Simultaneous bariatric surgery and liver transplant is safe and improves long-term health outcomes

Simultaneous liver transplant surgery and concurrent sleeve gastrectomy (LTSG) for patients living with severe obesity is safe and improves long-term health outcomes, according to a Mayo Clinic study. This combined approach offers a needed solution for these patients who are often denied a lifesaving liver transplant due to their weight.

Credit: Journal of Hepatology (2025). DOI: 10.1016/j.jhep.2025.02.030

The ten-year study compared patients who received only a liver transplant with those who underwent both a liver transplant and bariatric surgery. The combined approach resulted in sustained weight loss, reduced risk of type 2 diabetes and lower risk of fatty liver disease recurrence. Importantly, the combined procedure posed no additional risks compared to liver transplant alone.

"We've been amazed by the transformation our patients experience," said Dr Julie Heimbach, director of Mayo Clinic Transplant Center in Minnesota and the study's senior author. "This dual approach prevents long-term obesity complications like diabetes, heart disease and cancer, while also preventing fatty liver disease recurrence."

The percentage of liver transplant candidates in the US with obesity continues to climb, with more than 41% of candidates having a body mass index above 30 in 2022. Obesity puts people at risk of developing metabolic dysfunction-associated steatotic liver disease (MASLD, formerly known as nonalcoholic fatty liver disease). It's a condition where excess fat accumulates in the liver, which can lead to inflammation, scarring and advanced liver disease. Patients with a body mass index of 40 are more likely to be denied a transplant due to their weight.

This multicentre retrospective cohort study analysed patients undergoing LTSG using a single clinical protocol (n=72), and patients with BMI >30 who underwent LT alone for MASLD (n=185). Follow-up duration was 4-153 (median 41) months for LTSG and 12-161 (median 75) months for LT.

They reported that mortality and graft loss were not significantly different between LT and LTSG patients. Post-LTSG patients had significantly lower prevalence of diabetes for >8 years (p<0.05); hypertension decreased from 61.1% to 35.8% (p<0.01). LTSG patients, with average starting BMI of 45.5, had significant weight loss compared to baseline for >9 years (p<0.001). LT-alone patients, average starting BMI 34.0, experienced no significant change in BMI or diabetes. Development of allograft steatosis was significantly lower in LTSG vs LT patients (p=0.004). Fibrosis prevalence was reduced in LTSG vs LT patients 3-10 years postoperatively; although not statically significant, relative risk ratio was 0.46 (p=0.09). One LTSG patient had a gastric sleeve leak; one required hiatal hernia repair. Severe GERD occurred in 11.1% of LTSG patients; risk factors included pre-existing diabetes and GERD.

"Since MASLD is a leading cause of liver failure, it only makes sense to protect the precious, lifegiving new liver from the same damage that led to the patient needing a transplant in the first place. Safely combining the two procedures protects the transplanted liver and can provide profound health benefits to these patients," added Dr Todd Kellogg, Mayo Clinic bariatric surgeon and the study's co-author.

New weight loss medications, such as GLP-1s, are being used to help some pre-transplant and post-transplant patients manage their weight. Still, Mayo Clinic experts say bariatric surgery remains an important option for patients with severe obesity due to its safety, proven effectiveness and lasting results. Another recent Mayo study related to kidney transplant patients supports this.

"The patients that we're talking about really have a significant amount of extra weight. The issue with the GLP-1 medications is they are effective in terms of weight loss as well as other benefits which are being identified, but they may not get these patients with severe obesity to their lasting goal of a healthier weight," explained Heimbach.

Bringing together experts from different medical specialties is essential when treating these patients, said Dr Ty Diwan, Mayo Clinic transplant surgeon and the study's co-author: "This study shows that caring for these complex patients extends beyond the transplant itself. Multidisciplinary care is required to maximize patient outcomes, and that is what we see in this data. By bringing together experts in very different fields, we've improved patient care and overall health outcomes."

The findings were published in the paper, ‘Simultaneous liver transplant and sleeve gastrectomy provides durable weight loss, improves metabolic syndrome and reduces allograft steatosis’, published in the Journal of Hepatology. To access this paper, please click here (log-in maybe required)