Bariatric Surgery Improves Adverse Outcomes in Patients with MASH-Related Cirrhosis

Image credit: ake1150 | stock.adobe.com

An observational study published in Nature Medicine demonstrated that bariatric surgery significantly reduced long-term risk of adverse outcomes and decompensation in patients with obesity and compensated metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis. Due to the lack of medical therapies for compensated MASH-related cirrhosis, metabolic surgery can be a safe and effective therapeutic option for patients, according to the authors.¹

This observation study—entitled The Surgical Procedures Eliminate Compensated Cirrhosis in Advancing Long-term (SPECCIAL)—compared the effects of metabolic surgery and non-surgical treatment options in patients who have obesity and compensated histologically proven cirrhosis related to MASH. The authors noted that prior studies had reported benefits for metabolic surgery in patients with MASH, but these patients did not have cirrhosis.^1,2

A total of 62 patients (68% female) who underwent metabolic surgery (Roux-en-Y gastric bypass: n = 37; sleeve gastrectomy: n = 25, and 106 non-surgical controls (71% female patients) were enrolled in the study (mean age: 54.4 years). The mean follow-up was about 10.0 ± 4.5 years.^1,2

The findings showed that the 15-year cumulative incidence of major adverse liver outcomes in patients receiving bariatric surgery was approximately 20.1% (95% CI 2.5%–35.9%) compared with 46.4% (95% CI 25.6%–61.3%) in control patients (HR 0.28, 95% CI 0.12-0.64, P = .003). Additionally, decompensated cirrhosis was also noticeably lower in the surgical group (15.6%; 95% CI 0%–31.3%) compared with the non-surgical group (30.7%; 95% CI, 12.9%–44.8%; HR 0.20, 95% CI 0.06-0.68, P = .01).¹ Further, the authors suggested that bariatric surgery may help patients with MASH, obesity, and decompensated cirrhosis eventually obtain liver transplants if needed.²

“Currently, lifestyle intervention is the only therapeutic recommendation for compensated MASH-related cirrhosis," said Steven Nissen, MD, Cleveland Clinic, in a news release. "However, lifestyle changes alone rarely provide the weight loss and metabolic changes needed to reduce the risk of liver complications in this patient population. The SPECCIAL study shows that bariatric surgery is an effective treatment that can influence the trajectory of cirrhosis progression in select patients.”²

Further, a key limitation of the study is the unavailability of data on physical activity, dietary habits, alcohol use, and smoking status. Additionally, approximately 90% of study patients were White, limiting the generalizability of the results to other racial and ethnic groups. Patients who underwent metabolic surgery could have adopted healthier lifestyles than the non-surgical group, noted the authors, potentially leading to a healthy user bias.²

The findings demonstrate that this surgery can be a safe and effective therapeutic option to influence the trajectory of cirrhosis in patients. Despite this, experts still note cautions, such as implementation in smaller hospitals, should be made.^1,2

“[In my practice,] I would strongly recommend that bariatric surgery in patients with cirrhosis be done in large medical centers that are familiar with operating on people with cirrhosis,” said Wajahat Mehal, MD, DPhil, Yale School of Medicine in New Haven, Connecticut, in the news release.²

REFERENCES

1. Aminian A, Aljabri A, Wang S, et al. Long-term liver outcomes after metabolic surgery in compensated cirrhosis due to metabolic dysfunction-associated steatohepatitis. Nat Med. 2025. doi:10.1038/s41591-024-03480-y

2. Medpage Today. Bariatric Surgery in MASH Patients Improved Long-Term Outcomes. News release. January 27, 2025. Accessed February 4, 2025. https://bit.ly/3CDit1S