- Design
- Retrospective paired-biopsy cohort, single centre
- Population
- 30 adults with compensated MASH cirrhosis after metabolic bariatric surgery
- Primary outcome
- Regression from NASH CRN stage 4 to stage 3 or lower
- Effect
- 33% regressed (NASH CRN); 40% (modified Ishak); median biopsy interval 6.2 years
Surgeons and pathologists at Cleveland Clinic reviewed 30 adults with biopsy-proven compensated cirrhosis from metabolic dysfunction-associated steatohepatitis (MASH) who had metabolic bariatric surgery between 2004 and 2024 and a later liver biopsy. Median baseline BMI was 43.7 and median biopsy interval 6.2 years.
Median total weight loss was 23.9%. Cirrhosis regressed from stage 4 to stage 3 or lower in 33% by the NASH CRN system and 40% by modified Ishak staging; 60% showed regressive features on the Beijing classification. Steatosis, inflammation and ballooning also improved.
This challenges the view that established MASH cirrhosis is fixed. But it is a small retrospective series of patients selected for surgery and for repeat biopsy, with no comparison group, and decompensated patients were not included.
The practical point is to keep compensated cirrhosis from automatically excluding someone from bariatric assessment in a centre experienced with these patients, while recognising perioperative risk is higher.
- Consider referral for bariatric assessment in compensated MASH cirrhosis rather than excluding it outright.
- Confirm compensation and exclude clinically significant portal hypertension before surgery.
- Operate on these patients in centres with hepatology and bariatric experience.
- Decompensated cirrhosis was not studied and remains a different risk.
Why it matters
It suggests cirrhosis from MASH may partly reverse with sustained weight loss, changing what surgery can offer these patients.
Don't overread it
Thirty selected patients without a control group cannot show how often regression happens across all who might be offered surgery.
The statistics, in plain English
A third regressing means 10 of 30 patients by one staging system. With so few patients the true proportion could be considerably lower or higher. Different scoring systems gave 33%, 40% and 60%, which shows how much depends on how regression is defined.
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