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Sleeve Gastrectomy Reduces the Need for Liver Transplantation in Patients with Obesity and Non-Alcoholic Steatohepatitis: a Predictive Model

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Abstract

Background

Non-alcoholic steatohepatitis (NASH) is one of the leading indications for liver transplantation (LT) in the United States. As with the current obesity epidemic, the incidence of NASH continues to rise. However, the impact of broad utilization of bariatric surgery (BS) for patients with NASH is unknown, particularly in regard to mitigating the need for LT.

Methods

Markov decision analysis was performed to simulate the lives of 20,000 patients with obesity and concomitant NASH who were deemed ineligible to be waitlisted for LT unless they achieved a body mass index (BMI) < 35 kg/m2. Life expectancy following medical weight management (MWM) and sleeve gastrectomy (SG) were estimated. Base case patients were defined as having NASH without fibrosis and a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed.

Results

Simulated base case analysis patients who underwent SG gained 14.3 years of life compared to patients who underwent MWM. One year after weight loss intervention, 9% of simulated MWM patients required LT compared to only 5% of SG patients. Survival benefit for SG was observed above a BMI of 32.2 kg/m2.

Conclusion

In this predictive model of 20,000 patients with obesity and concomitant NASH, surgical weight loss is associated with a reduction in the progression of NASH, thereby reducing the need for LT. A reduced BMI threshold of 32 kg/m2 for BS may offer survival benefit for patients with obesity and NASH.

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References

  1. Sheka AC, Adeyi O, Thompson J, et al. Nonalcoholic steatohepatitis: a review [published correction appears in JAMA. 2020;323(16):1619]. JAMA. 2020;323(12):1175–1183. https://doi.org/10.1001/jama.2020.2298.

  2. Harnois F, Msika S, Sabaté JM, et al. Prevalence and predictive factors of non-alcoholic steatohepatitis (NASH) in morbidly obese patients undergoing bariatric surgery. Obes Surg. 2006;16(2):183–8. https://doi.org/10.1381/096089206775565122.

    Article  PubMed  Google Scholar 

  3. Boza C, Riquelme A, Ibañez L, et al. Predictors of nonalcoholic steatohepatitis (NASH) in obese patients undergoing gastric bypass. Obes Surg. 2005;15(8):1148–53. https://doi.org/10.1381/0960892055002347.

    Article  PubMed  Google Scholar 

  4. Ward ZJ, Bleich SN, Cradock AL, et al. Projected U.S. state-level prevalence of adult obesity and severe obesity. N Engl J Med. 2019;381(25):2440–50. https://doi.org/10.1056/NEJMsa1909301.

    Article  PubMed  Google Scholar 

  5. Estes C, Anstee QM, Arias-Loste MT, et al. Modeling NAFLD disease burden in China, France, Germany, Italy, Japan, Spain, United Kingdom, and United States for the period 2016–2030. J Hepatol. 2018;69(4):896–904. https://doi.org/10.1016/j.jhep.2018.05.036.

    Article  PubMed  Google Scholar 

  6. Haldar D, Kern B, Hodson J, et al. Outcomes of liver transplantation for non-alcoholic steatohepatitis: a European Liver Transplant Registry study. J Hepatol. 2019;71(2):313–22. https://doi.org/10.1016/j.jhep.2019.04.011.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Jadlowiec CC, Taner T. Liver transplantation: current status and challenges. World J Gastroenterol. 2016;22(18):4438–45. https://doi.org/10.3748/wjg.v22.i18.4438.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Yemini R, Nesher E, Braun M, et al. Long-term outcomes of Roux-en-Y gastric bypass or sleeve gastrectomy in patients with cirrhosis; before, during or after liver transplantation: a single center’s experience. Clin Transplant. 2021;35(8):e14374. https://doi.org/10.1111/ctr.14374.

    Article  PubMed  Google Scholar 

  9. Lassailly G, Caiazzo R, Ntandja-Wandji LC, et al. Bariatric surgery provides long-term resolution of nonalcoholic steatohepatitis and regression of fibrosis. Gastroenterology. 2020;159(4):1290-1301.e5. https://doi.org/10.1053/j.gastro.2020.06.006.

    Article  PubMed  Google Scholar 

  10. 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. 2021;326(20):2031–42. https://doi.org/10.1001/jama.2021.19569.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Martin P, DiMartini A, Feng S, et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014;59(3):1144–65. https://doi.org/10.1002/hep.26972.

    Article  PubMed  Google Scholar 

  12. European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu. EASL Clinical Practice Guidelines: liver transplantation. J Hepatol. 2016;64(2):433–85. https://doi.org/10.1016/j.jhep.2015.10.006.

    Article  Google Scholar 

  13. García-Sesma A, Calvo J, Manrique A, et al. Morbidly obese patients awaiting liver transplantation-sleeve gastrectomy: safety and efficacy from a liver transplant unit experience. Transplant Proc. 2019;51(1):33–7. https://doi.org/10.1016/j.transproceed.2018.01.060.

    Article  PubMed  Google Scholar 

  14. Hogendoorn W, Moll FL, Sumpio BE, et al. Clinical decision analysis and Markov modeling for surgeons: an introductory overview. Ann Surg. 2016;264(2):268–74. https://doi.org/10.1097/SLA.0000000000001569.

    Article  PubMed  Google Scholar 

  15. Naugler WE, Sonnenberg A. Survival and cost-effectiveness analysis of competing strategies in the management of small hepatocellular carcinoma. Liver Transpl. 2010;16(10):1186–94. https://doi.org/10.1002/lt.22129.

    Article  PubMed  Google Scholar 

  16. Choudhury RA, Hoeltzel G, Prins K, et al. Sleeve gastrectomy compared with gastric bypass for morbidly obese patients with end stage renal disease: a decision analysis. J Gastrointest Surg. 2020;24(4):756–63. https://doi.org/10.1007/s11605-019-04225-w.LA.0000000000001569.

    Article  PubMed  Google Scholar 

  17. Rouhi AD, Choudhury RA, Hoeltzel GD, et al. Ventricular remodeling following metabolic and bariatric surgery decreases need for heart transplantation: a predictive model. Obes Surg. Published online November 29, 2023. https://doi.org/10.1007/s11695-023-06948-x.

  18. Choudhury RA, Yoeli D, Moore HB, et al. Reverse epidemiology and the obesity paradox for patients with chronic kidney disease: a Markov decision model. Surg Obes Relat Dis. 2020;16(7):948–54. https://doi.org/10.1016/j.soard.2020.02.015.

    Article  PubMed  Google Scholar 

  19. Mosko JD, Nguyen GC. Increased perioperative mortality following bariatric surgery among patients with cirrhosis. Clin Gastroenterol Hepatol. 2011;9(10):897–901. https://doi.org/10.1016/j.cgh.2011.07.007.

    Article  PubMed  Google Scholar 

  20. Curioni CC, Lourenço PM. Long-term weight loss after diet and exercise: a systematic review. Int J Obes (Lond). 2005;29(10):1168–74. https://doi.org/10.1038/sj.ijo.0803015.

    Article  CAS  PubMed  Google Scholar 

  21. Salminen P, Helmiö M, Ovaska J, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial. JAMA. 2018;319(3):241–54. https://doi.org/10.1001/jama.2017.20313.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–70. https://doi.org/10.1053/jhep.2001.22172.

    Article  CAS  PubMed  Google Scholar 

  23. Segev DL, Thompson RE, Locke JE, et al. Prolonged waiting times for liver transplantation in obese patients. Ann Surg. 2008;248(5):863–70. https://doi.org/10.1097/SLA.0b013e31818a01ef.

    Article  PubMed  Google Scholar 

  24. Secunda K, Gordon EJ, Sohn MW, et al. National survey of provider opinions on controversial characteristics of liver transplant candidates. Liver Transpl. 2013;19(4):395–403. https://doi.org/10.1002/lt.23581.

    Article  PubMed  Google Scholar 

  25. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(2 Suppl):615S-619S. https://doi.org/10.1093/ajcn/55.2.615s.

  26. Billeter AT, Reiners B, Seide SE, et al. Comparative effectiveness of medical treatment vs. metabolic surgery for histologically proven non-alcoholic steatohepatitis and fibrosis: a matched network meta-analysis. Hepatobiliary Surg Nutr. 2022;11(5):696–708. https://doi.org/10.21037/hbsn-21-5.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Eisenberg D, Shikora SA, Aarts E, et al. American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis. 2022;18(12):1345–56. https://doi.org/10.1016/j.soard.2022.08.013.

    Article  PubMed  Google Scholar 

  28. Bower G, Toma T, Harling L, et al. Bariatric surgery and non-alcoholic fatty liver disease: a systematic review of liver biochemistry and histology. Obes Surg. 2015;25(12):2280–9. https://doi.org/10.1007/s11695-015-1691-x.

    Article  PubMed  Google Scholar 

  29. Billeter AT, Scheurlen KM, Israel B, et al. Gastric bypass resolves metabolic dysfunction-associated fatty liver disease (MAFLD) in low-BMI patients: a prospective cohort study. Ann Surg. 2022;276(5):814–21. https://doi.org/10.1097/SLA.0000000000005631.

    Article  PubMed  Google Scholar 

  30. Chauhan M, Singh K, Thuluvath PJ. Bariatric surgery in NAFLD. Dig Dis Sci. 2022;67(2):408–22. https://doi.org/10.1007/s10620-021-07317-3.

    Article  PubMed  Google Scholar 

  31. Aminian A, Wilson R, Al-Kurd A, et al. Can nonalcoholic steatohepatitis be surgically cured? Liver histological comparison after metabolic surgery versus usual care [published online ahead of print, 2023 May 22]. Ann Surg. 2023;https://doi.org/10.1097/SLA.0000000000005914. https://doi.org/10.1097/SLA.0000000000005914.

  32. Franchitto A, Carpino G, Alisi A, et al. The contribution of the adipose tissue-liver axis in pediatric patients with nonalcoholic fatty liver disease after laparoscopic sleeve gastrectomy [published correction appears in J Pediatr. 2020 Nov;226:321]. J Pediatr. 2020;216:117–127.e2. https://doi.org/10.1016/j.jpeds.2019.07.037.

  33. Hoeltzel GD, Swendiman RA, Tewksbury CM, et al. How safe is adolescent bariatric surgery? An analysis of short-term outcomes. J Pediatr Surg. 2022;57(8):1654–9. https://doi.org/10.1016/j.jpedsurg.2021.08.018.

    Article  PubMed  Google Scholar 

  34. Aminian A, Wilson R, Al-Kurd A, et al. can nonalcoholic steatohepatitis be surgically cured?: liver histologic comparison after metabolic surgery versus usual care. Ann Surg. 2024;279(2):276–82. https://doi.org/10.1097/SLA.0000000000005914.

    Article  PubMed  Google Scholar 

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Armaun D. Rouhi, Noel N. Williams & Kristoffel R. Dumon

  2. Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA

    Rose E. Castle, Maria Baimas-George, Michael Wachs, Trevor L. Nydam & Rashikh A. Choudhury

  3. Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA

    Gerard D. Hoeltzel

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  1. Armaun D. Rouhi
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Correspondence to Armaun D. Rouhi.

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Key Points

• Sleeve gastrectomy reduces the progression of NASH.

• Surgical weight loss reduces the need for liver transplantation.

• Sleeve gastrectomy improves access to liver transplantation when needed.

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Rouhi, A.D., Castle, R.E., Hoeltzel, G.D. et al. Sleeve Gastrectomy Reduces the Need for Liver Transplantation in Patients with Obesity and Non-Alcoholic Steatohepatitis: a Predictive Model. OBES SURG 34, 1224–1231 (2024). https://doi.org/10.1007/s11695-024-07102-x

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