Histologic Evidence of MASH Cirrhosis Regression After Metabolic Bariatric Surgery, With Sobia Laique, MD

For decades, cirrhosis has been understood as an irreversible, fibrotic scar replacing functional liver tissue, largely viewed as an endpoint. However, emerging evidence is challenging that assumption, particularly in the setting of metabolic dysfunction-associated steatohepatitis (MASH).

New research presented by Sobia Laique, MD, a gastroenterologist and transplant hepatologist, Chair of the MASLD Task Force, and director of the Multidisciplinary MASLD Center at Cleveland Clinic, at Digestive Disease Week (DDW) 2026 in Chicago, IL, suggests that for select patients with compensated MASH cirrhosis, metabolic bariatric surgery may not only halt disease progression, but actually reverse it.

The research builds on previously published findings from the SPECIAL study, which demonstrated a 72% reduction in major adverse liver outcomes, including variceal hemorrhage, hepatic encephalopathy, liver cancer, need for transplant, and liver-related death, in patients with compensated MASH cirrhosis who underwent MBS.

"When we saw that, it begged the question: did we potentially also reverse the cirrhosis itself?" Laique told HCPLive.

To explore that question, the team conducted a retrospective cohort study of 30 patients with biopsy-proven compensated MASH cirrhosis who underwent metabolic bariatric surgery between 2004 and 2024 at a single tertiary care center. All patients had F4 fibrosis on baseline biopsy, no prior decompensation or liver transplant, and a median biopsy interval of 6.2 years. The cohort was metabolically advanced, with a mean BMI of 43.7 kg/m² and 87% having diabetes, but carefully selected for compensated disease.

Laique noted that a key insight from the study was methodological: how cirrhosis regression is measured matters. Conventional staging systems, such as the NASH CRN scoring system, define regression as a transition from F4 to F3 or lower, capturing stage changes but potentially missing subtler architectural remodeling, such as thinning or fragmentation of fibrous septa that does not shift the overall stage. When the team applied more granular frameworks, including the Ishak and Beijing classifications, which specifically assess architectural changes within fibrotic tissue, regression rates were meaningfully higher.

Using conventional NASH CRN staging, approximately one-third of patients showed cirrhosis regression. With Ishak scoring, that figure rose to 40%, and with the Beijing classification, to 60%.

"Even if there's a 1-in-3 chance that I have the ability to reverse a patient's disease, that's something I would want to be able to offer them, let alone if that goes up to 40 or 60%," Laique said.

Beyond regression rates, the findings carry broader implications for clinical practice, according to Laique. First, metabolic bariatric surgery can now be positioned as a truly disease-modifying intervention for patients with compensated MASH cirrhosis, one capable of improving long-term outcomes and reversing underlying disease. Second, the field needs to reassess how it measures fibrosis regression, not only in the context of surgical intervention, but also as pharmacologic therapies continue to emerge.

Laique noted that next steps should include prospective studies comparing metabolic bariatric surgery with GLP-1 receptor agonists, as well as mechanistic investigations into what drives cirrhosis regression, work she says her team is actively pursuing at the Cleveland Clinic.

Editor's note: Laique reports no relevant disclosures.

References

1. Aminian, A., Aljabri, A., Wang, S. et al. Long-term liver outcomes after metabolic surgery in compensated cirrhosis due to metabolic dysfunction-associated steatohepatitis. Nat Med 31, 988–995 (2025). https://doi.org/10.1038/s41591-024-03480-y

2. Laique S, Hammad AF, Allende DS, et al. CAN METABOLIC SURGERY REGRESS MASH CIRRHOSIS? EVIDENCE FROM PAIRED BIOPSIES. Presented at Digestive Disease Week (DDW) 2026 in Chicago, IL, May 2-5, 2026.