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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 68-71

Impact of metabolic and bariatric surgery on liver diseases: Current evidence

1 Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
3 Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India

Date of Submission10-Jun-2022
Date of Acceptance15-Jun-2022
Date of Web Publication06-Jul-2022

Correspondence Address:
Dr. Sandeep Aggarwal
Departments of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbs.jbs_9_22

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The obesity pandemic has led to metabolic-associated fatty liver disease as being a major cause of chronic liver disease and liver transplantation worldwide. Metabolic and bariatric surgery (MBS), through a significant and sustained weight loss, has been shown to have a positive impact on both liver steatohepatitis and fibrosis. This review article aims to present and critically appraise the current literature on the impact of MBS on liver disease and highlight its increasing acceptance within the liver transplant community.

Keywords: Bariatric surgery, fatty liver disease, liver cirrhosis

How to cite this article:
Agarwal L, Chekuri R, Singla V, Kumar A, Shalimar, Aggarwal S. Impact of metabolic and bariatric surgery on liver diseases: Current evidence. J Bariatr Surg 2022;1:68-71

How to cite this URL:
Agarwal L, Chekuri R, Singla V, Kumar A, Shalimar, Aggarwal S. Impact of metabolic and bariatric surgery on liver diseases: Current evidence. J Bariatr Surg [serial online] 2022 [cited 2023 Feb 5];1:68-71. Available from: http://www.jbsonline.org/text.asp?2022/1/2/68/349955

  Introduction Top

The pertinacious pandemic of obesity has brought in metabolic-associated fatty liver disease (MAFLD) as an important forerunner of chronic liver disease worldwide. The natural history of MAFLD is that of a gradually progressive disease with cirrhosis and end-stage liver disease (ESLD) as the eventual results.[1] In addition, irrespective of the underlying etiology, obesity by itself has a detrimental impact on the natural history of liver disease. MAFLD is rapidly dawning as the most common indication for liver transplant (LT) and presents novel issues such as body mass index (BMI) criteria for LT and recurrence of graft steatosis and steatohepatitis.[2] Metabolic and bariatric surgery (MBS) is the current frontline treatment for severe obesity and its associated metabolic complications. Through a significant and sustained weight loss, MBS improves the metabolic milieu and benefits patients with obesity and underlying liver disease.[3] The impact of MBS on MAFLD and metabolic dysfunction-associated steatohepatitis (MASH) is an emerging area of interest. Building evidence demonstrates a significant biochemical and histological improvement in all stages of MAFLD and MASH after MBS.[4] However, with the increasing arena and popularity of MBS, concerns have arisen regarding its safety and efficacy in patients with liver cirrhosis, its outcomes in patients undergoing LT, and over incidental reports of liver decompensation following MBS.[5] This narrative review explores the implications of obesity and metabolic syndrome (MS) on liver functions, the impact of MBS on MAFLD, and the emerging role of MBS in the pre- and post-LT settings.

  Impact of Metabolic and Bariatric Surgery on Metabolic-Associated Fatty Liver Disease Top

MAFLD is intricately associated with visceral obesity, insulin resistance (IR), and Type 2 diabetes mellitus (T2DM).[6] MAFLD is not only a manifestation of but also can precede the development of components of the MS, such as T2DM, dyslipidemia, and hypertension.[7] The natural course of MAFLD is that of progression to MASH and eventually cirrhosis.[8] The exacerbation or persistence of metabolic risk factors (obesity, T2DM, and dyslipidemia) has been shown to account for this progression.[9] Fibrosis related to MAFLD may be reversible if underlying inciting factors such as obesity and IR are improved.[10],[11] Improvement in MAFLD histology directly correlates to the degree of weight loss achieved.[12] However, the lifestyle alterations and medical interventions required for weight loss are not only difficult to implement but also harder to sustain. MBS induces significant and sustained weight loss.[13] Several recent studies have examined the impact of MBS on the progression of MAFLD, as well as its correlation with obesity. Post-MBS, patients with steatosis and steatohepatitis show improvement in histology, although the effect on hepatic fibrosis has been a matter of debate.[14],[15],[16],[17],[18],[19] There are discrepancies in the literature regarding the impact on hepatic fibrosis.[20],[21] Recent systematic reviews and meta-analyses (SRMAs) published over the last decade have noted an overall improvement in liver fibrosis, with worsening noted in a few studies.[14],[15],[16],[18],[22] Zhou et al., in their SRMA on the effects of MBS on histopathological MAFLD, noted improvement in liver fibrosis in 25% of patients after MBS. Lee et al. noted biopsy-confirmed resolution of liver fibrosis in 40% of patients after MBS with new or worsening fibrosis noted in 12% of patients.[16] It suggested that the improvement of steatosis, fibrosis, alanine transaminase, and aspartate transaminase in Asian countries was better than that in non-Asian countries.[22] Evidence regarding even the reversal of biopsy-proven advanced fibrosis is now coming up and needs further investigation.[11],[23],[24] However, hitherto MAFLD is not a well-established comorbid condition with regard to eligibility for MBS.[25],[26] The effects of MBS on MAFLD and its sequelae are not well comprehended on the population level. Wirth et al., in their large database-driven study including over 8500 patients, noted the decreased progression of MAFLD to cirrhosis after MBS.[27] In a recent single-institution study, Yeo et al. showed a statistically significant improvement in NAFLD fibrosis score, correlating with weight loss at the 1st postoperative year after MBS.[28] Agarwal et al., in their prospective study using paired 1-year follow-up liver biopsies, found an overall significant improvement in all the histological parameters of MAFLD post-MBS.[11] In a prospective study including 64 patients with repeat liver biopsy 5 years after MBS, NASH was resolved in 84%, fibrosis stage decreased in 70%, and fibrosis disappeared in 56% of patients.[29] In a recent cohort study of 1158 patients with MASH, compared with nonsurgical management, MBS was associated with a significantly lower risk of incident major adverse liver outcomes and major adverse cardiovascular events.[30] Patients with MAFLD who underwent MBS were at a decreased risk for progression to cirrhosis compared to well-matched controls. The findings suggested that MBS was associated with an 88% lower risk of progression to major adverse liver outcomes during long-term follow-up. Based on the existing evidence showing a positive impact of MBS on MAFLD, future eligibility guidelines for MBS should include MAFLD as a comorbid indication.[27] An editorial by Ramai et al. also advocates for expanding indications for MBS in part through citing their recently published SRMA, documenting a reduction in hepatocellular carcinoma after MBS.[31],[32]

  Metabolic and Bariatric Surgery in Liver Cirrhosis Patients Top

Of late, several good-quality studies have addressed the pertinent issue of MBS in patients with liver cirrhosis.[24],[33],[34],[35],[36],[37],[38],[39],[40] However, as most of the studies included patients with well-compensated liver disease, there is no established consensus on which MBS technique is most suited for the patient with decompensated liver disease. A recent meta-analysis on the safety and efficacy of MBS in patients with hepatic cirrhosis found an overall low postoperative surgical and liver-related mortality post-MBS.[41] However, perioperative complications were higher than that seen in patients without liver disease. Among patients with obesity and liver disease, laparoscopic sleeve gastrectomy (LSG) was the most performed MBS procedure and was associated with lower overall and liver-related complications compared with Roux-en-Y gastric bypass (RYGB). However, due to the long-staple line, sleeve gastrectomy (SG) in the setting of portal hypertension (PHTN) may predispose to a higher bleeding risk. Transjugular intrahepatic portosystemic shunt placement prior to MBS in patients with PHTN helps reduce the risk of intraoperative bleeding by decreasing the portal pressure.[36],[40],[42],[43] One of the alarming complications post-MBS in cirrhotic patients is decompensation of the liver disease. Mendoza et al.[44] found that alcohol ingestion and malnourishment were the major causes of decompensation in the patients included. Majority of patients in this cohort underwent RYGB. Only 5 out of 17 patients had biopsy-confirmed cirrhosis preoperatively, all of whom underwent SG. While none of the patients had an alcohol use disorder (AUD) preoperatively, this development in postoperative period was associated with severe decompensation. All the patients were malnourished. Sixty-five percent of patients reverted to compensated status on nutritional supplementation and alcohol abstinence alone. Strict monitoring of weight loss and screening for AUD in postoperative period is especially important in cirrhotic patients. There is an unmet need of more good quality studies, to assess the long-term outcomes of patients with liver disease after MBS. The safety and efficacy of MBS in patients with PHTN and Child–Pugh Grade B cirrhosis remains to be established.

  Metabolic and Bariatric Surgery and Liver Transplant Top

ESLD and severe obesity are knitted together by the threads of MAFLD and MASH.[45] MBS in patients with ESLD and severe obesity carries two main objectives: first, improvement of the liver condition per se, in cases of MASH or MAFLD, and second, weight loss to favor wait-list eligibility for orthotopic liver transplantation (OLT). In view of the high peri- and intraoperative complication rates, severe obesity (BMI ≥40) remains a relative contraindication to LT. However, an increasing body of evidence is now emerging regarding the safety of LT post-MBS in such severely obese patients.[46],[47],[48],[49] At present, most transplant centers have the protocol of sequencing LT followed by MBS later to improve the graft outcomes.[50] In few high-volume LT centers, there is a tendency to perform both surgical procedures (LT and MBS) simultaneously, with SG being the preferred technique.[51]

In LT-eligible obese patients, the choice of the MBS procedure is crucial, because of two main reasons. One is impairment of the absorption of immunosuppressive medications. Second is the potential of future endoscopic access to the biliary tract. LSG strikes as being the most suitable procedure for individuals needing LT, as it does not interfere with drug absorption and retains potential future endoscopic access to the biliary system.[52] Furthermore, SG has been reported to be safe and feasible in combination with LT simultaneously and as a staged post-LT procedure.[51],[53] The optimal timing of performance MBS in patients with liver disease who are candidates for LT is contentious. In view of the high perioperative morbidity and mortality among decompensated LT candidates, the pre-LT approach has obvious limitations. The performance of concomitant MBS and LT minimizes the number of surgical procedures in high-risk patients. However, the simultaneous approach requires availability of both the surgical specialties and carries with it the risk of adding the complications of two major procedures.[54],[55] Even though there is no consensus yet, the approach that is currently most accepted is to perform LT first and MBS later.[56] After OLT, MBS can be a salvage procedure for patients gaining weight or with worsening metabolic comorbidities in relation to the immunosuppressant medications.

Heavy clouds still hang in the sky of LT for severely obese patients with liver disease. There is an unmet need to better classify obesity, going beyond the BMI criterion, and identify those candidates who may achieve the maximum survival benefit from LT. The severity of the liver disease per se, the associated co-morbidities and the compliance to a weight reduction program, are important factors driving the success of LT in severely obese patients.

  Conclusions Top

After facing decades of the obesity pandemic, the ordeal now is to treat patients with obesity and associated liver disease that in the near future will be the primary cause of LT. MBS has the potential to curtail and mitigate the impact of obesity on liver. The safety and efficacy of MBS in obese patients with compensated cirrhosis is now well established. In those obese individuals with decompensated cirrhosis and ESLD, the role of MBS in combination with LT is upcoming. LSG appears to be the most suitable and acceptable procedure in such scenario.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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