Table 2.

Best Practice Advice Statements for Bariatric Surgery in Obese Patients With Cirrhosis

Target audience	Hepatologists, gastroenterologists, liver transplant surgeons, bariatric surgeons, anesthesiologists, critical care physicians, nutrition experts, and other subspecialists seeing patients with obesity and cirrhosis
Target population	Obese patients with cirrhosis undergoing bariatric surgery, liver transplantation, or both
Baseline risk factors for surgical morbidity and mortality	CTP score, MELD score, ASA physical status classification, BMI, visceral fat, sarcopenia, portal hypertension, centers performing low-volume surgeries, age, and non-hepatic comorbidities prevalent in this patient population (cardiovascular and cerebrovascular disease, type 2 diabetes mellitus, renal impairment, and restrictive lung disease)
Postoperative complications common in these patients	Hepatic decompensation, protein calorie malnutrition, portal vein thrombosis, malabsorption of nutrients, vitamins, and trace metals, impaired absorption of vital medications including immunosuppressive agents, potential inability to endoscopically evaluate the biliary tree or endoscopically access portal hypertensive gastropathy or varices in the excluded gastric remnant, and the onset of alcohol use disorders
Best Practice Advice statements
1	Because obesity in patients with cirrhosis is a major risk factor for hepatic decompensation, portal vein thrombosis, hepatocellular carcinoma, and the development of acute on chronic liver disease, weight loss should be an important therapeutic goal for these patients.
2	The method and rapidity for obtaining a sustained loss of excess body fat in obese patients with cirrhosis need to be individualized and are dependent not only on the BMI but also the presence and degree of sarcopenia, edema/ascites, CSPH, whether the patient has compensated or decompensated cirrhosis, patient age, and potential candidacy for liver transplantation.
3	Weight management, ideally ≥10% total body weight loss, via lifestyle modification may decrease portal hypertension and histologic progression; however, success in implementing these interventions in clinical practice and uncertainties regarding durability of this approach limit the utility of this method for treatment of obese patients with cirrhosis.
4	Bariatric surgery should be considered in selected patients with compensated cirrhosis in an effort to reduce risk for hepatocellular carcinoma and improve survival.
5	Bariatric surgery in obese patients with cirrhosis should only be performed in those with compensated disease by an experienced surgeon at a high-volume bariatric center. Bariatric surgery in this patient population should only be performed after careful evaluation and management of extrahepatic comorbidities.
6	Assessment for CSPH should be included in the preoperative evaluation for bariatric surgery in patients with cirrhosis. Pending data to validate noninvasive testing for this purpose, cross-sectional imaging and upper endoscopy should be performed to evaluate features of CSPH.
7	Bariatric surgery may be associated with significant changes in alcohol drinking habits and deleterious changes in alcohol metabolism. The consequences of alcohol consumption after bariatric surgery among patients with cirrhosis warrant intensive assessment of these candidates preoperatively and long-term efforts to mitigate risk after surgery.
8	Currently approved endoscopic bariatric therapies include the intragastric balloon, a percutaneous gastric aspiration system, and endoscopic sleeve gastrectomy. Endoscopic bariatric therapies may have lower risk(s) compared with surgical approaches, although direct comparative studies to support this, as well as long-term efficacy data, are currently lacking. Endoscopic bariatric therapies should not be performed in patients with CSPH.
9	Programs offering bariatric surgical services for patients with cirrhosis must include a surgical and anesthesia team with experience in operating on patients with portal hypertension and cirrhosis as well as a medical team with experience in treating a postoperative patient with cirrhosis. Potential candidacy for liver transplantation should be determined as part of the preoperative assessment of obese patients with cirrhosis.
10	Because of preservation of endoscopic access to the biliary tree, gradual weight loss, and absence of malabsorption, the optimal bariatric surgical procedure for patients with cirrhosis is most likely a laparoscopic sleeve gastrectomy. The optimal timing is determined by the stage of liver disease. In decompensated liver disease, the only acceptable option at present is bariatric surgery concurrent with or after liver transplant.

ASA, American Society of Anesthesiologists; BMI, body mass index; CSPH, clinically significant portal hypertension; CTP, Child-Turcotte-Pugh; MELD, Model for End-Stage Liver Disease.