March 12, 2025
A new treatment approach that combines bariatric surgery with liver transplantation is increasing the number of patients eligible for transplants while improving their outcomes and quality of life. Justin M. Burns, M.D., a transplant surgeon, and Fernando F. Elli, M.D., a bariatric surgeon, share insights on this innovative protocol at Mayo Clinic in Jacksonville, Florida.
"Our specialties go hand in hand," says Dr. Elli. "Combined, these procedures offer improved well-being for patients with their new organ."
In select cases, Mayo Clinic surgeons conduct a liver transplant and sleeve gastrectomy together for patients who might otherwise not be eligible for transplant. Concurrent bariatric surgery aids in improving transplant outcomes by preventing recurrent obesity and lowering the risk of failure of the new liver. For referring physicians, that means their patients benefit from improved hepatic function and reduced harm from comorbidities.
Lowering the barrier for liver transplant
Obesity is a major risk factor in the development of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH). These conditions are leading causes of liver failure for both men and women. Both MASH and MASLD can lead to liver fibrosis and the need for transplantation.
Current protocols limit liver transplants in patients with high BMIs. However, Mayo Clinic surgeons have been able to operate on patients with BMIs up to 60. This protocol makes Mayo Clinic a referral destination for transplants for patients who would otherwise be excluded from consideration because of their BMIs.
"We are able to accept patients who otherwise wouldn't get a transplant and who have a higher risk of complication from obesity," says Dr. Elli. "Not only are we lowering the risk of redeveloping MASH and MASLD, we are also reducing the risk of death from complications of obesity like diabetes and high blood pressure. It is a more holistic approach that treats the whole patient."
Since surgeons have access to the stomach over the course of a liver transplant, they also have access to perform the gastric sleeve procedure.
"For patients awaiting a liver transplant, we recognize it's ideal to get the gastric sleeve before their liver transplant," says Dr. Burns. "However, we were able to develop this protocol to operate simultaneously on patients with higher Model for End-Stage Liver Disease (MELD) scores. For these patients, the concurrent surgery carries lower risk." Results of a feasibility study were published in Obesity Surgery in 2022.
Operationally, the bariatric surgery adds only nominal time to the overall transplant procedure, and the sleeve procedure is no more complicated than it would be without the transplant.
"We have been able to show this protocol is safe, and new research is delving into longer term benefits," says Dr. Burns. "The bariatric surgery component doesn't add complication to the transplant and offers the same benefits as it would for someone without liver disease."
Care coordination from across specialties
This combined surgery requires tight coordination from dozens of providers. The transplant and bariatric surgery teams work closely with experts from medical weight loss, hepatology, psychiatry and more to quickly get patients evaluated and on the transplant list. This care team works in lockstep with referring healthcare professionals on continuity of care before and after the transplant procedure as well.
"Once we see a patient, a transplant can happen at any time, and coordination becomes very important," says Dr. Burns. "The bariatric surgery team does a great job of accommodating very sick patients. It takes a lot of support from many teams to get these patients the treatment they need."
Mayo Clinic is uniquely equipped to help these patients given its high-volume, high-complexity transplant and bariatric services and is a destination for patients with suspected liver fibrosis, MASH or MASLD regardless of BMI.
"We have a charge of doing everything we can to make sure that those waiting for transplant can ultimately get one," says Dr. Burns.
For more information
Burns JM, et al. Combined sleeve gastrectomy with liver transplant in patients with obesity: A feasibility study. Obesity Surgery. 2022;32:3600.
Elli FE, et al. Outcomes of bariatric surgery before, during, and after solid organ transplantation. Obesity Surgery. 2022;32:3821.
Refer a patient to Mayo Clinic.