Endobariatric Management of Metabolic Dysfunction-Associated Steatotic Liver Disease: A Narrative Review

As the rates of type 2 diabetes and obesity have increased globally, the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic steatotic fatty liver disease (NAFLD), has risen concomitantly worldwide. MASLD is now the most common etiology of chronic liver disease and is the leading indication for liver transplantation in the United States. Patients with MASLD have an increased risk of progression to metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis, hepatocellular carcinoma, extrahepatic malignancies, as well as liver- and cardiovascular-related mortality. Diet and lifestyle modifications with a goal of ≥10% total body weight loss-required to reverse steatosis, steatohepatitis, and fibrosis-are often challenging and ineffective. Although novel pharmacotherapies have recently been approved and others are in development, cost, adherence, and adverse effects remain potential limitations. Bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy, is highly efficacious and a cost-effective treatment for obesity and associated medical problems. However, bariatric surgery may be associated with morbidity and mortality. Endoscopic bariatric and metabolic therapy (EBMT) has recently emerged as a promising treatment modality and offers an alternative to surgery. Primary EBMTs include intragastric balloon placement, aspiration therapy, endoscopic sleeve gastroplasty, duodenal mucosal resurfacing, duodenal-jejunal bypass liner, and primary obesity surgery endoluminal (POSE 2.0). Secondary EBMTs include transoral outlet reduction, argon plasma coagulation of the anastomosis, and revisional endoscopic sleeve procedure. We review the recent literature on primary EBMTs and secondary EBMTs for the treatment of obesity and MASLD, the pathophysiologic mechanisms, efficacy, safety, and patient outcomes in MASLD in this narrative review.