Weight loss surgery may protect liver with MASH-related cirrhosis
Study finds it effective in preventing further organ damage in obese patients
Weight loss surgery significantly lowers the risk of serious liver complications among obese people with cirrhosis, or irreversible liver scarring and damage, due to metabolic dysfunction-associated steatohepatitis (MASH), a severe form of fatty liver disease.
These are the findings of an observational study led by Cleveland Clinic researchers, called SPECCIAL, designed to evaluate if weight loss surgery, also known as bariatric surgery, could improve patients’ long-term outcomes relative to nonsurgical treatment.
“The SPECCIAL study shows that bariatric surgery is an effective treatment that can influence the trajectory of cirrhosis progression in select patients,” Steven Nissen, MD, chief academic officer of the Heart, Vascular, and Thoracic Institute at the Cleveland Clinic in Ohio, and the study’s senior author, said in a clinic news release.
The study, “Long-term liver outcomes after metabolic surgery in compensated cirrhosis due to metabolic dysfunction-associated steatohepatitis,” was published in Nature Medicine.
Weight loss or bariatric surgery makes changes to the digestive system
Fatty liver disease is characterized by the excessive accumulation of fat in the liver. In MASH, this fat buildup gives rise to inflammation and scarring (fibrosis). Its development is strongly associated with cardiometabolic risk factors such as obesity and type 2 diabetes.
Over time, MASH’s progression can cause serious harm to the liver, including cirrhosis. Cirrhosis initially may be compensated, meaning the liver is still able to perform most of its functions, but it eventually becomes decompensated, where the organ starts losing function.
Decompensated cirrhosis leads to life-threatening complications and eventual liver failure, where a liver transplant is usually required for survival. As such, a major disease treatment goal with compensated cirrhosis is to prevent its progression. However, treatment options to date once cirrhosis is present are limited.
“Currently, lifestyle intervention is the only therapeutic recommendation for compensated MASH-related cirrhosis,” but it “rarely [provides] the weight loss and metabolic changes needed to reduce the risk of liver complications,” Nissen said.
Bariatric surgery can lead to substantial weight loss and reductions in other cardiometabolic risk factors for people who are obese. There are a few different types, but all make changes to the digestive system to limit how much a person can eat and/or reduce the body’s ability to absorb fat and other calories.
Previous studies, including one from Cleveland Clinic, have shown that these surgeries can improve outcomes for people with MASH, including reductions in liver fat and scarring and a lower risk of disease progression. But these studies did not involve patients with cirrhosis.
Obese patients with cirrhosis given bariatric surgery or lifestyle management
That was the goal of the SPECCIAL study, comparing long-term outcomes in obese people with MASH-related compensated cirrhosis seen in the Cleveland Clinic’s U.S. health system between 1995 and 2020. A total of 62 people underwent bariatric surgery, while 106 others received standard nonsurgical medical management.
Long-term outcomes were monitored over a period of 25 years — through February 2024 — with a mean follow-up of about 10 years.
Specifically, the scientists looked for major liver complications such as liver cancer, a liver transplant, or death. Others included fluid buildup in the abdomen (ascites), bleeding from the veins in the gastrointestinal tract (variceal hemorrhage), or brain injury due to the liver’s inability to clear toxins from the blood (hepatic encephalopathy), all of which also were considered to mark the transition to decompensated cirrhosis.
By the study’s end, 10 people in the surgery group and 42 in the nonsurgical group had a major liver complication. Four people who underwent surgery progressed from compensated to decompensated cirrhosis, as did 33 of those in the nonsurgical group.
In final adjusted analyses, 20.9% in the surgery group and 46.4% in the nonsurgical group developed a major liver complication after 15 years, amounting to a 72% lower risk of such outcomes with weight loss surgery.
80% lower risk of decompensated cirrhosis seen with the surgery
Moreover, progression to decompensated cirrhosis was seen in 15.6% of those who underwent surgery and 30.7% of those with standard management, corresponding to an 80% lower risk of this complication with surgery.
At 15 years, patients in the surgery group had lost a mean of 26.6% of their weight, compared with 9.8% among the nonsurgical group.
Metabolic surgery was generally well tolerated, and associated with blood sugar reductions and diabetes resolution for many patients.
“Our study shows that metabolic surgery may positively influence the trajectory of cirrhosis with few procedure-related adverse effects,” the researchers wrote.
Study limitations included the absence of patient data regarding the adoption of healthy habits that could have influenced the results, the team noted. The majority of the patients also were white, so study findings “may not be generalizable to individuals in other racial and ethnic groups.”
Nevertheless, “in the absence of approved medical therapies for compensated MASH-related cirrhosis, metabolic surgery may represent a safe and effective therapeutic option to influence the trajectory of cirrhosis in selected patients,” the scientists wrote.
More research also may be needed into recently available anti-obesity medications to determine if they might carry similar benefits for this patient group.
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