We read with interest the retrospective study assessing the effect of bariatric surgery on metabolic dysfunction-associated steatotic liver disease (MASLD) with cirrhosis [1]. In this study using the California Department of Healthcare Access and Information database, Rouillard et al. found that compared to matched controls, patients who underwent bariatric surgery had lower 5-year overall, liver-related, and non-liver-related mortality [1]. Although the study provides impor tant insights, several methodological considerations regarding metabolic profiles, medication use, and lifestyle factors warrant further investigation to enhance the clinical applicability of these findings.

First, MASLD is defined as the presence of hepatic steatosis with at least one cardiometabolic risk factor, such as obesity/central adiposity, insulin resistance, hypertension, and/or dyslipidemia; however, various cardiometabolic risk factors, as well as the number of these risk factors, can exhibit different impacts on the clinical outcomes of patients with MASLD [2,3]. In this study, only the Charlson comorbidity index was balanced between groups, but there was no information about specific metabolic components. Especially for overweight/obesity, the body mass index could significantly differ between those with and without bariatric surgery. Given that these metabolic components could influence clinical outcomes, future studies should incorporate detailed metabolic profiles and conduct subgroup analyses based on different metabolic components.

Second, as insulin resistance is a common metabolic dysfunction in patients with MASLD, anti-diabetes medications may be prescribed for a significant portion of the individuals included in this study. Among anti-diabetes medications, sodium-glucose cotransporter-2 inhibitors, glucagonlike peptide-1 receptor agonists, and thiazolidinediones have been demonstrated to have potential effects on the outcomes of patients with MASLD [4,5]. In addition, cardiovascular medications such as ACE inhibitors or angiotensin receptor blockers are commonly used in these patients and can affect their clinical outcomes. To mitigate the confounding effects of these medications, future analyses should adjust for the prevalence of medication use between the study group and matched controls.

Lastly, several important lifestyle-related confounding factors were not addressed in this study. These include dietary habits, physical activity levels, smoking status, and alcohol consumption patterns, all of which can significantly impact the progression of MASLD and its associated outcomes [6-10]. Future studies should consider incorporating these factors to provide more comprehensive analyses.

In conclusion, while this study provides valuable insights into the potential benefits of bariatric surgery for patients with MASLD and cirrhosis, future research should address these limitations by including detailed metabolic profiles, medication use patterns, and lifestyle factors. Such comprehensive analyses would better inform clinical decisionmaking and patient selection for bariatric surgery in this high-risk population.