to be clearly defined. While ESG has shown potential benefits in reducing hepatic steatosis and improving insulin resistance, most data are derived from small, short-term, or observational studies. Significant heterogeneity in trial design, patient populations, and outcome measures further limits the ability to draw firm conclusions.

Although observational studies suggest that ESG is associated with fewer adverse events and a lower procedural risk profile than surgical options[46,49,57], prospective head-to-head randomized controlled trials are critically needed. Future studies should aim to evaluate ESG’s long-term efficacy, durability of metabolic and hepatic improvements, and safety across a broad spectrum of liver disease phenotypes. In parallel, combination strategies, such as integrating pharmacotherapy with endoscopic interventions, warrant direct comparison with surgical approaches to clarify their relative efficacy and define their role in routine clinical practice[90,91].

ESG plus anti-obesity medications

In line with the evolving treatment paradigm, combining ESG with anti-obesity medications (AOMs), particularly GLP-1 RA, has been proposed as a strategy to enhance and sustain weight loss in selected patient populations. This multimodal approach may help reduce the efficacy gap between endoscopic and surgical therapies[90].

A retrospective Taiwanese study reported greater TBWL and excess weight loss (EWL) at 1, 3, and 6 months in patients receiving ESG plus oral semaglutide compared to ESG alone. The combination also yielded greater reductions in HbA1c without an increase in adverse events[91].

Complementing these findings, a large United States multicenter retrospective study demonstrated that patients who initiated AOMs ≥ 12 months after ESG achieved significantly higher TBWL and EWL at 24 months, compared to those who received AOMs at the time of the procedure. Among late initiators, nearly 90% reached ≥ 10% TBWL, compared to 70% of those who never received AOMs and 50% of those who initiated AOMs before ESG. While differences between medication classes did not reach statistical significance, GLP-1 RAs showed a trend toward greater efficacy at 18 and 24 months[95].

These retrospective data support a phased and individualized approach to combining ESG with pharmacotherapy. In particular, delayed initiation of GLP-1 RAs may offer benefit in patients who experience a weight plateau or suboptimal response after ESG[95]. However, prospective studies are needed to determine optimal timing, patient selection, and the relative effectiveness of different AOM classes in this setting.

Personalized medicine in MASH and obesity care

The emergence of precision medicine is reshaping the management of MASH and obesity, recognizing these conditions as heterogeneous diseases influenced by genetic, epigenetic, and microbiome-related factors[24,25,96-100]. This complexity underscores the need for personalized strategies that account for individual variability in disease risk, treatment response, and progression. Recent multi-omics studies have begun identifying molecular signatures that may help stratify patients by their likelihood of disease progression and response to specific therapies[88].

Within this framework, precision medicine is being explored as a tool to guide the selection of bariatric and endobariatric interventions based on factors such as metabolic profile, fibrosis severity, and genetic predispositions[87,89]. For example, PNPLA3 and TM6SF2 polymorphisms have been linked to differential responses to weight loss and fibrosis improvement, while gut microbiome composition may influence the metabolic and hepatic effects of ESG and pharmacologic therapies[22,26,89].

The growing interest in combination therapies reflects a broader shift toward tailored, multimodal treatment approaches aimed at addressing the biological complexity of MASLD[90-92]. As biomarker discovery and computational modeling continue to evolve, future care pathways may incorporate noninvasive molecular diagnostics and predictive algorithms to guide therapy selection and improve long-term clinical outcomes.

CONCLUSION

ESG may represent a promising development in the treatment of obesity and MASH, particularly for individuals who are not ideal candidates for surgery. As outlined in this review, ESG has been associated with improvements in weight loss, insulin resistance, and liver markers across a range of patient populations. It may offer a less invasive alternative to traditional bariatric procedures, with a lower observed risk profile than LSG and RYGB in early studies[48,54,58,59]. These features are especially relevant in patients with compensated cirrhosis, where preserving hepatic reserve and minimizing procedural morbidity are critical considerations[42,43,45].

Nonetheless, the current evidence base remains limited. Long-term, head-to-head randomized trials comparing ESG to surgical options are scarce, and few studies have prioritized liver histology as a primary endpoint[40,48]. While short- and mid-term data-particularly involving noninvasive markers and metabolic outcomes-are encouraging, further robust, longitudinal research is necessary to clarify ESG’s potential role in reversing fibrosis and altering disease progression. Additionally, successful implementation in clinical practice depends on appropriate patient selection, structured long-term follow-up, and strong multidisciplinary coordination, all essential for achieving sustained therapeutic benefit[34,36,52].

The integration of pharmacologic agents, especially GLP-1 RA, into ESG-based treatment pathways is also under investigation and may enhance both metabolic and hepatic outcomes. However, these combination approaches require evaluation in well-designed, prospective trials to determine their safety, efficacy, and long-term utility[58,59,64].

As the global burden of MASH continues to grow-alongside rising rates of cirrhosis, HCC, and liver transplantation—clinicians are increasingly tasked with providing effective, scalable, and individualized care. While ESG does not yet rival surgical interventions in terms of absolute weight loss or histologic reversal, its minimally invasive nature, emerging safety data, and expanding evidence base suggest it may have an important role for patients previously excluded from procedural treatment pathways[33,54,60].

Looking forward, the continued development of high-quality clinical trials, biomarker-driven studies, and precision medicine frameworks will be essential to further defining the clinical utility of ESG and expanding access to comprehensive metabolic liver care.