Comprehensive management of MASLD in metabolic bariatric surgery： separate evaluation of weight-loss efficacy and hepatic risk and stratified decision-making

Song Ke; Du Qiang; Pu Yujie; Cheng Zhong; Chen Yi

doi:10.3969/j.issn.1003-5591.2026.05.003

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Comprehensive management of MASLD in metabolic bariatric surgery： separate evaluation of weight-loss efficacy and hepatic risk and stratified decision-making

更新时间：2026-10-22

- Comprehensive management of MASLD in metabolic bariatric surgery： separate evaluation of weight-loss efficacy and hepatic risk and stratified decision-making
- J Abdominal Surg Vol. 39, Issue 5, Pages: 341-345(2026)
- 作者机构：
  
  四川大学华西医院胃肠外科，四川成都 610041
- 作者简介：
  
  Chen Yi，Email：toddy@scu.edu.cn
- 基金信息：
- DOI：10.3969/j.issn.1003-5591.2026.05.003
  CLC： R589.2;R575.5
- Received：29 June 2026，
  
  Published：22 October 2026
- 稿件说明：
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宋可,杜强,蒲羽杰等.减重代谢外科中MASLD的全程管理：减重疗效和肝脏风险的分离评价及分层决策[J].腹部外科,2026,39(05):341-345.

Song Ke,Du Qiang,Pu Yujie,et al.Comprehensive management of MASLD in metabolic bariatric surgery： separate evaluation of weight-loss efficacy and hepatic risk and stratified decision-making[J].J Abdominal Surg,2026,39(05):341-345.
宋可,杜强,蒲羽杰等.减重代谢外科中MASLD的全程管理：减重疗效和肝脏风险的分离评价及分层决策[J].腹部外科,2026,39(05):341-345. DOI： 10.3969/j.issn.1003-5591.2026.05.003.

Song Ke,Du Qiang,Pu Yujie,et al.Comprehensive management of MASLD in metabolic bariatric surgery： separate evaluation of weight-loss efficacy and hepatic risk and stratified decision-making[J].J Abdominal Surg,2026,39(05):341-345. DOI： 10.3969/j.issn.1003-5591.2026.05.003.

摘要

减重代谢外科的临床获益已由体重控制扩展至代谢共病缓解和靶器官保护。肥胖病人常合并代谢功能障碍相关脂肪性肝病（metabolic dysfunction-associated steatotic liver disease，MASLD）及其进展形式，即代谢功能障碍相关脂肪性肝炎（metabolic dysfunction-associated steatohepatitis，MASH），肝纤维化程度则反映持续的代谢炎症负荷和长期肝脏风险。作者团队基于417例胃袖状切除术中肝活检队列的研究显示，基线MASH不影响术后12个月比例性减重，肝纤维化分期则与个体化减重目标达成有关。上述结果提示，应把短期减重疗效与长期肝脏风险分开评价。本文结合国内外指南、代表性临床试验及作者团队研究，梳理MASLD/MASH术前分层、术式和围术期管理、术后随访以及药物与手术的序贯关系，并提出低、中、高肝脏风险临床决策路径，以期为减重代谢外科全程管理提供参考。

Abstract

The clinical benefits of metabolic bariatric surgery have expanded from weight control to the alleviation of metabolic comorbidities and protection of target organs. Patients with obesity often have metabolic dysfunction-associated steatotic liver disease （MASLD） and its progressive form， metabolic dysfunction-associated steatohepatitis（MASH）， while the degree of liver fibrosis reflects persistent metabolic inflammatory burden and long-term hepatic risk. A study by the authors' team based on a liver biopsy cohort of 417 patients undergoing sleeve gastrectomy showed that baseline MASH did not affect proportional weight loss at 12 months after surgery， whereas the stage of liver fibrosis was associated with achievement of individualized weight-loss goals.These findings suggest that short-term weight-loss efficacy and long-term hepatic risk should be evaluated separately.Drawing on domestic and international guidelines， representative clinical trials， and studies from the authors' team， this article reviews preoperative stratification of MASLD/MASH， procedure selection and perioperative management， postoperative follow-up， and the sequential relationship between medication and surgery.It also proposes clinical decision-making pathways for low-，intermediate-，and high hepatic risk patients， with the aim of providing a reference for comprehensive management throughout the course of metabolic bariatric surgery.

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国家卫生健康委员会肥胖症诊疗指南编写委员会，张忠涛，纪立农 . 肥胖症诊疗指南（2024年版）［J］. 中国循环杂志， 2025 ， 40 （ 1 ）： 6 - 30 . DOI： 10.3969/j.issn.1000-3614.2025.01.002 http://dx.doi.org/10.3969/j.issn.1000-3614.2025.01.002 .

Eisenberg D ， Shikora SA ， Aarts E ， et al . 2022 American society of metabolic and bariatric surgery （ASMBS） and international federation for the surgery of obesity and metabolic disorders （IFSO） indications for metabolic and bariatric surgery ［J］. Obes Surg ， 2023 ， 33 （ 1 ）： 3 - 14 . DOI： 10.1007/s11695-022-06332-1 http://dx.doi.org/10.1007/s11695-022-06332-1 .

Mechanick JI ， Apovian C ， Brethauer S ， et al . Clinical practice guidelines for the perioperative nutrition，metabolic，and nonsurgical support of patients undergoing bariatric procedures - 2019 update：cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology，The Obesity Society，American Society for Metabolic & Bariatric Surgery，Obesity Medicine Association，and American Society of Anesthesiologists ［J］. Surg Obes Relat Dis ， 2020 ， 16 （ 2 ）： 175 - 247 . DOI： 10.1016/j.soard.2019.10.025 http://dx.doi.org/10.1016/j.soard.2019.10.025 .

Rinella ME ， Lazarus JV ， Ratziu V ， et al . A multisociety Delphi consensus statement on new fatty liver disease nomenclature ［J］. Hepatology ， 2023 ， 78 （ 6 ）： 1966 - 1986 . DOI： 10.1097/HEP.0000000000000520 http://dx.doi.org/10.1097/HEP.0000000000000520 .

European Association for the Study of the Liver ， European Association for the Study of Diabetes ， European Association for the Study of Obesity . EASL-EASD-EASO clinical practice guidelines on the management of metabolic dysfunction-associated steatotic liver disease （MASLD）：executive summary ［J］. Diabetologia ， 2024 ， 67 （ 11 ）： 2375 - 2392 . DOI： 10.1007/s00125-024-06196-3 http://dx.doi.org/10.1007/s00125-024-06196-3 .

Rinella ME ， Neuschwander-Tetri BA ， Siddiqui MS ， et al . AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease ［J］. Hepatology ， 2023 ， 77 （ 5 ）： 1797 - 1835 . DOI： 10.1097/HEP.0000000000000323 http://dx.doi.org/10.1097/HEP.0000000000000323 .

Cusi K ， Isaacs S ， Barb D ， et al . American association of clinical endocrinology clinical practice guideline for the diagnosis and management of nonalcoholic fatty liver disease in primary care and endocrinology clinical settings：co-sponsored by the American association for the study of liver diseases （AASLD）［J］. Endocr Pract ， 2022 ， 28 （ 5 ）： 528 - 562 . DOI： 10.1016/j.eprac.2022.03.010 http://dx.doi.org/10.1016/j.eprac.2022.03.010 .

Younossi ZM ， Golabi P ， Paik JM ， et al . The global epidemiology of nonalcoholic fatty liver disease （NAFLD） and nonalcoholic steatohepatitis （NASH）：a systematic review ［J］. Hepatology ， 2023 ， 77 （ 4 ）： 1335 - 1347 . DOI： 10.1097/HEP.0000000000000004 http://dx.doi.org/10.1097/HEP.0000000000000004 .

Sanyal AJ ， Van Natta ML ， Clark J ， et al . Prospective study of outcomes in adults with nonalcoholic fatty liver disease ［J］. N Engl J Med ， 2021 ， 385 （ 17 ）： 1559 - 1569 . DOI： 10.1056/NEJMoa2029349 http://dx.doi.org/10.1056/NEJMoa2029349 .

Angulo P ， Kleiner DE ， Dam-Larsen S ， et al . Liver fibrosis，but No other histologic features，is associated with long-term outcomes of patients with nonalcoholic fatty liver disease ［J］. Gastroenterology ， 2015 ， 149 （ 2 ）： 389 - 397.e10 . DOI： 10.1053/j.gastro.2015.04.043 http://dx.doi.org/10.1053/j.gastro.2015.04.043 .

Dulai PS ， Singh S ， Patel J ， et al . Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease：systematic review and meta-analysis ［J］. Hepatology ， 2017 ， 65 （ 5 ）： 1557 - 1565 . DOI： 10.1002/hep.29085 http://dx.doi.org/10.1002/hep.29085 .

Shah AG ， Lydecker A ， Murray K ， et al . Comparison of noninvasive markers of fibrosis in patients with nonalcoholic fatty liver disease ［J］. Clin Gastroenterol Hepatol ， 2009 ， 7 （ 10 ）： 1104 - 1112 . DOI： 10.1016/j.cgh.2009.05.033 http://dx.doi.org/10.1016/j.cgh.2009.05.033 .

Lassailly G ， Caiazzo R ， Ntandja-Wandji LC ， et al . Bariatric surgery provides long-term resolution of nonalcoholic steatohepatitis and regression of fibrosis ［J］. Gastroenterology ， 2020 ， 159 （ 4 ）： 1290 - 1301.e5 . DOI： 10.1053/j.gastro.2020.06.006 http://dx.doi.org/10.1053/j.gastro.2020.06.006 .

Aminian A ， Al-Kurd A ， Wilson R ， et al . Association of bariatric surgery with major adverse liver and cardiovascular outcomes in patients with biopsy-proven nonalcoholic steatohepatitis ［J］. JAMA ， 2021 ， 326 （ 20 ）： 2031 - 2042 . DOI： 10.1001/jama.2021.19569 http://dx.doi.org/10.1001/jama.2021.19569 .

Verrastro O ， Panunzi S ， Castagneto-Gissey L ， et al . Bariatric–metabolic surgery versus lifestyle intervention plus best medical care in non-alcoholic steatohepatitis （BRAVES）：a multicentre，open-label，randomised trial ［J］. Lancet ， 2023 ， 401 （ 10390 ）： 1786 - 1797 . DOI： 10.1016/S0140-6736（23）00634-7 http://dx.doi.org/10.1016/S0140-6736（23）00634-7 .

Pais R ， Aron-Wisnewsky J ， Bedossa P ， et al . Persistence of severe liver fibrosis despite substantial weight loss with bariatric surgery ［J］. Hepatology ， 2022 ， 76 （ 2 ）： 456 - 468 . DOI： 10.1002/hep.32358 http://dx.doi.org/10.1002/hep.32358 .

Pu YJ ， Cao Z ， Yang SQ ， et al . Impact of biopsy-proven hepatic fibrosis and steatohepatitis on short-term weight-loss outcomes after sleeve gastrectomy ［J］. Obes Surg ， 2026 ， 36 （ 3 ）： 1054 - 1061 . DOI： 10.1007/s11695-025-08452-w http://dx.doi.org/10.1007/s11695-025-08452-w .

Kleiner DE ， Brunt EM ， Van Natta M ， et al . Design and validation of a histological scoring system for nonalcoholic fatty liver disease ［J］. Hepatology ， 2005 ， 41 （ 6 ）： 1313 - 1321 . DOI： 10.1002/hep.20701 http://dx.doi.org/10.1002/hep.20701 .

Moolenaar LR ， de Waard NE ， Heger M ， et al . Liver injury and acute liver failure after bariatric surgery：an overview of potential injury mechanisms ［J］. J Clin Gastroenterol ， 2022 ， 56 （ 4 ）： 311 - 323 . DOI： 10.1097/MCG.0000000000001662 http://dx.doi.org/10.1097/MCG.0000000000001662 .

Wilding JPH ， Batterham RL ， Calanna S ， et al . Once-weekly semaglutide in adults with overweight or obesity ［J］. N Engl J Med ， 2021 ， 384 （ 11 ）： 989 - 1002 . DOI： 10.1056/NEJMoa2032183 http://dx.doi.org/10.1056/NEJMoa2032183 .

Jastreboff AM ， Aronne LJ ， Ahmad NN ， et al . Tirzepatide once weekly for the treatment of obesity ［J］. N Engl J Med ， 2022 ， 387 （ 3 ）： 205 - 216 . DOI： 10.1056/nejmoa2206038 http://dx.doi.org/10.1056/nejmoa2206038 .

Newsome PN ， Buchholtz K ， Cusi K ， et al . A placebo-controlled trial of subcutaneous semaglutide in nonalcoholic steatohepatitis ［J］. N Engl J Med ， 2021 ， 384 （ 12 ）： 1113 - 1124 . DOI： 10.1056/NEJMoa2028395 http://dx.doi.org/10.1056/NEJMoa2028395 .

Loomba R ， Hartman ML ， Lawitz EJ ， et al . Tirzepatide for metabolic dysfunction-associated steatohepatitis with liver fibrosis ［J］. N Engl J Med ， 2024 ， 391 （ 4 ）： 299 - 310 . DOI： 10.1056/NEJMoa2401943 http://dx.doi.org/10.1056/NEJMoa2401943 .

Sanyal AJ ， Newsome PN ， Kliers I ， et al . Phase 3 trial of semaglutide in metabolic dysfunction-associated steatohepatitis ［J］. N Engl J Med ， 2025 ， 392 （ 21 ）： 2089 - 2099 . DOI： 10.1056/NEJMoa2413258 http://dx.doi.org/10.1056/NEJMoa2413258 .

Harrison SA ， Bedossa P ， Guy CD ， et al . A phase 3，randomized，controlled trial of resmetirom in NASH with liver fibrosis ［J］. N Engl J Med ， 2024 ， 390 （ 6 ）： 497 - 509 . DOI： 10.1056/NEJMoa2309000 http://dx.doi.org/10.1056/NEJMoa2309000 .

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