Vertical Sleeve Gastrectomy Versus Comprehensive Lifestyle Intervention for Adolescents With Metabolic Dysfunction–Associated Steatotic Liver Disease: A Prospective Controlled Cohort Study

Background Adolescents with severe obesity and metabolic dysfunction–associated steatotic liver disease (MASLD) lack prospective comparative evidence to select between bariatric surgery and intensive lifestyle intervention. Aims To compare 52‐week histological and cardiometabolic outcomes of vertical sleeve gastrectomy (VSG) versus comprehensive lifestyle intervention (CLI). Methods Single‐centre, prospective, parallel‐arm study of adolescents aged 12–19 with severe obesity and biopsy‐confirmed MASLD with NAFLD Activity Score (NAS) ≥ 3. The primary endpoint was NAS ≥ 2‐point decrease without fibrosis worsening; secondary endpoints included MASH resolution, fibrosis regression, MRI proton density fat fraction (MRI‐PDFF) and elastography (MRE). Overlap‐weighted adjusted analysis addressed baseline imbalance. Conservative unadjusted intention‐to‐treat analogue analyses treated missing Week 52 histology as nonresponse and missing continuous outcomes as no change. Results Forty‐two adolescents enrolled (VSG = 17; CLI = 25) and 27 (64%) completed paired Week 52 histology. In the adjusted analysis, VSG was associated with a higher probability of NAS improvement (risk difference [RD] 0.68, 95% CI 0.45–0.91), fibrosis improvement (RD 0.36, 95% CI 0.12–0.59) and complete MASLD resolution (RD 0.49, 95% CI 0.26–0.72) when compared to CLI. VSG produced greater reductions in percent weight (−19.6%, 95% CI −30.0 to −9.1), percentage of the 95th percentile BMI (−27.6%, 95% CI −42.6 to −12.7), ALT (−54.0 U/L, 95% CI −80.8 to −27.1) and MRI‐PDFF (−8.0%, 95% CI −13.0 to −2.9). Findings were directionally consistent in conservative unadjusted intention‐to‐treat and paired‐biopsy completer analyses. Conclusion In this prospective cohort of adolescents with severe obesity and biopsy‐confirmed MASLD, VSG achieved greater 52‐week histological improvement, including steatosis and fibrosis, than CLI. Trial Registration ClinicalTrials.gov identifier: (NCT02412540)