For patients with obesity and metabolic dysfunction-associated steatotic liver disease (MASLD), bariatric surgery may slow or prevent the progression of liver disease, potentially reducing the need for liver transplantation. For those who do require a transplant, weight-loss procedures may also decrease the risk of disease recurrence.
These findings were highlighted by Dr. Julie K. Heimbach, professor of surgery and director of the William Von Liebig Center for Transplantation at Mayo Clinic College of Medicine in Rochester, Minnesota, during a presentation at The Liver Meeting 2025 hosted by the American Association for the Study of Liver Diseases (AASLD).
“The most important risk for adverse outcomes in patients with MASLD is fibrosis, so ideally obesity should be treated before fibrosis develops,” Heimbach said.
Potential Benefits of Bariatric Procedures
In patients with obesity, MASLD, and compensated cirrhosis, bariatric and endoscopic bariatric procedures can help reduce inflammation and fibrosis that contribute to metabolic dysfunction-associated steatohepatitis (MASH) and eventual liver failure. Endoscopic bariatric procedures, in particular, can promote weight loss, reduce liver steatosis, and prevent progression to fibrosis and cirrhosis.
Heimbach cited a 2020 study in which bariatric surgery led to long-term resolution of MASH without worsening fibrosis. Among 64 adults studied, 70% showed improved fibrosis and 84% experienced resolution of MASH five years after surgery. However, the stage of liver disease is crucial when determining whether surgical intervention is appropriate.
A 2022 meta-analysis confirmed that bariatric surgery is safe and effective for patients with compensated cirrhosis, with a mortality rate of only 0.9%. In contrast, patients with decompensated cirrhosis faced an 18.2% mortality rate following surgery.
Improving Outcomes After Liver Transplant
For patients with decompensated cirrhosis, liver transplantation may be necessary. In those with obesity, addressing weight is critical to preventing recurrence of liver disease and improving long-term outcomes. Strategies may include performing a sleeve gastrectomy at the time of transplant or using endobariatric procedures or medications post-transplant.
Endoscopic sleeve gastrectomy is minimally invasive and often performed on an outpatient basis, though it may not be sufficient for patients with severe obesity. A multicenter study in the Journal of Hepatology found that patients who underwent combined liver transplant and sleeve gastrectomy experienced sustained weight loss, reduced recurrence of MASLD, and improved management of diabetes and hypertension compared with transplant alone.
Optimal timing for bariatric interventions—whether before, during, or after liver transplant—remains an area for further research, Heimbach noted.
Additional Considerations
Dr. Kathleen E. Corey, associate professor of medicine at Harvard Medical School and director of the MGH Fatty Liver Program, emphasized the importance of carefully managing weight loss in patients with advanced liver disease. Elevated BMI increases the risk of hepatic decompensation, while weight reduction may improve transplant outcomes.
Patients with advanced liver disease are at risk for frailty, malnutrition, and sarcopenia, a loss of muscle mass and strength. “Weight-loss methods, whether surgical or pharmacologic, must avoid worsening these complications,” Corey said. She noted that bariatric procedures can reduce both pre- and post-transplant complications and lower the risk of recurrent MASLD.
Endoscopic sleeve gastrectomy may even prevent the need for transplant in patients with less severe disease, as fibrosis regression is possible in a high proportion of patients. Tailored programs are critical to safely manage weight loss while monitoring for sarcopenia, frailty, and malnutrition.
