Simultaneous liver transplant and sleeve gastrectomy provides durable weight loss, improves metabolic syndrome and reduces allograft steatosis

Abstract

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). We aimed to determine the long-term impact of simultaneous LT and sleeve gastrectomy (LTSG) in patients with obesity transplanted for MASLD.

Methods: We 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.

Impact and implications: The optimal approach to liver transplant for patients with obesity and end-stage liver disease remains uncertain, especially given the risk for recurrent metabolic dysfunction-associated steatotic liver disease. The current study provides the first multicenter analysis of outcomes for patients treated with combined liver transplant and sleeve gastrectomy and includes an assessment of key outcomes of interest such as weight loss efficacy, recurrent steatosis and fibrosis, and diabetes, as well as reflux (a known complication of sleeve gastrectomy) in addition to assessing for sarcopenia prior to transplant. The results demonstrate that combined liver transplant and sleeve gastrectomy can be successfully adopted at multiple centers and provides long-term efficacy in managing both end-stage liver disease and obesity, which may be of interest not only for clinicians and researchers, but also for patients and policy makers.

Keywords: bariatric surgery; liver transplant; metabolic associated steatotic liver disease; metabolic syndrome; obesity; sleeve gastrectomy; surgical outcomes.