Liver Disease Diagnosis and Treatment · Journal article

Impact of bariatric surgery on cardiovascular and cerebrovascular outcomes in metabolic dysfunction–associated steatotic liver disease: a nationwide analysis

Baylor University Medical Center Proceedings · September 4, 2026

Strong Evidence Why this matters to you Expert discussion

Well-designed and adequately powered for the question it asks.

AI Summary

This large retrospective cohort analysis of 3.67 million patients with metabolic dysfunction–associated steatotic liver disease demonstrates that bariatric surgery is associated with substantially reduced odds of major adverse cardiovascular and cerebrovascular events, mortality, and healthcare resource utilization. The findings are consistent across five hard clinical endpoints with tight confidence intervals and highly significant p-values, though causality cannot be inferred from observational data and unmeasured confounding remains a concern.

What was studied

Retrospective cohort study using National Inpatient Sample. Adults aged ≥18 years with hepatic steatosis or steatohepatitis and at least one metabolic risk factor, approximating established MASLD criteria; stratified by prior bariatric surgery status. Intervention: Prior bariatric surgery. Compared with: No prior bariatric surgery. n = 3,668,314. United States (National Inpatient Sample).

Key findings

All-cause mortality lower with bariatric surgery: aOR 0.33 (95% CI 0.32–0.34), p < 0.001 Myocardial infarction lower with bariatric surgery: aOR 0.38 (95% CI 0.36–0.39), p < 0.001 Stroke lower with bariatric surgery: aOR 0.87 (95% CI 0.86–0.88), p < 0.001

Safety

All-cause mortality lower with bariatric surgery: aOR 0.33 (95% CI 0.32–0.34), p < 0.001

Who this may help

Clinicians caring for patients with MASLD and obesity may view these findings as supportive evidence that bariatric surgery confers substantial cardiovascular protection. However, the observational design precludes definitive causal inference; randomized evidence or rigorous adjustment for all confounders would be needed to guide individual patient decisions.

Plain-language summary

Large retrospective cohort study from a national database with rigorous multivariable adjustment, reporting hard clinical endpoints (mortality, MI, stroke) with narrow confidence intervals and highly significant p-values across multiple cardiovascular outcomes.

Study design

As stated by the source record.

MethodsNational Inpatient Sample data from 2016 to 2022 were used to identify adults ≥18 years with hepatic steatosis or steatohepatitis and ≥1 metabolic risk factor. Patients were stratified by prior bariatric surgery status. Multivariable logistic regression was used to assess outcomes after adjustment for potential confounders. Outcomes were reported as adjusted odds ratios with 95% confidence intervals.

DesignRetrospective cohort study using National Inpatient Sample

PopulationAdults aged ≥18 years with hepatic steatosis or steatohepatitis and at least one metabolic risk factor, approximating established MASLD criteria; stratified by prior bariatric surgery status

Sample size3,668,314

InterventionPrior bariatric surgery

ComparatorNo prior bariatric surgery

SettingUnited States (National Inpatient Sample)

Reported figures

Quoted from the source exactly as published.

Sample size3668314

Bariatric surgery exposure394535

All-cause mortality aOR0.33

All-cause mortality 95% CI0.32–0.34

Myocardial infarction aOR0.38

Myocardial infarction 95% CI0.36–0.39

Stroke aOR0.87

Stroke 95% CI0.86–0.88

Clinical bottom line

Caveats

Retrospective administrative data; causality cannot be established; unmeasured confounding by indication (i.e., healthier patients may be selected for surgery) likely biases results toward benefit
Specific confounders adjusted for not listed in detail; residual confounding possible
Timing of bariatric surgery relative to outcome assessment not specified; follow-up duration not reported
Absolute event rates and absolute risk reductions not provided; only odds ratios reported

Evidence assessment

Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.

Study design

strong

Retrospective cohort with multivariable logistic regression and adjustment for confounders

Directness

strong

Hard clinical endpoints: mortality, MI, stroke, AF, heart failure directly address MACCE question

Consistency

moderate

Consistent direction of benefit across all five major outcomes; source does not report heterogeneity or subgroup analyses

Risk of bias

moderate

Retrospective administrative data; selection bias and unmeasured confounding likely; adjustment for listed confounders not specified in detail

Sample adequacy

strong

3.67 million MASLD patients with 394,535 exposed to bariatric surgery; large sample ensures narrow confidence intervals

Source abstract

Background The prevalence of metabolic dysfunction–associated steatotic liver disease (MASLD) continues to rise, with strong associations with obesity and cardiometabolic diseases. Bariatric surgery (BS) has shown metabolic benefits in MASLD, but its impact on major adverse cardiovascular and cerebrovascular events (MACCE) remains unclear.Methods National Inpatient Sample data from 2016 to 2022 were used to identify adults aged ≥18 years with hepatic steatosis or steatohepatitis and at least one metabolic risk factor, approximating established MASLD criteria. Patients were then stratified by prior BS status, and multivariable logistic regression was used to assess the outcomes after adjustment for potential confounders. Outcomes were reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI).Results Among 3,668,314 MASLD patients, 394,535 underwent BS. BS was associated with lower odds of all-cause mortality (aOR 0.33, 95% CI 0.32–0.34), myocardial infarction (aOR 0.38, 95% CI 0.36–0.39), stroke (aOR 0.87, 95% CI 0.86–0.88), atrial fibrillation (aOR 0.73, 95% CI 0.72–0.74), and heart failure (aOR 0.52, 95% CI 0.52–0.57); all P < 0.001. Length of stay and total hospital charges were also significantly reduced.Conclusion BS was associated with lower risk of MACCE, mortality, and resource utilization in patients with MASLD, supporting its beneficial role.

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