Bariatric Surgery in Patients Hospitalized with Decompensated Cirrhosis: A Nationwide Analysis

Stephen Firkins, MD

Both metabolic dysfunction-associated steatotic liver disease (MASLD) and bariatric surgery are becoming increasingly common in light of the rising obesity epidemic. Bariatric surgery offers well-established benefits on MASLD outcomes, including reduced adverse liver and cardiovascular events, improvement in steatohepatitis, and potential histologic regression of fibrosis.^1-3

Despite this, patients may still develop cirrhosis following bariatric surgery, either through progressive steatosis or other mechanisms. While many have sought to validate the efficacy and safety of performing bariatric surgery on patients with compensated cirrhosis, there is a paucity of literature describing the effect of bariatric surgery on outcomes of cirrhosis decompensation events.^4,5

We performed a retrospective, population-based analysis using the National Inpatient Sample database from October 2015 - December 2020 to identify all adults with obesity hospitalized with decompensated cirrhosis, including ascites, variceal hemorrhage, hepatic encephalopathy, or portal hypertension. These patients were then stratified into those with (n = 14,500) or without (n = 1,010,955) a history of bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy).

Table 1a, 1b

On outcomes analysis, inpatient mortality rates were lower in the bariatric surgery cohort (2.9% vs 4.1%; P = .002), as were rates of acute kidney injury (24% vs 27%; P <.001), respiratory failure requiring mechanical ventilation (0.7% vs 1.5%; P <.001), and upper GI bleed (6.7% vs 9.6%; P <.001). On univariate logistic regression analysis, bariatric surgery was protective against inpatient mortality (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.58-0.89; P = .002). However, after adjusting for age, race, Baveno stage, and Charlson Comorbidity Index, protective significance was lost (OR, 0.82; 95% CI, 0.66-1.03; P = .086).

Weight loss is the primary treatment for MASLD, and despite a growing armamentarium of non-surgical weight loss strategies, bariatric surgery remains the most effective and enduring treatment for obesity. A recent systematic review reported an overall lower risk of adverse liver outcomes among patients with obesity who underwent bariatric surgery compared to those who did not (Hazard ratio, 0.33; 95% CI, 0.31-0.34), including significantly reduced risk of developing cirrhosis.⁶ However, despite surgery, fibrosis may still progress and patients remain susceptible to other causes of cirrhosis, such as viral hepatitis or alcohol-associated liver disease. In fact, bariatric surgery is known to increase the risk of alcohol use disorder post-operatively, facilitating more rapid and higher peak alcohol delivery to the systemic circulation.^7,8

Regardless of etiology, our study illustrates improved outcomes among patients with obesity and a history of bariatric surgery hospitalized with decompensated cirrhosis compared to nonsurgical patients. This likely relates to overall improved metabolic and comorbid health conferred by bariatric surgery. Though an important finding, future analyses are needed to further understand this relationship, including identifying temporal relationships between surgery and the onset of cirrhosis and decompensation, as well as subanalysis based on cirrhosis etiology and ongoing risk factors.

References:

1. ^{Aminian A, Al-Kurd A, Wilson R, et al. Association of Bariatric Surgery With Major Adverse Liver and Cardiovascular Outcomes in Patients With Biopsy-Proven Nonalcoholic Steatohepatitis. JAMA. Nov 23 2021;326(20):2031-2042. doi:10.1001/jama.2021.19569}
2. ^{Lassailly G, Caiazzo R, Ntandja-Wandji LC, et al. Bariatric Surgery Provides Long-term Resolution of Nonalcoholic Steatohepatitis and Regression of Fibrosis. Gastroenterology. Oct 2020;159(4):1290-1301.e5. doi:10.1053/j.gastro.2020.06.006}
3. ^{Verrastro O, Panunzi S, Castagneto-Gissey L, et al. Bariatric-metabolic surgery versus lifestyle intervention plus best medical care in non-alcoholic steatohepatitis (BRAVES): a multicentre, open-label, randomised trial. Lancet. May 27 2023;401(10390):1786-1797. doi:10.1016/S0140-6736(23)00634-7}
4. ^{Are VS, Knapp SM, Banerjee A, et al. Improving Outcomes of Bariatric Surgery in Patients With Cirrhosis in the United States: A Nationwide Assessment. Am J Gastroenterol. Nov 2020;115(11):1849-1856. doi:10.14309/ajg.0000000000000911}
5. ^{Bai J, Jia Z, Chen Y, Li Y, Zheng S, Duan Z. Bariatric Surgery is Effective and Safe for Obese Patients with Compensated Cirrhosis: A Systematic Review and Meta-Analysis. World J Surg. May 2022;46(5):1122-1133. doi:10.1007/s00268-021-06382-z}
6. ^{Wang G, Huang Y, Yang H, Lin H, Zhou S, Qian J. Impacts of bariatric surgery on adverse liver outcomes: a systematic review and meta-analysis. Surg Obes Relat Dis. Jul 2023;19(7):717-726. doi:10.1016/j.soard.2022.12.025}
7. ^{Pepino MY, Okunade AL, Eagon JC, Bartholow BD, Bucholz K, Klein S. Effect of Roux-en-Y Gastric Bypass Surgery: Converting 2 Alcoholic Drinks to 4. JAMA Surg. Nov 2015;150(11):1096-8. doi:10.1001/jamasurg.2015.1884}
8. ^{King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. Jun 20 2012;307(23):2516-25. doi:10.1001/jama.2012.6147}