Bariatric surgery as a therapeutic strategy for metabolic dysfunction-associated steatotic liver disease in patients with obesity: a narrative review

Purpose: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide and is closely associated with obesity and metabolic dysfunction. As the global prevalence of obesity continues to rise, bariatric surgery has emerged as an effective treatment option for patients with MASLD. This narrative review summarizes the current evidence on the mechanisms, clinical efficacy, indications, and limitations of bariatric surgery in this population.Current concepts: Bariatric procedures, including sleeve gastrectomy and Roux-en-Y gastric bypass, produce substantial and sustained weight loss while improving insulin resistance, glucose metabolism, and systemic inflammation. Accumulating evidence indicates that bariatric surgery can reduce hepatic steatosis, promote resolution of metabolic dysfunction-associated steatohepatitis, and facilitate regression of liver fibrosis. In addition to weight loss, changes in enteroendocrine signaling, bile acid metabolism, gut microbiota composition, and adipokine pathways contribute to these hepatic benefits. Bariatric surgery also improves glycemic outcomes in patients with type 2 diabetes, favorably affects cardiovascular risk factors, and may be associated with a lower incidence of hepatocellular carcinoma. Current guidelines support bariatric surgery for eligible patients with obesity and non-cirrhotic MASLD, whereas surgery in patients with compensated cirrhosis may be considered only after careful evaluation at experienced centers.Discussion and conclusion: Bariatric surgery provides substantial hepatic and metabolic benefits in appropriately selected patients with MASLD. However, in patients with decompensated cirrhosis or clinically significant portal hypertension, surgical risks may outweigh the anticipated benefits. A multidisciplinary approach integrating hepatology and endocrinology expertise is essential for appropriate candidate selection and risk assessment.