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

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.

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.

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.