Considering Bariatric Surgery in Patients With Nonalcoholic Steatohepatitis—Worth the Risk

Obesity is the leading cause of nonalcoholic steatohepatitis (NASH) and is now the second most common indication for liver transplant.¹ With nearly 40% of adults in the United States now classified as obese, this epidemic is far from over. A growing body of evidence suggests that weight loss may stabilize or reverse the effects of NASH.² Bariatric surgery remains the most effective treatment for obesity, offering a significant opportunity to reduce the likelihood of progression to cirrhosis and the need for liver transplant.

Klebanoff et al³ assess the cost-effectiveness of several weight-loss interventions in patients with NASH compensated cirrhosis. Using a simulated patient population and a Markov-based state-transition model, the authors found that sleeve gastrectomy (SG), Roux-n-Y gastric bypass (GB), and intensive lifestyle interventions all increased quality-adjusted life-years and were cost-effective compared with usual care in patients with NASH compensated cirrhosis. They also show that, compared with GB, SG was the most cost-effective intervention, and its effectiveness was preserved across the continuum of patients ranging from overweight to severely obese. However, this study uses comparative statistics with a simulated patient population. Real-world decision making for patients with cirrhosis can be much less straightforward.

This article adds momentum to a growing literature by suggesting that bariatric surgery in patients with NASH is safe, beneficial, and now cost-effective.⁴ Historically, patients with cirrhotic physiological features of any kind were considered to have a prohibitively high surgical risk, which precluded the opportunity for elective or preventive interventions. Increasingly, with the advent of the model for end-stage liver disease score,⁵ a more granular risk profile can be delineated, and patients at lower risk can be identified. These patients with well-compensated cirrhosis are likely to benefit from bariatric intervention in several important ways. First, studies have shown that bariatric surgery can lead to a complete, biopsy-proven reversal of steatosis and hepatic inflammation in more than half of the patient population.⁶ In addition, in patients who experience progression of NASH over time, lower body mass index makes the liver transplant operation safer and less complicated. Importantly, from a technical and anatomical perspective, SG preserves gastric continuity for many common posttransplant endoscopic procedures (unlike the anatomy after GB). Finally, global improvements in the severity of medical comorbidities such as hypertension and diabetes are also appreciated in this population.²

During the last decade, SG has become the preferred bariatric procedure in the United States.⁷ This trend is particularly relevant for high-risk patient populations, among whom the complication profile may be more favorable than for GB. Growing momentum for the use of SG in patients with end-stage renal disease is a good example. Little to no previous work has characterized the use of bariatric surgery in this high-risk patient population. However, our group has performed preliminary analyses in the Medicare population indicating nearly 85% of patients with end-stage renal disease now undergo SG (K. H. Sheetz, K. J. Woodside, V. B. Shahinian, J. B. Dimick, J. R. Montgomer, S. A. Waits, unpublished data, January 2019). This shift in practice was also associated with a several-fold increase in the overall number of bariatric operations being performed on patients with organ failure. This makes intuitive sense: complication profiles are similar to those of healthy patients without end-stage renal disease, and some patients even experience stabilization of their kidney function. The renal transplant operation itself is also safer and technically easier after significant weight loss and metabolic improvement.⁸ Longitudinally, the additional improvements in medical comorbidity will also positively affect graft and patient survival in the long term.

Cirrhosis has historically been a strong relative contraindication to elective surgery. As such, surgeons have been reluctant to perform bariatric surgery on these high-risk patients. Further, physicians have also avoided placing referrals to bariatric surgery for this population. Understanding the key drivers of these decisions and shedding new light on the potential risks and benefits may change such practice patterns. Bariatric surgery outcomes (fairly or unfairly) are often placed under a microscope by accrediting bodies, payers, and society. Embracing a new, potentially high-risk and high-reward patient population may take some time. Patients benefit not only from significant weight loss, but also from stabilization of a progressive and deadly disease. Going forward, we must work to demystify cirrhosis. This process includes better education for all physicians regarding the spectrum of tools that can be used to manage obesity in patients with NASH compensated cirrhosis. With modern-day bariatric surgery’s exceedingly favorable safety profile, NASH cirrhosis should not preclude an evaluation for surgery. The effects are too great and the patients are too sick to throw the opportunity away because the risks are “too high.”

Published: February 22, 2019. doi:10.1001/jamanetworkopen.2019.0053

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Waits SA et al. JAMA Network Open.

Corresponding Author: Seth A. Waits, MD, Section of Transplant Surgery, Department of Surgery, Office F6688 UH-South, 1500 E Medical Center Dr, Mail Stop SPC 5296, Ann Arbor, MI 48109 (waitss@med.umich.edu).

Conflict of Interest Disclosures: Dr Ghaferi reported receiving grants from Blue Cross/Blue Shield of Michigan, Agency for Healthcare Research and Quality, and Patient-Centered Outcomes Research Institute outside the submitted work. No other disclosures were reported.