Bariatric surgery significantly reduced the risk of decompensation flare-up and adverse outcomes in patients with obesity and decompensation of metabolic syndrome-associated steatohepatitis (MASH), according to an observational study.
In 62 patients who underwent bariatric surgery, the 15-year cumulative incidence of major adverse liver outcomes was 21% compared with 46% in control patients treated nonoperatively (HR 0.28, 95% CI 0.12-0.64, p= 0.003), reported Steven Nissen, MD, of the Cleveland Clinic, and colleagues.
The 15-year cumulative incidence of cirrhosis was 16% in the surgical group versus 31% in the non-surgical group (HR 0.20, 95% CI 0.06-0.68, p= 0.01), the study authors detailed in Natural medicine.
“Currently, lifestyle intervention is the only treatment recommendation for Mash-associated cirrhosis,” Nissen said in a statement. “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 meta-study showed that bariatric surgery is an effective treatment that can influence the course of progression of liver cirrhosis in selected patients.”
Patients in the surgery group lost an average of 32 kg (27% of body weight) 15 years after surgery. “Sustained weight loss was sufficient to prevent progression of refractory cirrhosis to end-stage liver disease,” the study authors noted.
One potential implication of the study is that bariatric surgery could help patients with obesity and disabling cirrhosis eventually get liver transplants, the researchers suggested. Severe obesity is a contraindication for liver transplantation in many centers because of the increased risk of morbidity after transplantation. However, surgically induced weight loss can shift the eligibility status of patients with severe obesity.
Wajahat Mehal, MD, of the School of Medicine in New Haven, Connecticut, who was not involved in the study, said. This is good news for patients with obesity and liver disease who may need bariatric surgery for other reasons, such as bad knees or sleep apnea, he said.
“It actually seems to greatly help the liver as well. Which is not a surprise, honestly. It’s what I expected,” added Mihal, a volunteer for the American Liver Foundation. “But obviously it’s good to see that this is actually the case.”
However, “I strongly recommend that bariatric surgery in patients with cirrhosis be performed at large medical centers familiar with working on people with cirrhosis.” “This is not a selective planche for every small hospital to go ahead and start doing this.”
Nissen and colleagues said a sufficiently powered randomized clinical trial with adequate follow-up would be needed to evaluate how treatment affects long-term outcomes in patients with wasting-associated liver cirrhosis. Therefore, the team conducted a carefully designed observational study.
The parallel study (Surgical Procedures to Eliminate Decompensated Liver Fibrosis in Long-Term Progression) included 168 patients with obesity and decompensated liver cirrhosis associated with wasting. The mean age was 54.4 years, the mean BMI was 42.7, and 69.6% were women.
Sixty-two participants who underwent metabolic surgery, including Roux-en-Y gastric bypass (n = 37) and sleeve gastrectomy (n = 25), were compared with 106 non-surgical control patients. Mean follow-up 10.0±4.5 years.
Efficacy outcomes included 15-year cumulative incidence of major adverse liver outcomes and cirrhosis. Nissen and colleagues said that key baseline variables such as type 2 diabetes, fibrosis score-4, and ICH score were carefully balanced between the study groups through weighting techniques, which can reproduce many key aspects of randomized trials.
In addition, statistical models were fully adjusted based on several other covariates including Charlson Comorbidity Index score, insulin use, and smoking status using the Firth method, which can increase the precision of estimates in COX proportional hazards models.
Previous studies have reported benefits for metabolic surgery in patients with MERS but without cirrhosis. The current study is the first to evaluate long-term clinical outcomes after metabolic surgery in patients with obesity and liver cirrhosis associated with liver failure.
However, a major limitation was that data on physical activity, dietary habits, alcohol use, and smoking status during long-term follow-up were not available. The researchers noted that patients who underwent metabolic surgery could have adopted healthier lifestyles than the non-surgical control group, leading to a healthy user bias. Also, 90% of the study patients were white, which limits the generalizability of the results to other racial and ethnic groups.
Disclosures
No funding source was reported for this study.
Nissen reports receiving grants for clinical trials from Abbvie, Astrazeneca, Amgen, Bristol Myers Squibb, Eli Lilly, Esperion Therapeutics, Medtronic, Myocardia, New Amsterdam Pharmaceuticals, Novartis, and Silence. The co-authors reported multiple relationships with industry.
Primary source
Natural medicine
Source reference: Aminia A, et al “Long-term liver outcome after metabolic surgery in refractory liver cirrhosis due to metabolic dysregulation-associated liver disease” Nat Med 2025; doi: 10.1038/s41591-024-03480-y.
