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

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.