Differential Impact of Metabolic Bariatric Surgery Versus Semaglutide on Adverse Hepatic and Extrahepatic Outcomes in Individuals With Metabolic Dysfunction‐Associated Steatotic Liver Disease and Type 2 Diabetes

AIM: We compared the impact of metabolic bariatric surgery (MBS) versus semaglutide on clinical outcomes in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) and type 2 diabetes (T2D). METHODS: Patients with MASLD and T2D who had MBS or semaglutide in 2018-2023 were identified (TriNetX database). The primary outcome was a composite of major adverse liver outcomes (MALO): decompensation events or liver transplant. Secondary outcomes included a composite of major adverse cardiovascular events (MACE), first diagnosis of cirrhosis, heart failure, or obesity-associated cancer (OAC), and all-cause mortality (ACM). Subgroup analyses were performed for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). RESULTS: MBS, compared with semaglutide, was associated with a higher hazard rate (HR) of MALO (HR 1.63; 95% CI 1.12-2.37); this was driven by RYGB (2.01; 1.26-3.20) but not by SG (0.97; 0.52-1.78). However, after excluding patients with pre-existing cirrhosis, MBS was associated with a reduced HR of new cirrhosis (0.46; 0.29-0.73). For extrahepatic events, MBS was associated with a reduced HR of MACE (0.51; 0.38-0.67), heart failure (0.41; 0.27-0.62), and OAC (0.56; 0.34-0.92). There was no difference in ACM between MBS and semaglutide, but in subgroup analysis, RYGB was associated with increased ACM compared to semaglutide (1.64; 1.01-2.67). CONCLUSION: In patients with MASLD and T2D, MBS, and specifically RYGB, as compared to semaglutide, may drive a relatively increased risk of MALO despite protection against MACE, the first diagnosis of cirrhosis, heart failure, and OAC. Liver evaluation in individuals with T2D referred for MBS may help optimize their treatment.