Stephen Firkins, MD

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.

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.

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).

On outcomes analysis, inpatient mortality rates were lower in the bariatric surgery cohort (2.9% vs 4.1%; 

= .002), as were rates of acute kidney injury (24% vs 27%; 

<.001), respiratory failure requiring mechanical ventilation (0.7% vs 1.5%; 

<.001), and upper GI bleed (6.7% vs 9.6%; 

<.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; 

= .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; 

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.

 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.

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.

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. 

. Nov 23 2021;326(20):2031-2042. doi:10.1001/jama.2021.19569

Lassailly G, Caiazzo R, Ntandja-Wandji LC, et al. Bariatric Surgery Provides Long-term Resolution of Nonalcoholic Steatohepatitis and Regression of Fibrosis. 

. Oct 2020;159(4):1290-1301.e5. doi:10.1053/j.gastro.2020.06.006

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. 

. May 27 2023;401(10390):1786-1797. doi:10.1016/S0140-6736(23)00634-7

Are VS, Knapp SM, Banerjee A, et al. Improving Outcomes of Bariatric Surgery in Patients With Cirrhosis in the United States: A Nationwide Assessment. 

. Nov 2020;115(11):1849-1856. doi:10.14309/ajg.0000000000000911

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. 

. May 2022;46(5):1122-1133. doi:10.1007/s00268-021-06382-z

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. 

. Jul 2023;19(7):717-726. doi:10.1016/j.soard.2022.12.025

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. 

. Nov 2015;150(11):1096-8. doi:10.1001/jamasurg.2015.1884

King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. 

. Jun 20 2012;307(23):2516-25. doi:10.1001/jama.2012.6147

Articles

The retrospective analysis highlights improved outcomes among patients with obesity and a history of bariatric surgery hospitalized with decompensated cirrhosis.

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

) is the third leading cause of cancer-related death despite only accounting for 3% of all new cancer diagnoses.

 Obesity is a well-known risk factor for multiple types of cancer, including PDAC. In fact, there exists a relative risk of PDAC of 1.10 for every 5-unit increment increase in body mass index (BMI).

 While bariatric surgery has been demonstrated to reduce overall cancer incidence and mortality, conflicting data exist regarding the effects of bariatric surgery on PDAC.

We performed a retrospective case-control study utilizing the National Inpatient Sample (NIS) database from October 2015 to December 2020. All adult subjects (age ≥18 years) with a BMI >40 kg/m2 or >35 kg/m2 with ≥1 metabolic comorbidity were identified and stratified into those with and without a history of bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy).

, Tenth Edition Clinical Modification (ICD-10-CM) codes were used to define variables of interest. Baseline characteristics and comorbidities among the 2 groups were compared using chi-squared and Wilcoxon rank-sum tests and logistic regression analysis was performed to assess the risk of PDAC after adjusting for multiple risk factors, including tobacco use, acute and chronic pancreatitis, diabetes mellitus and various stages of obesity.

Over 19 million subjects were included, 1,656,329 of whom had a history of bariatric surgery. Patients with a history of bariatric surgery were significantly younger, more frequently female (75% vs 58%), had higher rates of class 3 obesity (69% vs 52%) and lower prevalence of hypertension, hyperlipidemia, chronic kidney disease, Charlson Comorbidity Index (CCI) ≥3, tobacco use, acute and chronic pancreatitis and pancreatic cancer (0.1% vs 0.2%) while having a higher prevalence of OSA (

 <.001). Additionally, in-hospital mortality (0.5% vs 1.8%), total hospital charges and overall length of stay were lower in the bariatric surgery cohort compared to the nonsurgical cohort (

 <.001). After adjusting for multiple comorbidities and risk factors, history of bariatric surgery was demonstrated to significantly reduce the risk of PDAC on both univariable (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.44 - 0.56) and multivariable analysis (OR, 0.68; 95% CI, 0.61 - 0.77).

This is the largest analysis to date investigating the effects of bariatric surgery on pancreatic cancer risk reduction and serves to clarify previously inconclusive data. We have shown bariatric surgery to exhibit an independently protective effect against PDAC oncogenesis. It is reasonable to suggest that patients at increased risk of PDAC as well as other obesity-related malignancies may be recommended for surgically-assisted weight loss earlier and more frequently.

With advancements in minimally invasive bariatric procedures, expanding patient eligibility and indications for surgery, increasing utilization of bariatric surgery and endoscopic bariatric and metabolic therapies may help alleviate the growing burden of pancreatic cancer.

Surveillance, Epidemiology and End Result (SEER) Program. Surveillance Research Program, National Cancer Institute. 2023 Apr 25. https://seer.cancer.gov.

Aune D, Greenwood DC, Chan DS, et al. Body mass index, abdominal fatness and pancreatic cancer risk: a systematic review and non-linear dose-response meta-analysis of prospective studies. Ann Oncol. Apr 2012;23(4):843-52. doi:10.1093/annonc/mdr398

Schauer DP, Feigelson HS, Koebnick C, et al. Bariatric Surgery and the Risk of Cancer in a Large Multisite Cohort. Ann Surg. Jan 2019;269(1):95-101. doi:10.1097/SLA.0000000000002525

Adams TD, Stroup AM, Gress RE, et al. Cancer incidence and mortality after gastric bypass surgery. Obesity (Silver Spring). Apr 2009;17(4):796-802. doi:10.1038/oby.2008.610

Sjöström L, Gummesson A, Sjöström CD, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol. Jul 2009;10(7):653-62. doi:10.1016/S1470-2045(09)70159-7

Tee MC, Cao Y, Warnock GL, Hu FB, Chavarro JE. Effect of bariatric surgery on oncologic outcomes: a systematic review and meta-analysis. Surg Endosc. Dec 2013;27(12):4449-56. doi:10.1007/s00464-013-3127-9

Bulsei J, Chierici A, Alifano M, et al. Bariatric surgery reduces the risk of pancreatic cancer in individuals with obesity before the age of 50 years: A nationwide administrative data study in France. Eur J Surg Oncol. Apr 2023;49(4):788-793. doi:10.1016/j.ejso.2022.11.013

Fan H, Mao Q, Zhang W, Fang Q, Zou Q, Gong J. The Impact of Bariatric Surgery on Pancreatic Cancer Risk: a Systematic Review and Meta-Analysis. Obes Surg. Apr 05 2023;doi:10.1007/s11695-023-06570-x

Wilson RB, Lathigara D, Kaushal D. Systematic Review and Meta-Analysis of the Impact of Bariatric Surgery on Future Cancer Risk. Int J Mol Sci. Mar 24 2023;24(7)doi:10.3390/ijms24076192

A history of bariatric surgery was associated with up to 50% reduced risk of PDAC among a national cohort.