Modern Era Experience with Concurrent Liver Transplantation and Sleeve Gastrectomy: A MBSAQIP-Based Analysis of 30-Day Outcomes

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Wills, Valentin Mocanu, Juan S. Barajas-Gamboa, Chase Werhle, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7237223/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Concurrent sleeve gastrectomy and liver transplantation (LT + SG) is an emerging approach for patients with decompensated cirrhosis and severe obesity. Recent technical advancements may have improved outcomes, yet contemporary data remain limited. Objectives To evaluate trends, characteristics, and 30-day outcomes of patients undergoing concurrent LT + SG in the modern surgical era. Setting: Analysis of 902 accredited bariatric surgery centers across the United States and Canada participating in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Methods Retrospective analysis of the MBSAQIP database (2020–2023) to identify patients undergoing primary sleeve gastrectomy with concurrent liver transplantation. Demographic characteristics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression identified predictors of serious complications. Results Of 523,243 SG patients, 22 (0.004%) underwent concurrent LT + SG. These patients were older (49.5 ± 8.8 vs. 42.9 ± 11.9 years, p = 0.010), had higher BMI (47.5 ± 4.9 vs. 44.8 ± 7.7 kg/m², p < 0.0001), and were predominantly male (81.8%) compared to the primarily female SG-alone group (81.7%), p < 0.0001. The LT + SG cohort experienced significantly higher bleeding rates (63.6% vs. 0.7%, p < 0.0001), reoperation (18.2% vs. 0.64%, p < 0.0001), and serious complications (36.4% vs. 1.82%, p < 0.0001). However, mortality rates were comparable (0.0% vs. 0.06%, p = 0.91). Conclusions Despite higher complication rates compared to SG alone, concurrent LT + SG appears feasible with acceptable 30-day mortality. The significantly elevated bleeding rates warrant specialized hemostatic strategies and careful patient selection. Future research should compare LT + SG to LT-only patients to determine the true additional risk of performing concurrent SG. liver transplantation sleeve gastrectomy bariatric surgery transplant-related coagulopathy MASLD MASH perioperative protocol Highlights • LT + SG patients represented only 0.004% of primary sleeve gastrectomy cases in the MBSAQIP database • LT + SG bleeding rates exceeded reported rates for liver transplantation alone, suggesting synergistic hemorrhagic risk • Despite higher complication rates, mortality remained comparable between LT + SG and SG-alone patients (0.0% vs. 0.06%) • A comprehensive patient stratification system based on portal hypertension severity can optimize metabolic surgery timing in cirrhosis Introduction The global rise in obesity has transformed the landscape of liver disease and transplantation. In the United States, over 40% of adults have obesity, which plays a central role in the progression of metabolic dysfunction-associated steatotic liver disease (MASLD) and its inflammatory phenotype, metabolic dysfunction-associated steatohepatitis (MASH) [ 1 , 2 ] . MASLD now ranks as the second leading indication for liver transplantation (LT) and is poised to surpass alcohol-related liver disease as the primary driver of LT demand. There is a need for strategies targeting both obesity and liver disease [ 3 ] . Beyond its pathogenic role, obesity complicates the care of patients with advanced liver disease. Transplant candidates with a body mass index (BMI) ≥ 40 kg/m² face higher perioperative risks. Obesity-related comorbidities further exacerbate post-transplant morbidity and mortality. As LT remains the only curative option for decompensated cirrhosis, therapeutic approaches must simultaneously address both obesity and end-stage liver disease [ 4 ] . Metabolic and bariatric surgery (MBS) effectively treats patients with obesity and compensated MASH cirrhosis. In the SPECCIAL study, early MBS led to an 80% reduction in hepatic decompensation, emphasizing its potential to favorably modify disease trajectory [ 5 ] . However, MBS is contraindicated in patients with decompensated cirrhosis due mortality risk. While bariatric surgery after LT is feasible, it remains technically challenging, underutilized, and often delayed due to concerns about graft integrity, surgical complexity, and immunosuppression [ 6 ] . Concurrent SG performed at the time of LT (LT + SG) addresses these limitations. Pioneered by Dr. Julie Heimbach and colleagues at the Mayo Clinic (2014), this approach offers patients with decompensated cirrhosis and obesity a solution for metabolic optimization [ 7 ] . The technique has evolved with promising outcomes: LT + SG achieves weight loss and improves obesity-related comorbidities in a single operation without increasing graft loss or mortality risk. Meta-analyses have confirmed its safety and efficacy, showing low perioperative mortality and improved BMI, glycemic control, and cardiovascular parameters [ 8 , 9 ] . Despite growing interest in LT + SG, national-level data on its utilization and outcomes remain limited. The "modern era" of this technique—with greater institutional adoption, refined patient selection, and standardized protocols—has yet to be comprehensively described. Technical advancements since 2014 have likely improved outcomes. These include machine perfusion technologies that optimize graft quality and reduce ischemia-reperfusion injury, such as the FDA-approved OrganOx Metra device (2019). Furthermore, surgical tools with enhanced tissue selection and staple line reinforcement have increased precision while reducing complications. Ex situ liver perfusion and bioengineering approaches using stem cells and gene modulation have also further advanced graft preservation and regeneration techniques [ 10 , 11 ] . To address this gap, we analyzed the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database to evaluate trends, characteristics, and short-term outcomes of patients who underwent concurrent LT + SG between 2020 and 2023, reflecting contemporary surgical practices. Our primary aim is to characterize this emerging population in the modern surgical era and understand perioperative outcomes in these complex patients. This study seeks to define the role of LT + SG in transplant candidates with decompensated cirrhosis and severe obesity, informing integration of MBS into multidisciplinary transplant care. Methods Study Design and Ethical Approval A retrospective analysis of the MBSAQIP database (2020–2023) was conducted. This study was exempt from Institutional Review Board review due to the data’s anonymized nature. Data Source The MBSAQIP database prospectively collects standardized data from 902 accredited bariatric surgery centers across the United States and Canada. This includes demographics, comorbidities, operative details, and 30-day outcomes Study Population and Variables Patients who underwent primary SG were identified using Current Procedural Terminology (CPT) codes 43775 and 43843. Concurrent LT cases were identified by CPT code 47135 in either the "concpt" or "othcpt" fields. Collected variables included demographics (age, sex, race, BMI) and comorbidities (diabetes, hypertension, reflux disease, COPD, hyperlipidemia, renal insufficiency, dialysis, venous thromboembolism history, therapeutic anticoagulation, sleep apnea, and previous myocardial infarction). We recorded functional status. Complications analysis included readmissions, interventions, and reoperations. Serious complications encompassed anastomotic leak, bleeding, reoperation, non-operative intervention, readmission, cardiac events, pneumonia, acute kidney injury, thromboembolism, sepsis, unplanned intubation, cerebrovascular events, and death. Statistical Analysis Categorical data were expressed as percentages and continuous data as mean ± standard deviation. Our primary objective was to characterize the LT + SG population rather than draw direct comparisons between inherently different surgical populations. Comparisons between SG with and without LT used chi-square tests (categorical variables) and t-tests or Wilcoxon rank-sum tests (continuous variables). Multivariable logistic regression identified predictors of 30-day serious complications. All analyses were completed using STATA 17 (StataCorp, College Station, TX) Results Demographics Of 523,243 patients who underwent primary SG, 22 (0.004%) underwent concurrent LT (LT + SG). These patients were older (49.5 ± 8.8 v.s. 42.9 ± 11.9 years, p = 0.010), with higher BMI (47.5 ± 4.9 v.s. 44.8 ± 7.7 kg/m 2 , p < 0.0001), and predominantly male (81.8% male in LT + SG vs. 18.3% male in SG-alone, p < 0.0001). While most patients were fully independent (95.5% v.s. 99.5%), LT + SG patients showed higher rates of partial dependence (4.6% v.s. 0.46%, p = 0.02). LT + SG patients had significantly higher rates of diabetes (36.4% v.s. 20.5%, p = 0.001), dialysis dependence (13.6% v.s. 0.35%, p < 0.0001) and anticoagulation use (13.6% v.s. 2.8%, p = 0.002). They had similar rates of tobacco use (13.6% v.s. 6.6%, p = 0.19), hypertension (50.0% v.s. 42.2%, p = 0.46), COPD (0.0% v.s. 1.04%, p = 0.63), hyperlipidemia (13.6% v.s. 21.0%, p = 0.73), and renal insufficiency (0.0% v.s. 0.53%, p = 0.73) ( Table I) . Operative Outcomes and Complications LT + SG cases had significantly longer operative times (356.5 ± 105.6 vs 70.5 ± 37.3 minutes) and length of stay (14.0 ± 16.0 vs 1.2 ± 1.0 days) (both p < 0.0001). Case distribution across years was similar between groups ( p = 0.16), with the highest proportion of LT + SG cases in 2023 (45.5%). The LT + SG cohort experienced higher rates of bleeding (63.6% vs 0.7%, p < 0.0001), reoperation (18.2% vs 0.64%, p < 0.0001), reintervention (9.1% vs 0.47%, p < 0.0001), and readmission (9.1% vs 2.3%, p = 0.03). They also had higher rates of acute kidney injury (4.6% vs 0.09%, p < 0.0001), acute renal failure (4.6% v.s. 0.04%, p < 0.0001), and venous thromboembolism (4.6% vs 0.4%, p = 0.0001). Both groups had similar rates of pneumonia (0.0% v.s. 0.12%, p = 0.87), deep surgical site infection (0.0% v.s. 0.3%, p = 0.81), sepsis (0.0% v.s. 0.08%, p = 0.90), pulmonary embolism (0.0% v.s. 0.1%, p = 0.88), and deaths (0.0% v.s. 0.06%, p = 0.91) (Supplementary Table I). Multivariable Regression Analysis Multivariable logistic regression showed serious complications were independently associated with older age (OR 1.12 per 10 years; 95% CI 1.10–1.14; p < 0.0001), higher BMI (OR 1.04 per 5 kg/m²; 95% CI 1.03–1.06; p < 0.0001), insulin-dependent diabetes (OR 1.29; 95% CI 1.19–1.40; p < 0.0001), history of myocardial infarction (OR 1.46; 95% CI 1.27–1.69; p < 0.0001), hypertension (OR 1.20; 95% CI 1.15–1.26; p < 0.0001), renal insufficiency (OR 2.38; 95% CI 2.03–2.79; p < 0.0001), and therapeutic anticoagulation (OR 2.07; 95% CI 1.90–2.25; p < 0.0001). Female sex was protective (OR 0.88; 95% CI 0.84–0.92, p < 0.0001). Notably, concurrent LT was the strongest predictor of serious complications (OR 23.2; 95% CI 9.62–55.83, p < 0.0001) (Table II). Discussion This represents the first large-scale international multi-centered cohort study analyzing complications and mortality of concurrent liver transplant and sleeve gastrectomy in the modern surgical era. Using MBSAQIP data, we found patients undergoing LT + SG experienced significantly higher complication rates than those undergoing SG alone, with a 20-fold increase in serious complications, affecting over one-third of patients. This finding is not surprising and aligns with the inherently higher risk profile of LT recipients compared to patients undergoing SG alone. The primary value of our analysis lies not in this comparison but in providing the first comprehensive characterization of this emerging population using contemporary multicenter data. While comparing these fundamentally different surgical populations has limitations, our analysis offers valuable insights into this complex approach. Most notably, despite the overall higher complication burden, outcomes such as leak and mortality rates remained comparable between groups. LT was independently associated with serious complications, with LT + SG patients significantly more likely to experience bleeding than SG-alone patients. This reflects the expected physiologic complexity of end-stage liver disease, rather than a critique of the combined approach. This outcome aligns with the inherent coagulopathy and portal hypertension associated with end-stage liver disease and the perioperative LT period. Importantly, bleeding rate in our LT + SG cohort exceeded reported rates for LT alone (17.3–37%) [ 12 ] , suggesting potential additive risk with the combined procedure. Registry limitations prevent determination of whether bleeding originated from the gastric staple line or liver graft. However, several factors likely contribute to this elevated risk. First, LT + SG involves significant manipulation of highly vascular gastric tissue in patients already susceptible to coagulopathy and bleeding. Portal hypertension—characteristic of end-stage liver disease—creates friable tissue, engorged vessels, and collateral circulation prone to bleeding during dissection and stapling [ 13 ] . Splenomegaly and thrombocytopenia compound these risks by impairing primary hemostasis [ 14 ] . Second, obesity introduces additional complexity through extensive vascular networks in adipose tissue and limited visualization during surgery. Finally, these patients often require perioperative anticoagulation due to thromboembolic risk, further increasing bleeding potential [ 15 ] . The convergence of these factors likely explains the high bleeding rates observed. Future studies with matched controls from both bariatric and transplant registries would better illustrate these mechanisms. These findings warrant consideration of specialized hemostatic techniques for LT + SG patients. Staple line reinforcement—including oversewing, bioabsorbable polymers, and fibrin sealants—has shown efficacy in reducing bleeding in SG [ 16 – 18 ] . Combining multiple approaches may benefit these cases. Prophylactic tranexamic acid administration can reduce staple line bleeding and overall blood loss [ 15 ] . Technical optimizations, including appropriate staple heights and loading pressures for gastric tissue, may further minimize risk [ 19 ] . Intraoperative blood pressure management, such as elevating systolic pressure to 140 mmHg before closure, can also help identify bleeding points [ 20 ] . Prospective studies should evaluate these hemostatic strategies specifically in LT + SG patients to establish evidence-based protocols. A multicenter retrospective study by Larson et al. showed findings parallel to ours regarding safety and feasibility of concurrent LT + SG [ 21 ] . Like our study, they found high postoperative complication rates that did not increase mortality, suggesting an acceptable risk profile. Their study provides complementary perspective by comparing LT + SG with LT-only patients (versus our SG-only comparison) and by assessing long-term outcomes (median 41 months). Their follow-up demonstrated substantial metabolic benefits, including sustained weight loss, diabetes resolution, and reduced allograft steatosis in LT + SG versus LT alone ( p = 0.004). Our smaller LT + SG sample (n = 22 versus n = 72) likely reflects that transplant surgeons often perform the SG portion during combined procedures, and that these cases are not captured in bariatric-specific registries. This limitation highlights the need for studies linking transplant and bariatric surgery databases to enable matched analyses of this approach. Obesity is a well-established risk factor for liver disease, particularly MASLD and MASH [ 1 ] . Weight loss improves liver function, with ≥ 10% body weight loss potentially resulting in fibrosis regression [ 22 ] . However, the timing of these procedures remains controversial. García-Sesma et al. demonstrated that pre-transplant SG was safe in a small series (n = 8), with no immediate morbidity [ 23 ] . Sharpton et al. reported lower post-transplant diabetes, hypertension, and recurrent MASLD with pre-transplant SG compared to medical weight loss [ 24 ] . This is likely because pre-transplant SG improves metabolic parameters and reduces the risk of post-transplant complication [ 24 ] , while addressing obesity before transplant reduces surgical complexity [ 8 ] . However, pre-transplant SG presents important tradeoffs. Rapid weight loss increases circulating free fatty acids from adipose tissue breakdown, potentially compromising function of an already vulnerable liver. This approach may benefit patients who eventually will require transplantation but have sufficient hepatic reserve to tolerate accelerated weight loss. In decompensated cirrhosis, however, SG may worsen portal hypertension and precipitate further hepatic decompensation [ 25 ] . For advanced disease, the timing decision is nuanced. Concurrent LT + SG, as documented by Zamora-Valdes et al ., demonstrates significant metabolic efficacy, even in patients with severe decompensation (MELD 32 ± 9.5) [ 26 ] . This approach also eliminates the need for a second operation while providing immediate protection against obesity-related allograft steatosis. Conversely, delayed post-transplant SG as studied by Morris et al . and Tsamalaidze et al. offers different advantages: patient stabilization, optimized immunosuppression, and potentially lower procedure-specific complications with comparable weight loss outcomes [ 27 , 28 ] . Clinical decision-making must balance these competing factors against patient-specific variables including decompensation severity, coagulopathy profile, and surgeon expertise. For severely decompensated patients, concurrent LT + SG may represent the only viable option, as their status precludes SG either before or after transplantation. Further research is needed to establish optimal timing algorithms for this complex population. As more centers adopt concurrent LT + SG approaches, questions arise about pre-surgical preparation. Both procedures independently require extensive evaluation—transplant necessitates nutritional assessment, psychological evaluation, medication adherence training, and thorough medical workup, while bariatric surgery requires mental health evaluation, micronutrient assessment, and nutritionist collaboration [ 29 , 30 ] . How will these pathways integrate for patients with both conditions? Will all candidates undergo both comprehensive regimens, or will approaches be stratified by disease severity? Given significant overlap in requirements, a joint LT + SG preparation program could integrate aspects of both surgeries, streamlining evaluations and reducing redundancy and costs. At our institution, we have developed a comprehensive stratification system for cirrhotic patients undergoing metabolic surgery. For compensated cirrhosis without portal hypertension, qualification includes liver stiffness measurements below established thresholds (transient elastography < 20 kPa or magnetic resonance elastography < 5 kPa) or hepatic venous pressure gradient (HVPG) 10 mmHg, endoscopic findings of varices, or imaging showing collaterals or splenomegaly) undergo a staged approach: transjugular intrahepatic portosystemic shunt (TIPS) placement followed by confirmation of adequate decompression through vascular ultrasound and repeat endoscopy before proceeding to SG. For decompensated cirrhosis, we perform concurrent LT + SG, while post-transplant patients are offered SG, which minimizes immunosuppression malabsorption risk and preserves gastrointestinal tract continuity to accommodate potential post-transplant biliary complications. This stratified approach, incorporating recent trial data including the SPECCIAL study and our developing OPTIMAL randomized controlled trial, tailors the surgical strategy to disease severity while minimizing complications [ 5 ] . This study has several important limitations. Despite using the large-scale MBSAQIP database, our LT + SG cohort remained small as we included only patients from 2020–2023 to reflect current surgical practices. MBSAQIP variable definitions changed substantially in 2020, preventing the inclusion of earlier cases without risking analytical inconsistencies. As LT + SG procedures increase, incorporating post-2023 data and harmonizing pre-2020 data could yield larger samples for comprehensive temporal analyses. A key limitation is the absence of a LT-only comparison group, preventing assessment of whether SG adds incremental risk beyond liver transplantation alone. The database lacks critical transplant-specific variable (MELD scores, pre-operative ACLF, graft type, donor quality metrics, and immunosuppression regimens) and clinical parameters (coagulation status, elastography measurements, cirrhosis etiology, portal hypertension severity) that influence outcomes. We cannot determine whether patients underwent TIPS- a potentially significant confounder. Nuanced technical aspects like staple line reinforcement and stapler types are not captured, limiting operative technique recommendations. Finally, the database only captures 30-day outcomes, preventing analysis of long-term weight loss maintenance and graft survival. Future research should link MBSAQIP data with transplant-specific registries such as UNOS (United Network for Organ Sharing) or SRTR (Scientific Registry of Transplant Recipients), enabling matched cohort analyses comparing LT + SG patients to LT-only controls with similar baseline characteristics to determine the true additional risk of performing concurrent SG. Conclusion This first large-scale analysis of concurrent sleeve gastrectomy and liver transplantation demonstrates that despite higher complication rates compared to sleeve gastrectomy alone, which are expected given the inherently high-risk nature of liver transplant recipients, LT + SG appears to be a feasible approach with an acceptable 30-day mortality. Our findings specifically reflect contemporary surgical techniques and perioperative management protocols from 2020–2023, providing clinically relevant insights into current practice rather than historical comparisons that may not accurately represent today's risk profile. The significantly elevated bleeding rates observed with LT + SG raise important clinical concerns, and while decisions must be made on a case-by-case basis currently, larger multi-institutional studies are needed to better define acceptable risk thresholds and patient selection criteria. Centers performing these procedures should develop standardized perioperative protocols that address the unique needs of this population, and future research should compare matched cohorts of LT + SG versus LT alone to establish long-term outcomes and definitive risk-benefit profiles. Declarations Acknowledgments None Conflict of Interest Statement The authors have no conflicts of interest relevant to the present publication to declare. Funding Sources This study was not supported by any sponsor or funder. Data Statement The data that support the findings of this study are available on request from the corresponding author. References Kanwal F, Neuschwander-Tetri BA, Loomba R, Rinella ME. 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Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant. Hepatology 2024; Tables Tables I and II are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files TableI.docx TableII.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7237223","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":531741001,"identity":"8b476de1-ee83-4cb7-891d-079c24f6ea48","order_by":0,"name":"Mélissa V. 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Barajas-Gamboa","email":"","orcid":"","institution":"Cleveland Clinic Abu Dhabi","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"S.","lastName":"Barajas-Gamboa","suffix":""},{"id":531741004,"identity":"b19c4aa5-aff0-4cd5-a667-a9573f73f1d6","order_by":3,"name":"Chase Werhle","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Chase","middleName":"","lastName":"Werhle","suffix":""},{"id":531741005,"identity":"1ed784d8-e918-4187-a88e-d2b884001afd","order_by":4,"name":"Pattharasai Kachornvitaya","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Pattharasai","middleName":"","lastName":"Kachornvitaya","suffix":""},{"id":531741006,"identity":"37481eaf-7a09-45f9-b28a-3509949e44df","order_by":5,"name":"Andrew T. Strong","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"T.","lastName":"Strong","suffix":""},{"id":531741007,"identity":"b35137aa-0ad4-4c9c-9c40-9b216c49e368","order_by":6,"name":"Ricard Corcelles","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ricard","middleName":"","lastName":"Corcelles","suffix":""},{"id":531741008,"identity":"d624df76-10d9-4590-b76a-bb086beb58f3","order_by":7,"name":"Jerry T. Dang","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jerry","middleName":"T.","lastName":"Dang","suffix":""},{"id":531741009,"identity":"1f22822d-4f5e-49cc-ac44-bde3e36fc96a","order_by":8,"name":"Sobia Laique","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sobia","middleName":"","lastName":"Laique","suffix":""},{"id":531741010,"identity":"1e806fd2-1c2e-437e-9fbe-2ab35acf9c3d","order_by":9,"name":"Matthew Kroh","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Kroh","suffix":""},{"id":531741011,"identity":"9cc562a0-67e0-4ea4-92f2-528656680ea1","order_by":10,"name":"Salvador Navarrete","email":"","orcid":"","institution":"Cleveland Clinic Lerner College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Salvador","middleName":"","lastName":"Navarrete","suffix":""}],"badges":[],"createdAt":"2025-07-28 21:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7237223/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7237223/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94039532,"identity":"6463009c-2d7f-43c4-8aa4-16203050a24f","added_by":"auto","created_at":"2025-10-21 17:59:05","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70661,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptV1.6.docx","url":"https://assets-eu.researchsquare.com/files/rs-7237223/v1/26adaac9dc4d8e49f18a4306.docx"},{"id":94039540,"identity":"ed3e2a12-2227-4814-ac00-363bf13d0f21","added_by":"auto","created_at":"2025-10-21 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11:09:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":589993,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7237223/v1/e3cd88ba-3621-4230-8e64-d72c7c3fdd56.pdf"},{"id":94039531,"identity":"8a755012-7107-4671-a45d-2dfd7fbf30fb","added_by":"auto","created_at":"2025-10-21 17:59:05","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16936,"visible":true,"origin":"","legend":"","description":"","filename":"TableI.docx","url":"https://assets-eu.researchsquare.com/files/rs-7237223/v1/31b54b0285326a7a06ce8b21.docx"},{"id":94039533,"identity":"6f1aca22-38a8-4f6d-88dd-3ec93e729877","added_by":"auto","created_at":"2025-10-21 17:59:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15942,"visible":true,"origin":"","legend":"","description":"","filename":"TableII.docx","url":"https://assets-eu.researchsquare.com/files/rs-7237223/v1/3fc6ffe0392a4168eafe6d7a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Modern Era Experience with Concurrent Liver Transplantation and Sleeve Gastrectomy: A MBSAQIP-Based Analysis of 30-Day Outcomes","fulltext":[{"header":"Highlights","content":"\u003cp\u003e\u0026bull; LT\u0026thinsp;+\u0026thinsp;SG patients represented only 0.004% of primary sleeve gastrectomy cases in the MBSAQIP database\u003c/p\u003e\u003cp\u003e\u0026bull; LT\u0026thinsp;+\u0026thinsp;SG bleeding rates exceeded reported rates for liver transplantation alone, suggesting synergistic hemorrhagic risk\u003c/p\u003e\u003cp\u003e\u0026bull; Despite higher complication rates, mortality remained comparable between LT\u0026thinsp;+\u0026thinsp;SG and SG-alone patients (0.0% vs. 0.06%)\u003c/p\u003e\u003cp\u003e\u0026bull; A comprehensive patient stratification system based on portal hypertension severity can optimize metabolic surgery timing in cirrhosis\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe global rise in obesity has transformed the landscape of liver disease and transplantation. In the United States, over 40% of adults have obesity, which plays a central role in the progression of metabolic dysfunction-associated steatotic liver disease (MASLD) and its inflammatory phenotype, metabolic dysfunction-associated steatohepatitis (MASH)\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. MASLD now ranks as the second leading indication for liver transplantation (LT) and is poised to surpass alcohol-related liver disease as the primary driver of LT demand. There is a need for strategies targeting both obesity and liver disease\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eBeyond its pathogenic role, obesity complicates the care of patients with advanced liver disease. Transplant candidates with a body mass index (BMI)\u0026thinsp;\u0026ge;\u0026thinsp;40 kg/m\u0026sup2; face higher perioperative risks. Obesity-related comorbidities further exacerbate post-transplant morbidity and mortality. As LT remains the only curative option for decompensated cirrhosis, therapeutic approaches must simultaneously address both obesity and end-stage liver disease\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eMetabolic and bariatric surgery (MBS) effectively treats patients with obesity and compensated MASH cirrhosis. In the SPECCIAL study, early MBS led to an 80% reduction in hepatic decompensation, emphasizing its potential to favorably modify disease trajectory\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. However, MBS is contraindicated in patients with decompensated cirrhosis due mortality risk. While bariatric surgery after LT is feasible, it remains technically challenging, underutilized, and often delayed due to concerns about graft integrity, surgical complexity, and immunosuppression\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eConcurrent SG performed at the time of LT (LT\u0026thinsp;+\u0026thinsp;SG) addresses these limitations. Pioneered by Dr. Julie Heimbach and colleagues at the Mayo Clinic (2014), this approach offers patients with decompensated cirrhosis and obesity a solution for metabolic optimization\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. The technique has evolved with promising outcomes: LT\u0026thinsp;+\u0026thinsp;SG achieves weight loss and improves obesity-related comorbidities in a single operation without increasing graft loss or mortality risk. Meta-analyses have confirmed its safety and efficacy, showing low perioperative mortality and improved BMI, glycemic control, and cardiovascular parameters\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite growing interest in LT\u0026thinsp;+\u0026thinsp;SG, national-level data on its utilization and outcomes remain limited. The \"modern era\" of this technique\u0026mdash;with greater institutional adoption, refined patient selection, and standardized protocols\u0026mdash;has yet to be comprehensively described. Technical advancements since 2014 have likely improved outcomes. These include machine perfusion technologies that optimize graft quality and reduce ischemia-reperfusion injury, such as the FDA-approved OrganOx Metra device (2019). Furthermore, surgical tools with enhanced tissue selection and staple line reinforcement have increased precision while reducing complications. Ex situ liver perfusion and bioengineering approaches using stem cells and gene modulation have also further advanced graft preservation and regeneration techniques\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTo address this gap, we analyzed the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database to evaluate trends, characteristics, and short-term outcomes of patients who underwent concurrent LT\u0026thinsp;+\u0026thinsp;SG between 2020 and 2023, reflecting contemporary surgical practices. Our primary aim is to characterize this emerging population in the modern surgical era and understand perioperative outcomes in these complex patients. This study seeks to define the role of LT\u0026thinsp;+\u0026thinsp;SG in transplant candidates with decompensated cirrhosis and severe obesity, informing integration of MBS into multidisciplinary transplant care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Ethical Approval\u003c/h2\u003e\u003cp\u003eA retrospective analysis of the MBSAQIP database (2020\u0026ndash;2023) was conducted. This study was exempt from Institutional Review Board review due to the data\u0026rsquo;s anonymized nature.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Source\u003c/h3\u003e\n\u003cp\u003eThe MBSAQIP database prospectively collects standardized data from 902 accredited bariatric surgery centers across the United States and Canada. This includes demographics, comorbidities, operative details, and 30-day outcomes\u003c/p\u003e\n\u003ch3\u003eStudy Population and Variables\u003c/h3\u003e\n\u003cp\u003ePatients who underwent primary SG were identified using Current Procedural Terminology (CPT) codes 43775 and 43843. Concurrent LT cases were identified by CPT code 47135 in either the \"concpt\" or \"othcpt\" fields.\u003c/p\u003e\u003cp\u003eCollected variables included demographics (age, sex, race, BMI) and comorbidities (diabetes, hypertension, reflux disease, COPD, hyperlipidemia, renal insufficiency, dialysis, venous thromboembolism history, therapeutic anticoagulation, sleep apnea, and previous myocardial infarction). We recorded functional status. Complications analysis included readmissions, interventions, and reoperations. Serious complications encompassed anastomotic leak, bleeding, reoperation, non-operative intervention, readmission, cardiac events, pneumonia, acute kidney injury, thromboembolism, sepsis, unplanned intubation, cerebrovascular events, and death.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eCategorical data were expressed as percentages and continuous data as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Our primary objective was to characterize the LT\u0026thinsp;+\u0026thinsp;SG population rather than draw direct comparisons between inherently different surgical populations. Comparisons between SG with and without LT used chi-square tests (categorical variables) and t-tests or Wilcoxon rank-sum tests (continuous variables). Multivariable logistic regression identified predictors of 30-day serious complications. All analyses were completed using STATA 17 (StataCorp, College Station, TX)\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDemographics\u003c/h2\u003e\u003cp\u003eOf 523,243 patients who underwent primary SG, 22 (0.004%) underwent concurrent LT (LT\u0026thinsp;+\u0026thinsp;SG). These patients were older (49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 v.s. 42.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010), with higher BMI (47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 v.s. 44.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 kg/m\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and predominantly male (81.8% male in LT\u0026thinsp;+\u0026thinsp;SG vs. 18.3% male in SG-alone, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). While most patients were fully independent (95.5% v.s. 99.5%), LT\u0026thinsp;+\u0026thinsp;SG patients showed higher rates of partial dependence (4.6% v.s. 0.46%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). LT\u0026thinsp;+\u0026thinsp;SG patients had significantly higher rates of diabetes (36.4% v.s. 20.5%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), dialysis dependence (13.6% v.s. 0.35%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and anticoagulation use (13.6% v.s. 2.8%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). They had similar rates of tobacco use (13.6% v.s. 6.6%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.19), hypertension (50.0% v.s. 42.2%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.46), COPD (0.0% v.s. 1.04%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.63), hyperlipidemia (13.6% v.s. 21.0%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.73), and renal insufficiency (0.0% v.s. 0.53%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.73) (\u003cb\u003eTable I)\u003c/b\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOperative Outcomes and Complications\u003c/h3\u003e\n\u003cp\u003eLT\u0026thinsp;+\u0026thinsp;SG cases had significantly longer operative times (356.5\u0026thinsp;\u0026plusmn;\u0026thinsp;105.6 vs 70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;37.3 minutes) and length of stay (14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;16.0 vs 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 days) (both \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Case distribution across years was similar between groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.16), with the highest proportion of LT\u0026thinsp;+\u0026thinsp;SG cases in 2023 (45.5%). The LT\u0026thinsp;+\u0026thinsp;SG cohort experienced higher rates of bleeding (63.6% vs 0.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), reoperation (18.2% vs 0.64%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), reintervention (9.1% vs 0.47%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and readmission (9.1% vs 2.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03). They also had higher rates of acute kidney injury (4.6% vs 0.09%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), acute renal failure (4.6% v.s. 0.04%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and venous thromboembolism (4.6% vs 0.4%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0001). Both groups had similar rates of pneumonia (0.0% v.s. 0.12%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.87), deep surgical site infection (0.0% v.s. 0.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.81), sepsis (0.0% v.s. 0.08%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.90), pulmonary embolism (0.0% v.s. 0.1%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.88), and deaths (0.0% v.s. 0.06%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.91) \u003cb\u003e(Supplementary Table I).\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eMultivariable Regression Analysis\u003c/h3\u003e\n\u003cp\u003eMultivariable logistic regression showed serious complications were independently associated with older age (OR 1.12 per 10 years; 95% CI 1.10\u0026ndash;1.14; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), higher BMI (OR 1.04 per 5 kg/m\u0026sup2;; 95% CI 1.03\u0026ndash;1.06; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), insulin-dependent diabetes (OR 1.29; 95% CI 1.19\u0026ndash;1.40; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), history of myocardial infarction (OR 1.46; 95% CI 1.27\u0026ndash;1.69; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), hypertension (OR 1.20; 95% CI 1.15\u0026ndash;1.26; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), renal insufficiency (OR 2.38; 95% CI 2.03\u0026ndash;2.79; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and therapeutic anticoagulation (OR 2.07; 95% CI 1.90\u0026ndash;2.25; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Female sex was protective (OR 0.88; 95% CI 0.84\u0026ndash;0.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Notably, concurrent LT was the strongest predictor of serious complications (OR 23.2; 95% CI 9.62\u0026ndash;55.83, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) \u003cb\u003e(Table II).\u003c/b\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis represents the first large-scale international multi-centered cohort study analyzing complications and mortality of concurrent liver transplant and sleeve gastrectomy in the modern surgical era. Using MBSAQIP data, we found patients undergoing LT\u0026thinsp;+\u0026thinsp;SG experienced significantly higher complication rates than those undergoing SG alone, with a 20-fold increase in serious complications, affecting over one-third of patients. This finding is not surprising and aligns with the inherently higher risk profile of LT recipients compared to patients undergoing SG alone. The primary value of our analysis lies not in this comparison but in providing the first comprehensive characterization of this emerging population using contemporary multicenter data. While comparing these fundamentally different surgical populations has limitations, our analysis offers valuable insights into this complex approach. Most notably, despite the overall higher complication burden, outcomes such as leak and mortality rates remained comparable between groups.\u003c/p\u003e\u003cp\u003eLT was independently associated with serious complications, with LT\u0026thinsp;+\u0026thinsp;SG patients significantly more likely to experience bleeding than SG-alone patients. This reflects the expected physiologic complexity of end-stage liver disease, rather than a critique of the combined approach. This outcome aligns with the inherent coagulopathy and portal hypertension associated with end-stage liver disease and the perioperative LT period. Importantly, bleeding rate in our LT\u0026thinsp;+\u0026thinsp;SG cohort exceeded reported rates for LT alone (17.3\u0026ndash;37%)\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, suggesting potential additive risk with the combined procedure.\u003c/p\u003e\u003cp\u003eRegistry limitations prevent determination of whether bleeding originated from the gastric staple line or liver graft. However, several factors likely contribute to this elevated risk. First, LT\u0026thinsp;+\u0026thinsp;SG involves significant manipulation of highly vascular gastric tissue in patients already susceptible to coagulopathy and bleeding. Portal hypertension\u0026mdash;characteristic of end-stage liver disease\u0026mdash;creates friable tissue, engorged vessels, and collateral circulation prone to bleeding during dissection and stapling\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Splenomegaly and thrombocytopenia compound these risks by impairing primary hemostasis\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Second, obesity introduces additional complexity through extensive vascular networks in adipose tissue and limited visualization during surgery. Finally, these patients often require perioperative anticoagulation due to thromboembolic risk, further increasing bleeding potential\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The convergence of these factors likely explains the high bleeding rates observed. Future studies with matched controls from both bariatric and transplant registries would better illustrate these mechanisms.\u003c/p\u003e\u003cp\u003eThese findings warrant consideration of specialized hemostatic techniques for LT\u0026thinsp;+\u0026thinsp;SG patients. Staple line reinforcement\u0026mdash;including oversewing, bioabsorbable polymers, and fibrin sealants\u0026mdash;has shown efficacy in reducing bleeding in SG\u003csup\u003e[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Combining multiple approaches may benefit these cases. Prophylactic tranexamic acid administration can reduce staple line bleeding and overall blood loss\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Technical optimizations, including appropriate staple heights and loading pressures for gastric tissue, may further minimize risk \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Intraoperative blood pressure management, such as elevating systolic pressure to 140 mmHg before closure, can also help identify bleeding points\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Prospective studies should evaluate these hemostatic strategies specifically in LT\u0026thinsp;+\u0026thinsp;SG patients to establish evidence-based protocols.\u003c/p\u003e\u003cp\u003eA multicenter retrospective study by Larson \u003cem\u003eet al.\u003c/em\u003e showed findings parallel to ours regarding safety and feasibility of concurrent LT\u0026thinsp;+\u0026thinsp;SG\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Like our study, they found high postoperative complication rates that did not increase mortality, suggesting an acceptable risk profile. Their study provides complementary perspective by comparing LT\u0026thinsp;+\u0026thinsp;SG with LT-only patients (versus our SG-only comparison) and by assessing long-term outcomes (median 41 months). Their follow-up demonstrated substantial metabolic benefits, including sustained weight loss, diabetes resolution, and reduced allograft steatosis in LT\u0026thinsp;+\u0026thinsp;SG versus LT alone (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004). Our smaller LT\u0026thinsp;+\u0026thinsp;SG sample (n\u0026thinsp;=\u0026thinsp;22 versus n\u0026thinsp;=\u0026thinsp;72) likely reflects that transplant surgeons often perform the SG portion during combined procedures, and that these cases are not captured in bariatric-specific registries. This limitation highlights the need for studies linking transplant and bariatric surgery databases to enable matched analyses of this approach.\u003c/p\u003e\u003cp\u003eObesity is a well-established risk factor for liver disease, particularly MASLD and MASH\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Weight loss improves liver function, with \u0026ge;\u0026thinsp;10% body weight loss potentially resulting in fibrosis regression\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. However, the timing of these procedures remains controversial. Garc\u0026iacute;a-Sesma \u003cem\u003eet al.\u003c/em\u003e demonstrated that pre-transplant SG was safe in a small series (n\u0026thinsp;=\u0026thinsp;8), with no immediate morbidity\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Sharpton \u003cem\u003eet al.\u003c/em\u003e reported lower post-transplant diabetes, hypertension, and recurrent MASLD with pre-transplant SG compared to medical weight loss\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. This is likely because pre-transplant SG improves metabolic parameters and reduces the risk of post-transplant complication\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e, while addressing obesity before transplant reduces surgical complexity\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, pre-transplant SG presents important tradeoffs. Rapid weight loss increases circulating free fatty acids from adipose tissue breakdown, potentially compromising function of an already vulnerable liver. This approach may benefit patients who eventually will require transplantation but have sufficient hepatic reserve to tolerate accelerated weight loss. In decompensated cirrhosis, however, SG may worsen portal hypertension and precipitate further hepatic decompensation\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. For advanced disease, the timing decision is nuanced. Concurrent LT\u0026thinsp;+\u0026thinsp;SG, as documented by Zamora-Valdes \u003cem\u003eet al\u003c/em\u003e., demonstrates significant metabolic efficacy, even in patients with severe decompensation (MELD 32\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5)\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. This approach also eliminates the need for a second operation while providing immediate protection against obesity-related allograft steatosis. Conversely, delayed post-transplant SG as studied by Morris \u003cem\u003eet al\u003c/em\u003e. and Tsamalaidze \u003cem\u003eet al.\u003c/em\u003e offers different advantages: patient stabilization, optimized immunosuppression, and potentially lower procedure-specific complications with comparable weight loss outcomes\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Clinical decision-making must balance these competing factors against patient-specific variables including decompensation severity, coagulopathy profile, and surgeon expertise. For severely decompensated patients, concurrent LT\u0026thinsp;+\u0026thinsp;SG may represent the only viable option, as their status precludes SG either before or after transplantation. Further research is needed to establish optimal timing algorithms for this complex population.\u003c/p\u003e\u003cp\u003eAs more centers adopt concurrent LT\u0026thinsp;+\u0026thinsp;SG approaches, questions arise about pre-surgical preparation. Both procedures independently require extensive evaluation\u0026mdash;transplant necessitates nutritional assessment, psychological evaluation, medication adherence training, and thorough medical workup, while bariatric surgery requires mental health evaluation, micronutrient assessment, and nutritionist collaboration\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. How will these pathways integrate for patients with both conditions? Will all candidates undergo both comprehensive regimens, or will approaches be stratified by disease severity? Given significant overlap in requirements, a joint LT\u0026thinsp;+\u0026thinsp;SG preparation program could integrate aspects of both surgeries, streamlining evaluations and reducing redundancy and costs.\u003c/p\u003e\u003cp\u003eAt our institution, we have developed a comprehensive stratification system for cirrhotic patients undergoing metabolic surgery. For compensated cirrhosis without portal hypertension, qualification includes liver stiffness measurements below established thresholds (transient elastography\u0026thinsp;\u0026lt;\u0026thinsp;20 kPa or magnetic resonance elastography\u0026thinsp;\u0026lt;\u0026thinsp;5 kPa) or hepatic venous pressure gradient (HVPG)\u0026thinsp;\u0026lt;\u0026thinsp;5 mmHg on biopsy. Patients with compensated cirrhosis and clinically significant portal hypertension (CSPH) (HVPG\u0026thinsp;\u0026gt;\u0026thinsp;10 mmHg, endoscopic findings of varices, or imaging showing collaterals or splenomegaly) undergo a staged approach: transjugular intrahepatic portosystemic shunt (TIPS) placement followed by confirmation of adequate decompression through vascular ultrasound and repeat endoscopy before proceeding to SG. For decompensated cirrhosis, we perform concurrent LT\u0026thinsp;+\u0026thinsp;SG, while post-transplant patients are offered SG, which minimizes immunosuppression malabsorption risk and preserves gastrointestinal tract continuity to accommodate potential post-transplant biliary complications. This stratified approach, incorporating recent trial data including the SPECCIAL study and our developing OPTIMAL randomized controlled trial, tailors the surgical strategy to disease severity while minimizing complications\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study has several important limitations. Despite using the large-scale MBSAQIP database, our LT\u0026thinsp;+\u0026thinsp;SG cohort remained small as we included only patients from 2020\u0026ndash;2023 to reflect current surgical practices. MBSAQIP variable definitions changed substantially in 2020, preventing the inclusion of earlier cases without risking analytical inconsistencies. As LT\u0026thinsp;+\u0026thinsp;SG procedures increase, incorporating post-2023 data and harmonizing pre-2020 data could yield larger samples for comprehensive temporal analyses. A key limitation is the absence of a LT-only comparison group, preventing assessment of whether SG adds incremental risk beyond liver transplantation alone. The database lacks critical transplant-specific variable (MELD scores, pre-operative ACLF, graft type, donor quality metrics, and immunosuppression regimens) and clinical parameters (coagulation status, elastography measurements, cirrhosis etiology, portal hypertension severity) that influence outcomes. We cannot determine whether patients underwent TIPS- a potentially significant confounder. Nuanced technical aspects like staple line reinforcement and stapler types are not captured, limiting operative technique recommendations. Finally, the database only captures 30-day outcomes, preventing analysis of long-term weight loss maintenance and graft survival. Future research should link MBSAQIP data with transplant-specific registries such as UNOS (United Network for Organ Sharing) or SRTR (Scientific Registry of Transplant Recipients), enabling matched cohort analyses comparing LT\u0026thinsp;+\u0026thinsp;SG patients to LT-only controls with similar baseline characteristics to determine the true additional risk of performing concurrent SG.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis first large-scale analysis of concurrent sleeve gastrectomy and liver transplantation demonstrates that despite higher complication rates compared to sleeve gastrectomy alone, which are expected given the inherently high-risk nature of liver transplant recipients, LT\u0026thinsp;+\u0026thinsp;SG appears to be a feasible approach with an acceptable 30-day mortality. Our findings specifically reflect contemporary surgical techniques and perioperative management protocols from 2020\u0026ndash;2023, providing clinically relevant insights into current practice rather than historical comparisons that may not accurately represent today's risk profile. The significantly elevated bleeding rates observed with LT\u0026thinsp;+\u0026thinsp;SG raise important clinical concerns, and while decisions must be made on a case-by-case basis currently, larger multi-institutional studies are needed to better define acceptable risk thresholds and patient selection criteria. Centers performing these procedures should develop standardized perioperative protocols that address the unique needs of this population, and future research should compare matched cohorts of LT\u0026thinsp;+\u0026thinsp;SG versus LT alone to establish long-term outcomes and definitive risk-benefit profiles.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest relevant to the present publication to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any sponsor or funder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKanwal F, Neuschwander-Tetri BA, Loomba R, Rinella ME. 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Hepatology 2018;68(2):485\u0026ndash;95. \u003c/li\u003e\n\u003cli\u003eMorris MC, Jung AD, Kim Y, Lee TC, Kaiser TE, Thompson JR, et al. Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience. Liver Transpl 2019;25(11):1673\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eTsamalaidze L, Stauffer JA, Arasi LC, Villacreses DE, Franco JSS, Bowers S, et al. Laparoscopic Sleeve Gastrectomy for Morbid Obesity in Patients After Orthotopic Liver Transplant: a Matched Case-Control Study. Obes Surg 2018;28(2):444\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eMechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, et al. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020;28(4):O1\u0026ndash;58. \u003c/li\u003e\n\u003cli\u003eCruz C, Prado CM, Gillis C, Martindale R, B\u0026eacute;meur C, Lai JC, et al. Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant. Hepatology 2024;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables I and II are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"liver transplantation, sleeve gastrectomy, bariatric surgery, transplant-related coagulopathy, MASLD, MASH, perioperative protocol","lastPublishedDoi":"10.21203/rs.3.rs-7237223/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7237223/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eConcurrent sleeve gastrectomy and liver transplantation (LT\u0026thinsp;+\u0026thinsp;SG) is an emerging approach for patients with decompensated cirrhosis and severe obesity. Recent technical advancements may have improved outcomes, yet contemporary data remain limited.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eTo evaluate trends, characteristics, and 30-day outcomes of patients undergoing concurrent LT\u0026thinsp;+\u0026thinsp;SG in the modern surgical era.\u003c/p\u003e\u003ch2\u003eSetting:\u003c/h2\u003e\u003cp\u003e Analysis of 902 accredited bariatric surgery centers across the United States and Canada participating in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eRetrospective analysis of the MBSAQIP database (2020\u0026ndash;2023) to identify patients undergoing primary sleeve gastrectomy with concurrent liver transplantation. Demographic characteristics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression identified predictors of serious complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 523,243 SG patients, 22 (0.004%) underwent concurrent LT\u0026thinsp;+\u0026thinsp;SG. These patients were older (49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 vs. 42.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010), had higher BMI (47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 vs. 44.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 kg/m\u0026sup2;, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and were predominantly male (81.8%) compared to the primarily female SG-alone group (81.7%), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001. The LT\u0026thinsp;+\u0026thinsp;SG cohort experienced significantly higher bleeding rates (63.6% vs. 0.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), reoperation (18.2% vs. 0.64%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and serious complications (36.4% vs. 1.82%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). However, mortality rates were comparable (0.0% vs. 0.06%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.91).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eDespite higher complication rates compared to SG alone, concurrent LT\u0026thinsp;+\u0026thinsp;SG appears feasible with acceptable 30-day mortality. The significantly elevated bleeding rates warrant specialized hemostatic strategies and careful patient selection. Future research should compare LT\u0026thinsp;+\u0026thinsp;SG to LT-only patients to determine the true additional risk of performing concurrent SG.\u003c/p\u003e","manuscriptTitle":"Modern Era Experience with Concurrent Liver Transplantation and Sleeve Gastrectomy: A MBSAQIP-Based Analysis of 30-Day Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-21 17:59:01","doi":"10.21203/rs.3.rs-7237223/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fd5d9070-7fdb-4fd2-aac6-4b1cfc05c31d","owner":[],"postedDate":"October 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-28T11:09:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-21 17:59:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7237223","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7237223","identity":"rs-7237223","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}