Written by Peter Liu
Spoon Feed
Weight loss surgery in patients with metabolic dysfunction-associated steatohepatitis (MASH) cirrhosis and obesity reduces major liver adverse outcomes and may prevent cirrhosis decompensation, even after propensity-score adjustment.
Bariatric surgery improves outcomes in MASH cirrhosis
MASH cirrhosis, formerly called non-alcoholic steatohepatitis (NASH) cirrhosis, is an important cause of cirrhosis associated with metabolic disorders such as obesity, diabetes, hyperlipidemia, and hypertension. As our understanding of these metabolic disorders have advanced, so too have disease-specific treatments for MASH cirrhosis. Today, there is growing evidence for therapies such as GLP1 agonists, resmetirom (a THR-ß agonist), and vitamin E.
Today’s propensity-score matched observational study (SPECCIAL) investigated whether metabolic surgery reduces the risk of major adverse liver outcomes (MALO) in patients with compensated MASH cirrhosis. MALO was defined as the first occurrence of ascites, variceal hemorrhage, hepatic encephalopathy, hepatocellular carcinoma (HCC), liver transplantation, or death. Surgery patients had either roux-en-y gastric bypass or gastric sleeve surgery. Among 168 patients with obesity and biopsy-proven MASH cirrhosis (62 surgical, 106 nonsurgical), the 15-year cumulative MALO incidence was significantly lower in the surgical group (20.9% vs. 46.4%; HR 0.28, 95%CI 0.12–0.64, P = 0.003), as was liver decompensation (HR: 0.20, P = 0.01). Weight loss was greater in the surgical group (mean between-group difference, 20.9 kg (95%CI, 17.3–24.5 kg).
This observational trial provides lower-quality evidence than an RCT (confounding remains possible) and does not clearly allow for direct comparisons between surgery and other MASH cirrhosis treatments. The data from this trial was probably also collected prior to the widespread use of more contemporary beta-blocker therapies for compensated cirrhosis (i.e. carvedilol). Nevertheless, the findings strongly support weight loss surgery as an effective treatment option for compensated MASH cirrhosis with obesity.
How does this change my practice?
SPECCIAL supports weight loss surgery for patients with obesity and compensated MASH cirrhosis. Patients open to surgery who have MASH and and class 2 obesity or obesity with type 2 diabetes are likely to have not only weight loss, but improvement in liver disease as well.
Source
Long-term liver outcomes after metabolic surgery in compensated cirrhosis due to metabolic dysfunction-associated steatohepatitis. Nat Med. 2025 Mar;31(3):988-995. doi: 10.1038/s41591-024-03480-y. Epub 2025 Jan 27. PMID: 39870816
