Bariatric surgery reduces liver complications in obese patients with cirrhosis

A Cleveland Clinic study shows that patients with obesity and fatty liver-related cirrhosis who had bariatric (weight-loss) surgery significantly lowered their future risk of developing serious liver complications compared with patients who received medical therapy alone. The results were published in Nature Medicine journal. 

Ali Aminian, M.D., director of Cleveland Clinic's Bariatric & Metabolic Institute and lead investigator of the study, said results show that bariatric surgery should be considered as a treatment option in patients with cirrhosis and obesity. "Bariatric surgery was associated with a 72% lower risk of developing serious complications of liver disease and an 80% lower risk of progression to decompensated stage among patients with compensated cirrhosis and obesity." 

Obesity and diabetes are the leading causes of metabolic dysfunction-associated steatohepatitis (MASH), which is the most common form of chronic liver disease in the United States. Accumulation of fat within liver cells triggers a cascade of events ultimately leading to liver scarring. About 20% of people with MASH can progress to late-stage liver scarring which is called cirrhosis. Approximately three million people in the United States are estimated to have MASH-related cirrhosis. 

Cirrhosis is categorized into two distinct stages: compensated and decompensated. In the compensated stage, despite presence of considerable damage, the liver maintains sufficient residual function to support the body's needs and patients can appear relatively healthy. In the decompensated stage, severe and life-threatening complications occur reflecting the liver's inability to sustain vital functions and liver transplantation becomes essential for survival. 

Patients with MASH-related cirrhosis have extremely limited treatment options. Currently, no therapeutic interventions have demonstrated efficacy in mitigating the risk of severe liver complications within this patient population. This underscores a critical unmet need for the development of effective therapies specifically targeting patients with compensated MASH-related cirrhosis." 

Sobia Laique, M.D., transplant hepatologist and study coinvestigator at Cleveland Clinic

The aim of the SPECCIAL (Surgical Procedures Eliminate Compensated Cirrhosis In Advancing Long-term) study was to examine the long-term outcomes of bariatric surgery on the risk of developing major liver complications in patients with obesity and compensated MASH-related cirrhosis, compared with nonsurgical management. 

A group of 62 Cleveland Clinic's patients with compensated MASH-related cirrhosis and obesity who had bariatric surgery were compared with a control group of 106 nonsurgical patients and followed for 15 years. Study participants had similar characteristics such as severity of liver disease at their baseline liver biopsy. 

Fifteen years after enrollment, study results show that 20.9% in the surgical group and 46.4% in the nonsurgical group developed one of the major complications of liver disease including liver cancer and death. 

Over the course of 15 years, 15.6% in the surgical group and 30.7% in the nonsurgical group progressed from compensated cirrhosis to the decompensated stage. At 15 years, patients in the bariatric surgery group lost 26.6% (31.6 kg) of their weight and patients in the nonsurgical control group lost 9.8% (10.7 kg) of their weight. 

Steven Nissen, M.D., Chief Academic Officer of the Heart, Vascular and Thoracic Institute at Cleveland Clinic and the study's senior investigator, said: "Currently, lifestyle intervention is the only therapeutic recommendation for compensated MASH-related cirrhosis. However, lifestyle changes alone rarely provide the weight loss and metabolic changes needed to reduce the risk of liver complications in this patient population. The SPECCIAL study shows that bariatric surgery is an effective treatment that can influence the trajectory of cirrhosis progression in select patients." 

The authors note that the SPECCIAL study is the first to examine long-term clinical outcomes after bariatric surgery in patients with MASH-related cirrhosis. In 2021, the Cleveland Clinic-led SPLENDOR study suggested bariatric surgery as the first effective treatment for MASH without cirrhosis. 

Future research is needed to study the new generation of anti-obesity medications and whether they can provide similar benefits in this patient population.