We recently wrote an editorial on the significant work of Rouillard et al. [1], and we were delighted to receive their insightful response [2]. Their correspondence provided additional details and insightful reflections on their study. Undoubtedly, the findings of Rouillard et al. offer important insights into the treatment of patients with metabolic dysfunction-associated steatotic liver disease (MASLD)-related cirrhosis, especially highlighting the clinical efficacy of laparoscopic bariatric surgery and its positive impact on long-term prognosis [3]. Their research confirms the substantial advantages of laparoscopic surgery over open surgery in these patients. Such evidence not only reinforces the scientific basis for the current clinical guidelines recommending laparoscopic surgery for treatment of MASLD regardless of compensated cirrhosis but also provides valuable data to support further research in this area [4,5]. Therefore, the choice of laparoscopic surgery not only reflects the technical superiority of the surgical approach but also signifies a more comprehensive evaluation of patient prognosis in clinical treatment. Future research should continue to explore the long-term effects of laparoscopic surgery in patients with MASLD-related cirrhosis, particularly in terms of cardiovascular-kidney-liver-metabolic diseases improvement, hepatic and extrahepatic tumor risk reduction, and overall health outcomes. As treatment strategies become increasingly personalized to enhance the overall quality of life, optimizing postoperative management within a multidisciplinary framework is recommended to prevent malnutrition, sarcopenia, and complications of liver cirrhosis and underlying cardiometabolic diseases.

In patients with MASLD-related cirrhosis, the body mass index (BMI) threshold for determining eligibility for bariatric surgery is a critical clinical decision. Although the study by Rouillard et al. did not address BMI directly, as noted in their correspondence, relevant guidelines do provide clear criteria for BMI selection. However, it is important to acknowledge that definitions of overweight and obesity vary across different countries and regions [6], indicating the need for personalized BMI thresholds tailored to specific patient populations from diverse ethnic and geographical backgrounds. Currently, BMI is widely used as the standard measure for assessing obesity. However, studies have shown that BMI is not a completely reliable indicator of the obesity status. To improve the accuracy of obesity diagnosis, it is recommended to combine BMI with additional body fat measurements, such as waist circumference, hip circumference, or direct body fat percentage. This approach helps reduce the risk of misclassification of obesity, especially when it coexists with sarcopenia [5,7]. Incorporating these additional measurement methods into the clinical diagnosis of obesity not only enhances diagnostic precision but also provides more detailed and personalized guidance for determining bariatric surgery eligibility. Recently, the Lancet Diabetes & Endocrinology Commission published the “Definition and Diagnostic Criteria of Clinical Obesity,” which proposes an evidence-based distinction between “clinical obesity” and “preclinical obesity”. Considering the limitations of BMI, the commission recommends integrating additional body measurement methods, such as waist circumference, waist-to-hip ratio, or waist-to-height ratio to define clinical obesity more comprehensively [8,9]. This innovative definition provides a new perspective for updating clinical obesity standards, urging future research to assess how adjustments in bariatric surgery eligibility and long-term outcomes under varying definitions and degrees of obesity can be implemented. For patients with MASLD-related cirrhosis, the appropriate criteria for bariatric surgery eligibility, whether stricter or modified, need further clarification. The single BMI standard may be insufficient to address the complexity of this specific population. Therefore, further research should investigate how novel obesity definitions can refine and adjust treatment standards, and assess the practical implications of these standards in MASLD patients with compensated cirrhosis.

While some studies suggest that bariatric surgery is more effective than lifestyle interventions and optimized pharmacotherapy in treating metabolic dysfunction-associated steatohepatitis and related fibrosis [10], advancements in new generation anti-obesity medications (e.g., semaglutide, tirzepatide, survodutide, mazdutide, pemvidutide, retatrutide, CagriSema) and their potential benefits for liver outcomes also warrant attention. We look forward to further validating the effectiveness of these evolving anti-obesity drugs in patients with MASLD-related cirrhosis through larger, more comprehensive clinical trials. Moreover, integrating pharmacotherapy with laparoscopic surgery may become a critical direction for future treatment strategies. Evaluating the synergistic effects or relative advantages of both treatments across different stages of MASLD will provide a more comprehensive foundation for optimizing treatment plans. However, given the complex pathology of MASLD, relying solely on surgical or anti-obesity pharmacological treatment may not solve all issues of MASLD, particularly in patients with normal BMI or coexisting severe sarcopenia.

As our understanding of the pathological mechanisms underlying MASLD and related cirrhosis continues to evolve, future treatment strategies should increasingly focus on personalized approaches, tailoring interventions to individual patients based on their specific conditions, genetic and epigentic profiles, and responses to medications. This approach will require extensive biomarker research and clinical trials to generate scientific support for individualized treatment. Given the considerable variability in disease progression and metabolic status among patients with MASLD-related cirrhosis, future studies should further refine patient stratification, developing more precise treatment plans based on liver function, severity of cardiometabolic diseases, and other individual factors such as age, gender, and lifestyle. Moreover, alongside surgical treatment, it is crucial to explore the effects of combined lifestyle interventions and medications on post-surgical long-term outcomes. Studies have shown that postoperative lifestyle changes not only help sustain weight loss following surgery but also improve metabolic function and slow liver disease progression [11]. Strengthening postoperative comprehensive interventions could significantly improve liver-related outcomes and overall prognosis. A multi-faceted treatment approach offers MASLD patients with cirrhosis comprehensive support, addressing not only liver disease but also cardiovascular-kidney-metabolic health, psychological well-being, and quality of life, thereby enhancing long-term health outcomes for patients.