Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes

Abstract

Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End‐Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux‐en‐Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention‐to‐treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1‐year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2‐15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8‐13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105‐141] cm2 versus 153 [131‐191] cm2; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.

Reply

“…We appreciate the interest by Yildiz in our work that looked at the association between bariatric surgery and outcomes among patients evaluated for liver transplantation . We share the sentiment that some of the outcomes noted in the study may be related to malabsorptive rather than restrictive weight reduction surgery.…”

Obesity: Weighty Challenges for the Liver Transplant Community

“…(9) On the other hand, a recent article reported that a prior history of BS is associated with higher rates of delisting as well as lower survival rates from the time of listing on an intent-to-treat analysis. (10) Many other key questions remain unanswered. Is obesity alone a risk factor for poor outcomes after LT or simply a marker of other confounding risk factors like sarcopenia, frailty, or metabolic syndrome?…”

“…On the one hand, there is evidence that BS provides histological improvement in nonalcoholic fatty liver disease, suggesting possible benefits after LT in obese patients . On the other hand, a recent article reported that a prior history of BS is associated with higher rates of delisting as well as lower survival rates from the time of listing on an intent‐to‐treat analysis …”

Prior Bariatric Surgery in Liver Transplant Candidates: Unforeseen Consequences?

“…Sleeve gastrectomy (SG) prior to or at the time of LT has been reported to be safe and to reduce weight and/or metabolic complications before and after LT, though published experience is modest and patients are carefully selected . In contrast to this positive experience, Idriss et al found a higher rate of delisting or death on the waiting list in patients with versus without bariatric surgery. This finding is striking and concerning, although a single‐center study of modest sample size might be subject to bias and unmeasured confounding.…”

Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes

“…We read with great interest the article in Liver Transplantation by Idriss et al The authors gave a unique perspective to bariatric surgery and its relation to liver transplantation (LT).…”