Written by Babatunde Carew
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After bariatric surgery, patients with Metabolic Dysfunction-associated SteatoHepatitis (MASH) resolution without worsening fibrosis had improved 15-year survival compared to those with persistent MASH and/or worsening fibrosis.
Cutting weight, adding years?
MASH is a major public health concern, with adult prevalence estimated to rise to 7.9% by 2050. Liver fibrosis related to MASH is a part of the natural disease course and increases all cause mortality. Bariatric surgery resolves histologic findings of MASH and decreases fibrosis, but the effect on mortality is not well studied.
This prospective cohort study assessed the impact of MASH resolution and fibrosis progression on mortality after bariatric surgery. Of 3,028 enrolled patients, 2,641 (89%) had baseline biopsies, 232 (8.7%) were diagnosed with MASH, and 266 (10.8%) with significant fibrosis (F2–F4). Among 594 patients with paired biopsies, 89 achieved MASH resolution without fibrosis worsening, while 32 had persistent MASH or worsening fibrosis. 15-year mortality was higher in patients with persistent MASH and/or worsening fibrosis (HR 2.54, 95%CI 1.06–6.10). Compared to those without significant baseline fibrosis, patients with persistent significant fibrosis had increased mortality (HR 4.03, 95%CI 1.86–8.72), but fibrosis improvement (F2–F4 to F0–F1) was not associated with lower mortality (HR 1.49, 95%CI 0.52–4.24). This study has several key limitations. The wide confidence intervals for hazard ratios indicate uncertainty in effect size, likely due to the limited number of patients with paired biopsies. Additionally, bariatric surgery has numerous metabolic benefits, making it difficult to attribute the mortality benefit to MASH alone. Finally, while patients with excessive alcohol use were excluded at baseline, alcohol use was not monitored during the follow-up period and could be a significant confounder.
How does this change my practice?
This study does not change my current practice. While it highlights the association between MASH/liver fibrosis and mortality, larger studies are needed to directly compare the effect of bariatric surgery and newer medications such as GLP1RAs, SGLT2 inhibitors, and resmetirom on disease progression and mortality.
Source
Resolution of Metabolic Dysfunction-associated Steatohepatitis With No Worsening of Fibrosis After Bariatric Surgery Improves 15-year Survival: A Prospective Cohort Study. Clin Gastroenterol Hepatol. 2024 Dec 19:S1542-3565(24)01078-4. doi: 10.1016/j.cgh.2024.10.025. Epub ahead of print. PMID: 39709138
