<p>Metabolic bariatric surgery (MBS) may be considered for patients with obesity class III or obesity class II with associated medical problems, including hypertension. However, referrals to MBS teams from hypertension clinics remain low. This meta-analysis of randomised controlled trials compares surgical and non-surgical interventions for the long-term management of obesity-related hypertension. Ten randomised controlled trials were identified, totalling 692 patients. Significant differences were found favouring MBS for all outcomes assessed, including systolic blood pressure (BP) (<i>P</i> &lt; 0.00001), diastolic BP (<i>P</i> = 0.005), changes in systolic (<i>P</i> &lt; 0.0001), and diastolic BP (<i>P</i> = 0.004), number of anti-hypertensives (<i>P</i> = 0.01), mean change in anti-hypertensive use per patient (<i>P</i> = 0.0001), and the number of patients not requiring anti-hypertensives (<i>P</i> = 0.02). MBS significantly improves long-term obesity-related primary hypertension management when compared with non-surgical management. The authors recommend that hypertension guidelines should reflect this.</p>