Bariatric–metabolic surgery versus lifestyle intervention in non-alcoholic steatohepatitis

Non-alcoholic fatty liver disease (NAFLD) is a growing public health issue, set to be the major cause of liver transplantation and liver cancer, with increasing socioeconomic costs. 1 Younossi ZM Stepanova M Ong J et al. Nonalcoholic steatohepatitis is the most rapidly increasing indication for liver transplantation in the United States. Clin Gastroenterol Hepatol. 2021; 19 (89.e5): 580 Summary Full Text Full Text PDF PubMed Scopus (164) Google Scholar NAFLD is strongly associated with obesity (BMI ≥30 kg/m2) and metabolic syndrome, with an increased standardised mortality ratio of 1·34 compared with the general population. 2 Adams LA Lymp JF St Sauver J et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology. 2005; 129: 113-121 Summary Full Text Full Text PDF PubMed Scopus (2326) Google Scholar Despite progress being made regarding our understanding of the cause and pathophysiology of NAFLD, there are no approved treatments for NAFLD. Physical activity and weight-loss strategies are the mainstay for the treatment of non-alcoholic steatohepatitis (NASH), with aerobic and resistance training having been shown to reduce hepatic steatosis and NAFLD-associated cardiovascular risks. 3 Bacchi E Negri C Targher G et al. Both resistance training and aerobic training reduce hepatic fat content in type 2 diabetic subjects with nonalcoholic fatty liver disease (the RAED2 Randomized Trial). Hepatology. 2013; 58: 1287-1295 Crossref PubMed Scopus (227) Google Scholar Bodyweight loss of more than 10% has been shown to improve fibrosis, 4 Vilar-Gomez E Martinez-Perez Y Calzadilla-Bertot L et al. Weight loss through lifestyle modification significantly reduces features of nonalcoholic steatohepatitis. Gastroenterology. 2015; 149 (78.e5): 367 Summary Full Text Full Text PDF PubMed Scopus (1229) Google Scholar but this level of weight loss is seldom reached with lifestyle change, let alone maintained in the longer term. Moreover, in an open-label study, Pais and colleagues showed that despite substantial weight loss after bariatric surgery, 47% of patients still had advanced fibrosis, although many more had improvements in fibrosis. 5 Pais R Aron-Wisnewsky J Bedossa P et al. Persistence of severe liver fibrosis despite substantial weight loss with bariatric surgery. Hepatology. 2022; 76: 456-468 Crossref PubMed Scopus (11) Google Scholar Bariatric–metabolic surgery versus lifestyle intervention plus best medical care in non-alcoholic steatohepatitis (BRAVES): a multicentre, open-label, randomised trialBariatric-metabolic surgery is more effective than lifestyle interventions and optimised medical therapy in the treatment of NASH. Full-Text PDF Open Access