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Background & Aims The ultrasound‐based controlled attenuation parameter (CAP) is a non‐invasive tool widely validated for assessing liver steatosis across different etiologies. However, few studies, with liver biopsy available, have investigated its performance in individuals with morbid obesity. Herein, we aimed to evaluate the diagnostic accuracy of CAP in participants with morbid obesity from the MAFALDA study before bariatric surgery. Methods A total of 120 individuals with valid examinations within three months from bariatric surgery were included. Clinical, laboratory, FibroScan® (XL probe), and liver biopsy data were collected using standardized procedures. The overall accuracy of CAP for detecting liver steatosis was estimated by the area under the receiver‐operating characteristics curve (AUROC). Optimal cut‐offs were chosen at points with the highest Youden index. Results The AUROCs of CAP for detecting S ≥ S1, S ≥ S2, and S = S3 were 0.91 (95% CI 0.86–0.97), 0.83 (95% CI 0.76–0.90), and 0.86 (95% CI 0.79–0.94), respectively. The best CAP cut‐offs for S ≥ S1, S ≥ S2, and S = S3 were 300 dB/m (95% CI 275–316), 328 dB/m (95% CI 296–345), and 344 dB/m (95% CI 343–352), respectively. CAP values were independently influenced by steatosis grade (estimate 20.60, 95% CI 12.70–28.40, P = 1.05 × 10−6). The AUROC of FibroScan‐AST (FAST) score for detecting progressive non‐alcoholic steatohepatitis was 0.76 (95% CI 0.66–0.86). Conclusions In individuals with morbid obesity, CAP measured by XL probe is an accurate non‐invasive tool for grading liver steatosis. Measurement of liver fat content by CAP may help identify those eligible for bariatric procedures and estimate the effect of bariatric surgery on hepatic steatosis. Lay Summary The ultrasound‐based controlled attenuation parameter (CAP) by using the XL probe has an excellent performance for grading liver steatosis among individuals with morbid obesity. CAP may represent an accurate tool for the non‐invasive assessment of liver steatosis among individuals with morbid obesity before and after bariatric surgery.

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Background Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS. Methods To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus. Results Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items). Conclusions ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.