Impact of metabolic endoscopy on fibrosis regression in steatotic liver disease

Metabolic endoscopy represents a promising alternative in the management of steatotic liver disease, particularly metabolic dysfunction-associated steatohepatitis (MASH), a progressive form of metabolic dysfunction-associated steatotic liver disease (MASLD). With the rising global prevalence of MASLD-affecting over one-third of the adult population-and its close association with obesity, insulin resistance, and metabolic syndrome, there is an urgent need for innovative, minimally invasive therapies that can reverse liver fibrosis and prevent progression to cirrhosis and hepatocellular carcinoma. Traditional management of MASLD relies on lifestyle modifications and bariatric surgery, yet these approaches are hampered by issues of adherence, invasiveness, and accessibility. This review examines endoscopic bariatric metabolic therapies including endoscopic sleeve gastroplasty (ESG), intragastric balloons (IGB), duodenal mucosal resurfacing (DMR), and duodeno-jejunal bypass liners (DJBL), as well as revisional procedures like endoscopic revisional gastroplasty (ERG) and transoral outlet reduction (TORe). Clinical studies and meta-analyses indicate that metabolic endoscopy is safe and effective for liver fibrosis in MASH. ESG appears to offer the greatest fibrosis reduction, while IGB and DJBL yield modest improvements, and DMR shows no significant effect. Among revisional therapies, ERG has demonstrated fibrosis reduction, although the benefits of TORe remain to be fully evaluated.