How do metabolic bariatric surgery (MBS) and semaglutide compare in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) and type 2 diabetes mellitus (T2DM)? A database analysis published in Diabetes, Obesity and Metabolism found that MBS was associated with higher major adverse liver outcomes (MALO), while also showing lower rates of several extrahepatic complications compared with semaglutide.

The study used the TriNetX database to identify individuals with MASLD and T2D who underwent MBS or received semaglutide between 2018 and 2023. The primary outcome was a composite of MALO, defined as decompensation events or liver transplant. Secondary outcomes included major adverse cardiovascular events (MACE), first diagnosis of cirrhosis, heart failure, obesity-associated cancer (OAC), and all-cause mortality (ACM). Subgroup analyses evaluated Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

Compared with semaglutide, MBS was associated with a higher hazard rate of MALO (HR 1.63; 95% CI 1.12-2.37). This finding was driven by RYGB (HR 2.01; 95% CI 1.26-3.20), while SG did not differ significantly (HR 0.97; 95% CI 0.52-1.78). 

After excluding individuals with pre-existing cirrhosis, MBS was associated with a lower risk of new cirrhosis (HR 0.46; 95% CI 0.29-0.73). MBS was also associated with a lower risk of MACE (HR 0.51; 95% CI 0.38-0.67), heart failure (HR 0.41; 95% CI 0.27-0.62), and OAC (HR 0.56; 95% CI 0.34-0.92). There was no overall difference in ACM, although RYGB was associated with higher ACM in subgroup analysis (HR 1.64; 95% CI 1.01-2.67).

The findings suggest that treatment selection in MASLD with T2DM may involve balancing liver outcomes against cardiometabolic outcomes.