For adolescents with severe obesity and metabolic dysfunction–associated steatotic liver disease (MASLD), vertical sleeve gastrectomy (VSG) yields greater improvements in histologic and cardiometabolic outcomes compared with comprehensive lifestyle intervention, as shown in a single-centre, nonrandomized cohort study.
At 52 weeks, the primary endpoint of a 2-point decrease in NAFLD Activity Score (NAS) without worsening of fibrosis occurred in significantly greater percentage of participants who underwent VSG vs comprehensive lifestyle intervention (92 percent vs 20 percent; risk difference [RD], 0.68, 95 percent CI, 0.45–0.9; p<0.05). [Aliment Pharmacol Ther 2026;doi:10.1111/apt.70766]
Participants who underwent VSG were also more likely to achieve complete MASLD resolution (58 percent vs 0 percent; RD, 0.49, 95 percent CI, 0.26–0.72; p<0.05) and fibrosis improvement (50 percent vs 7 percent; RD, 0.36, 95 percent CI, 0.12–0.59; p<0.05) compared with those who underwent lifestyle intervention.
Moreover, the VSG group had greater reductions in percent weight (−19.6 percent), percentage of the 95th percentile BMI (−27.6 percent), alanine aminotransferase (−54 U/L), and MRI proton density fat fraction (−8 percent) compared with comprehensive lifestyle intervention group.
These findings indicate that metabolic surgery should be considered as an important treatment option within multidisciplinary care for selected adolescents with high-risk disease, according to lead researcher Dr Toshifumi Yodoshi from Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US, and colleagues.
Yodoshi and colleagues emphasized that it can be difficult to achieve significant weight loss and histologic improvement with lifestyle therapy alone in the presence of class II/III obesity and established steatohepatitis, as evidenced by the low response rate to comprehensive lifestyle intervention in the study cohort.
The role of weight loss
“The marked histological response after VSG is biologically plausible and largely mediated by the magnitude of weight loss achieved after surgery and its associated cardiometabolic benefits,” Yodoshi and colleagues said.
“VSG produced weight loss far exceeding what is typically achievable or durable with behavioural therapy in severe paediatric obesity, with 75 percent achieving >10-percent weight loss compared with 13 percent achieving this degree of weight loss in the comprehensive lifestyle intervention group,” the researchers added.
They also pointed out that the favourable hepatic effects of VSG may involve factors other than weight loss. Prior physiological and experimental studies have shown postoperative changes in appetite regulation, gut hormone signalling, and bile acid pathways that may influence hepatic glucose and lipid metabolism.
“Our study was not designed to distinguish weight-dependent from weight-independent mechanisms, but the substantial metabolic improvement observed after VSG, which often persists despite some weight regain, is consistent with [the mentioned] broader physiological effects,” Yodoshi and colleagues said.
Methodological limitations
In an accompanying editorial, Dr Ilias Papadimopoulos from the University of Bologna in Italy and Dr Frank Tacke from the Charité – Universitätsmedizin Berlin in Germany congratulated Yodoshi and colleagues for providing rigorous prospective biopsy evidence on the efficacy of VSG in carefully selected adolescents with severe obesity and MASLD. [Aliment Pharmacol Ther 2026;doi:10.1111/apt.70810]
Papadimopoulos and Tacke, however, noted that the comprehensive lifestyle intervention did not include glucagon-like peptide-1 (GLP-1) receptor agonists, which are now approved for obesity in adolescents, “thereby underestimating the efficacy of therapeutic management in the nonsurgical group.”
Additionally, the cohort is small and at low risk of liver-related outcomes, with two-thirds of patients having no or minimal fibrosis at baseline. “Thirty-six percent of participants lacked week-52 biopsies, a dropout rate that risks selection bias, as completers in both arms are more likely to represent treatment responders,” they said.
“MASLD arising in adolescence confers a uniquely long cumulative window for disease progression, cardiometabolic morbidity, and premature mortality. Designing trials with histologic endpoints, sufficient power, and long-term follow-up in this population is the defining challenge for paediatric hepatology in the years ahead,” Papadimopoulos and Tacke concluded.
Single-centre, nonrandomized study
The single-centre, prospective, nonrandomized, cohort-controlled study included 42 adolescents ages 12–19 years (median age 16 years, 67 percent male) who had severe obesity (median BMI 41 kg/m2) and biopsy-confirmed MASLD with a median NAS of 4 at baseline.
The participants were randomly allocated to the VSG group (n=17) or the comprehensive lifestyle intervention group (n=25). Those in the VSG group underwent standardized preoperative evaluation and postoperative follow-up at 2 weeks and at 3, 6, 9, and 12 months. Those in the comprehensive lifestyle intervention group were enrolled in a structured medium-intensity lifestyle programme (aiming for at least 26 contact hours over the 52-week study) delivered by a trained multidisciplinary team. The intervention also included dietary modification, with participants receiving counselling on portion control and reducing saturated fat and sugar intake, in addition to increasing physical activity and adopting behavioural strategies. Counselling visits were scheduled every other week during the first 3 months, then every 2–4 weeks until week 52.
Baseline and week 52 liver biopsies were obtained via core needle biopsy either percutaneously or intraoperatively (at the time of bariatric surgery). Of the participants, 64 percent completed paired liver biopsies.