Correspondence to editorial on “Bariatric surgery reduces long-term mortality in patients with metabolic dysfunction-associated steatotic liver disease and cirrhosis”

Article information

Clin Mol Hepatol. 2025;31(2):e173-e175

Publication date (electronic) : 2025 January 9

doi : https://doi.org/10.3350/cmh.2025.0001

Nicholas A. Rouillard, Linda Henry, Mindie H. Nguyen

Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA

Corresponding author : Mindie H. Nguyen Division of Gastroenterology and Hepatology, Stanford University Medical Center, 780 Welch Road, Palo Alto, CA 94304, USA Tel: +1-650-498-6081, E-mail: mindiehn@stanford.edu

Editor: Han Ah Lee, Chung-Ang University College of Medicine, Korea

Received 2025 January 1; Accepted 2025 January 4.

Dear Editor,

We appreciate Drs. Zeng and Fan’s editorial on our recent study where we investigated outcomes of patients with metabolic dysfunction associated steatotic liver disease (MASLD)-related cirrhosis who did and did not undergo bariatric surgery [1,2]. As noted in our manuscript, this is a novel approach to determining outcomes for patients with MASLD-related cirrhosis and bariatric surgery. Many studies in the past have compared outcomes amongst patients with and without MASLD-related cirrhosis and outcomes following bariatric surgery.

With this unique approach, we found that among patients with MASLD-related cirrhosis who had a low Charlson Comorbidity Index (CCI <3), bariatric surgery provided a reduction in overall and liver-related mortality as well as a reduction in risk for liver-related events such as liver decompensation, hepatocellular carcinoma (HCC), liver transplantation and non-liver-related mortality to include mortality-related to cardiovascular disease and chronic kidney disease. However, importantly, these benefits were conferred only with the laparoscopic surgical approach and not with the open surgical approach. These findings uphold the current bariatric surgery guidelines that only the laparoscopic approach should be considered for those with liver cirrhosis.

Additionally, our study comes at such a time when new drugs for treatment of MASLD-related fibrosis are under clinical trial investigation. Most recently, promising preliminary results were announced from a phase III clinical trial investigating the use of semaglutide, a glucagon-like peptide-1 receptor agonist, to induce fibrosis regression without disease progression [3,4]. In this ongoing trial, the use of semaglutide met the study endpoints for fibrosis regression without disease progression as well as disease regression without fibrosis progression. Patients in the semaglutide arm also experienced an 11% reduction in body weight compared to 2% with placebo. Although not yet approved for clinical use, regulatory approval will be sought in the near future. Nonetheless, key questions remain about long-term outcomes, such as overall and cirrhosis-free survival, following pharmacological therapies. Also, these trials were only conducted in participants who had fibrosis stages 2 and 3 but not cirrhosis. As such, our findings provide novel insight into possible treatment options for those with MASLD-related cirrhosis and are obese.

It is in this context that Drs. Zeng and Fan raised a question about what the ideal body mass index (BMI) is when selecting patients with MASLD-related cirrhosis for bariatric surgery. Since our data were obtained from a healthcare administrative database, individual anthropometric data, such as BMI, were not accessible to us. Current guidelines from the American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) state that bariatric surgery is recommended for those who have a BMI ≥35 kg/m² regardless of comorbidity status but can be considered for those with a BMI ≥30 kg/m² and metabolic disease (appropriate ethnic adjustments were also considered) [5]. Therefore, we surmise that the BMI of bariatric surgery recipients within our study population would be between 30 and 35 kg/m² or higher.

Although we were not able to analyze data regarding patient quality of life, we were able to compare objective, long-term outcomes via both overall and liver-related mortality. In addition, our results serve as valuable proxies for liver function—we observed that the risk of HCC, decompensation, and liver transplant were all significantly less in those who underwent bariatric surgery. Notably, we were unable to study the possible effects of adherence to medications, vitamins, and lifestyle modifications that may be necessary to maintain weight loss and optimal health after bariatric surgery. Recent research has suggested that adherence to suggested lifestyle changes and vitamin supplementation can be as high as 50% to 80% at one year post surgery with support, especially intensive psychosocial support [6-8]. Ultimately, further investigation of behavioral and lifestyle modifications among patients with MASLD following bariatric surgery is required to provide a more holistic picture of long-term, post-operative care.

As the field of study for treatment of MASLD expands, it is imperative that exploration of existing treatments continue. In this light, Dr. Zeng and Dr. Fan have highlighted further areas of study that will help us understand the overall impact of bariatric surgery in those with MASLD-related cirrhosis. Nonetheless, our current research has provided encouraging findings on the long-term clinical outcomes of those with MASLD-related cirrhosis who have undergone laparoscopic bariatric surgery.