Bariatric surgery significantly reduced major adverse liver outcomes in MASH cirrhosis
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Key takeaways:
- Metabolic surgery reduced major adverse liver outcomes in patients with MASH with compensated cirrhosis by 72%.
- In addition, metabolic surgery reduced progression to decompensation by 80%.
At 15 years of follow-up, metabolic surgery “was not only safe” but also significantly reduced major adverse liver outcomes and decompensation in patients with metabolic dysfunction-associated steatohepatitis and compensated cirrhosis.
“Previous studies suggested excellent clinical outcomes in patients with MASH and fibrosis stages 1 to 3 with improvement in both cardiac and liver events,” Naim Alkhouri, MD, FAASLD, chief medical officer, chief of transplant hepatology and director of the fatty liver program at Arizona Liver Health, told Healio. “The long-term effects of bariatric surgery on outcomes in patients with MASH cirrhosis, or F4, are not known.”
In the observational Surgical Procedures Eliminate Compensated Cirrhosis in Advancing Long-term (SPECCIAL) study, Alkhouri and colleagues assessed 36,912 liver biopsies performed at the Cleveland Clinical Health System between 1995 and 2020 in adult patients with obesity and compensated histologically-proven MASH-related cirrhosis.
Researchers identified 62 patients who underwent metabolic surgery (Roux-en-Y gastric bypass, n = 37; sleeve gastrectomy, n = 25) with simultaneous liver biopsies, who were matched with 106 nonsurgical control patients. After overlap weighting, baseline characteristics of surgical patients and nonsurgical controls were similar, with a mean age of 54.4 years, BMI of 42.7 kg/m² and fibrosis-4 score of 2.1. In each group, 84% had type 2 diabetes and 85% were on antihypertensive medications.
The primary endpoint was major adverse liver outcomes (MALO), defined as first occurrence of ascites, variceal hemorrhage, hepatic encephalopathy, hepatocellular carcinoma, transplantation or all-cause mortality. The secondary endpoint was progression from compensated to decompensated cirrhosis.
Patients were followed over a 25-year period, with a mean follow-up of 10 years. Follow-up ended in February 2024, and only 8% of patients had less than 5 years of follow-up.
According to results presented at EASL Congress, there were 52 composite MALO events (metabolic surgery group, n = 10; nonsurgical group, n = 42) and 37 decompensation events (metabolic surgery group, n = 4; nonsurgical group, n = 33) in an unadjusted dataset.
At 15 years, the cumulative incidence of MALO was 20% in the metabolic surgery group vs. 46% in the nonsurgical group (adjusted HR = 0.28; 95% CI, 0.12-0.64). In addition, the incidence of progression to decompensation was 15% vs. 30%, respectively (aHR = 0.2; 95% CI, 0.06-0.68).
“The surgical group had a 72% reduction in major adverse liver outcomes and 80% reduction in developing liver decompensation,” Alkhouri told Healio.
Fifteen years from baseline, the mean total weight loss was 26% in the metabolic surgery group vs. 9.8% in the nonsurgical group, with a mean difference of 16.8%, he reported.
According to sensitivity analysis, five patients had grade 2 nonbleeding esophageal varices at baseline, and findings remained consistent after excluding those patients (MALO, aHR = 0.29; 95% CI, 0.12-1.69; progression to decompensation, aHR = 0.22; 95% CI, 0.06-0.74).
Ten patients developed adverse events after metabolic surgery, including wound-related complications and bleeding, but no deaths were reported.
“Bariatric surgery was not only safe in compensated cirrhosis patients, it also significantly decreased the development of major adverse liver outcomes over a long follow-up period,” Alkhouri told Healio.
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Alkhouri N, et al. 15-year liver outcomes after metabolic surgery in patients with compensated MASH-related cirrhosis. Presented at: EASL Congress; June 5-8,2024; Milan (hybrid meeting).
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