The role of endoscopic therapies for patients with metabolic dysfunction-associated steatotic liver disease (MASLD)

INTRODUCTION: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a major public health challenge closely linked to obesity and metabolic syndrome. Effective, durable weight-loss strategies are needed to modify its natural history, particularly in patients at high surgical risk or with limited response to pharmacotherapy. AREAS COVERED: This review summarizes current and emerging weight-loss approaches for MASLD, focusing on pharmacological therapies, bariatric surgery and endoscopic interventions. From an expert narrative perspective, we discuss key randomized and observational studies on endoscopic sleeve gastroplasty (ESG), cost-effectiveness analyses, and the limited evidence in patients with compensated advanced chronic liver disease (cACLD), who represent an unmet need. EXPERT OPINION: ESG could be a promising, minimally invasive option for patients with MASLD who are ineligible for bariatric surgery or refractory to medical therapy. Early data suggest clinically meaningful weight loss, metabolic improvement, and a favorable safety profile, but long-term outcomes and direct histological benefits remain to be defined, particularly in patients with advanced fibrosis or cACLD. Combining ESG with pharmacological agents, such as GLP-1 receptor agonists, theoretically may enhance outcomes and deserves further study. Well-designed trials are required to better define the role of ESG in MASLD management and its potential integration into clinical practice.