Liver transplantation and obesity – Combined bariatric surgery shows benefits
Larson EL et al, J Hepatol. 2025;83(3):729-737
A U.S. study reports positive outcomes of performing bariatric surgery combined with liver transplantation. In this retrospective analysis, 72 patients who underwent combined liver transplantation and sleeve gastrectomy achieved more pronounced and sustained weight loss, reduced graft steatosis, and improved metabolic profiles compared to 185 patients receiving transplantation alone. Although no significant differences in overall mortality or graft survival were observed during the follow-up period, the findings highlight a promising strategy for the growing population of obese liver transplant candidates.
Background and aims: The prevalence of obesity and metabolic syndrome is rising among liver transplant (LT) candidates, many of whom have metabolic dysfunction-associated steatotic liver disease (MASLD). The authors aimed to determine the long-term impact of simultaneous LT and sleeve gastrectomy (LTSG) in patients with obesity transplanted for MASLD.
Methods: The authors analyzed patients undergoing LTSG using a single clinical protocol (n = 72), and patients with BMI > 30 who underwent LT alone for MASLD (n = 185) in a multicenter retrospective cohort study. Follow-up duration was 4–153 (median 41) months for LTSG and 12–161 (median 75) months for LT. Outcomes included mortality, graft loss, BMI, metabolic syndrome components, allograft steatosis and fibrosis.
Results: Mortality and graft loss were not significantly different between the LT and LTSG groups. The prevalence of diabetes was significantly lower in patients undergoing LTSG vs. LT alone after 8 years of follow-up (p < 0.05), while hypertension decreased from 61.1% to 35.8% in the LTSG group (p < 0.01). Patients undergoing LTSG (average starting BMI of 45.5) experienced significant weight loss compared to baseline for > 9 years (p < 0.001), while no significant change was seen for the LT-alone group (average starting BMI 34.0). The incidence of allograft steatosis was significantly lower in the LTSG vs. LT group (p = 0.004). The prevalence of fibrosis was reduced in the LTSG vs. LT group 3-10 years postoperatively (relative risk ratio 0.46; p = 0.09). One patient in the LTSG group had a gastric sleeve leak and one required hiatal hernia repair. Severe gastroesophageal reflux disease occurred in 11.1% of the LTSG group; risk factors included pre-existing diabetes and gastroesophageal reflux disease.
Conclusions: LTSG results in sustained weight loss, resolution of diabetes and hypertension, and reduced recurrence of steatosis and possibly fibrosis compared to LT alone. It confers no increase in mortality or graft loss.