Introduction

New research has emerged highlighting the potential of metabolic surgery to drastically improve long-term liver outcomes in patients suffering from compensated metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis. With no current FDA-approved medical therapies for this condition, the study’s findings are a beacon of hope for a population facing limited treatment options.

Study Findings

The Surgical Procedures Eliminate Compensated Cirrhosis In Advancing Long-term (SPECCIAL) study has unveiled astonishing results: patients with compensated MASH-related cirrhosis who underwent metabolic surgery experienced a 72% reduction in the risk of significant liver complications, known as major adverse liver outcomes (MALO), and an 80% decrease in the risk of progression to decompensation compared to those who received nonsurgical treatment.

Current Treatment Landscape

Despite the recent approval of resmetirom (Rezdiffra) on March 14, 2024, as the first MASH therapeutic by the FDA, its use is limited to patients with moderate to advanced fibrosis, leaving a vast unmet need among those with cirrhosis. Renowned transplant hepatologist Dr. Sobia Laique from Cleveland Clinic emphasizes that "no therapeutic interventions have shown efficacy in preventing severe liver complications in this group," underscoring the pressing need for effective treatments tailored specifically for compensated MASH-related cirrhosis patients.

SPECCIAL Study Overview

The SPECCIAL study involved a meticulous examination of over 36,000 patients who underwent liver biopsies at the Cleveland Clinic Health System between 1995 and 2020. From this pool, 168 patients were identified with histologically confirmed compensated MASH-related cirrhosis and obesity. Among them, 62 underwent metabolic surgery, including 37 who had Roux-en-Y gastric bypass and 25 who had sleeve gastrectomy, while 106 received nonsurgical care.

Results of the Study

Over an average follow-up period of 10 years, the results were telling: only 20.9% of patients who had surgery developed MALO over the 15 years, compared to 46.4% in the nonsurgical group. When considering the transition from compensated to decompensated cirrhosis, the figures were even more striking, with 15.6% in the surgical group versus 30.7% in the nonsurgical group.

Weight Loss and Complications

Furthermore, the surgical group experienced a substantial average weight loss of 26.6% over 15 years, in stark contrast to the mere 9.8% in the nonsurgical cohort, which is significant in managing and potentially reversing MASH-related complications.

While some complications were reported—including wound issues and a few cases requiring reoperation—there were no fatalities directly related to the metabolic surgery, reinforcing the procedure's safety and effectiveness.

Conclusion

Dr. Steven Nissen, chief academic officer at Cleveland Clinic and senior investigator of the study, remarked, "The SPECCIAL study shows that bariatric surgery is an effective treatment that can influence the trajectory of cirrhosis progression in select patients," paving the way for new treatment protocols in this vulnerable population.

With the weight of this evidence, the medical community is urged to reconsider treatment strategies for patients with MASH-related cirrhosis, opening doors to metabolic surgery as a crucial option that could change lives for those grappling with this challenging condition. As discussions surrounding liver health evolve, this breakthrough highlights the importance of innovative surgical interventions and their potential in combating chronic liver diseases.