Network Meta-Analysis of Metabolic Surgery Procedures for the Treatment of Obesity and Diabetes

Baseline 25(OH)D level is a prognostic indicator for bariatric surgery readmission: a matched retrospective cohort study

Introduction

Managing postsurgical complications is crucial in optimizing the outcomes of bariatric surgery, for which preoperative nutritional assessment is essential. In this study, we aimed to evaluate and validate the efficacy of vitamin D levels as an immunonutritional biomarker for bariatric surgery prognosis.

Methods

This matched retrospective cohort study included adult patients who underwent bariatric surgery at a tertiary medical center in China between July 2021 and June 2022. Patients with insufficient and sufficient 25(OH)D (< 30 ng/mL) were matched in a 1:1 ratio. Follow-up records of readmission at 3 months, 6 months, and 1 year were obtained to identify prognostic indicators.

Results

A matched cohort of 452 patients with a mean age of 37.14 ± 9.25 years and involving 69.47% females was enrolled. Among them, 94.25 and 5.75% underwent sleeve gastrectomy and gastric bypass, respectively. Overall, 25 patients (5.54%) were readmitted during the 1-year follow-up. The prognostic nutritional index and controlling nutritional status scores calculated from inflammatory factors did not efficiently detect malnourishment. A low 25(OH)D level (3.58 [95% CI, 1.16-11.03]) and surgery season in summer or autumn (2.68 [95% CI, 1.05-6.83]) increased the risk of 1-year readmission in both the training and validation cohorts. The area under the receiver operating characteristic curve was 0.747 (95% CI, 0.640-0.855), with a positive clinical benefit in the decision curve analyses. The relationship between 25(OH)D and 6-month readmission was U-shaped.

Conclusion

Serum 25(OH)D levels have prognostic significance in bariatric surgery readmission. Hence, preferable 25(OH)D levels are recommended for patients undergoing bariatric surgery.

Surgery is associated with better long-term outcomes than pharmacological treatment for obesity: a systematic review and meta-analysis

Obesity is a highly prevalent disease with numerous complications. Both intensive medical treatment with the use of pharmacological drugs and bariatric surgery are current options. The objective of this meta-analysis was to compare, in the long-term, intensive medical treatment and surgery based on twelve parameters related to weight loss, cardiovascular and endocrine changes. A review of the literature was conducted in accordance with the PRISMA guidelines (PROSPERO: CRD42021265637). The literature screening was done from inception to October 2023 through PubMed, EMBASE and Web of Science databases. We included randomized clinical trials that had separate groups for medical treatment and bariatric surgery as an intervention for obesity. The risk of bias was assessed through RoB2. A meta-analysis was performed with measures of heterogeneity and publication bias. Subgroup analysis for each surgery type was performed. Data is presented as forest-plots. Reviewers independently identified 6719 articles and 6 papers with a total 427 patients were included. All studies were randomized controlled trials, three had a follow up of 5 years and two had a follow up of 10 years. Both groups demonstrated statistical significance for most parameters studied. Surgery was superior for weight loss (- 22.05 kg [- 28.86; - 15.23), total cholesterol (- 0.88 [- 1.59; - 0.17]), triglycerides (- 0.70 [- 0.82; - 0.59]), HDL (0.12 [0.02; 0.23]), systolic pressure (- 4.49 [- 7.65; - 1.33]), diastolic pressure (- 2.28 [- 4.25; - 0.31]), Hb glycated (- 0.97 [- 1.31; - 0.62]), HOMA IR (- 2.94; [- 3.52; - 2.35]) and cardiovascular risk (- 0.08; [- 0.10; - 0.05]). Patient in the surgical treatment group had better long term outcomes when compared to the non-surgical group for most clinical parameters.

Variation in HbA1c in Patients with Obesity and type 2 Diabetes Mellitus 12 months after Laparoscopic One-Anastomosis Gastric Bypass and Laparoscopic Roux-en-Y Gastric Bypass: a Retrospective Matched Cohort Study

BACKGROUND

Glycemic control is an important goal of bariatric surgery in patients with type 2 diabetes mellitus (T2DM) and obesity. The laparoscopic one-anastomosis gastric bypass (OAGB) has potential metabolic benefits over the laparoscopic Roux-en-Y gastric bypass (RYGB). Aim of this study is to examine whether RYGB or OAGB grants better glycemic control 12 months post-surgery.

METHODS

For this retrospective cohort study, patients with T2DM and obesity, who underwent primary OAGB between 2008 and 2017 were reviewed. For each OAGB patient, three primary RYGB patients were matched for age, gender and body mass index (BMI). Glycemic control was expressed by the glycated hemoglobin (HbA1c), which was measured pre- and 12 months post-operatively. Weight loss was reported in percentage total weight loss (%TWL).

RESULTS

A total of 152 patients, of whom 38 had OAGB and 114 RYGB, were included. Mean (standard deviation (SD)) HbA1c was 7.49 (1.51)% in the OAGB group and 7.56(1.23)% in the RYGB group at baseline. Twelve months after surgery the mean (SD) HbA1c dropped to 5.73 (0.71)% after OAGB and 6.09 (0.76)% after RYGB (adjusted p = 0.011). The mean (SD) BMI was reduced from 42.5(6.3) kg/m2 to 29.6(4.7) kg/m2 after OAGB and 42.3(5.8) kg/m2 to 29.9 (4.5) kg/m2 after RYGB; reflecting 30.3 (6.8) %TWL post-OAGB and 29.0 (7.3) %TWL post-RYGB (p = 0.34).

CONCLUSION

This study indicates that OAGB leads to lower HbA1c one year after surgery compared to RYGB, without a difference in weight loss. Prospective (randomized) studies are needed to ascertain the most optimal metabolic treatment for patients with obesity and T2DM.

Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Malnutrition Following One-Anastomosis Gastric Bypass: a Systematic Review

Severe malnutrition following one-anastomosis gastric bypass (OAGB) remains a concern. Fifty studies involving 49,991 patients were included in this review. In-hospital treatment for severe malnutrition was needed for 0.9% (n = 446) of patients. Biliopancreatic limb (BPL) length was 150 cm in five (1.1%) patients, > 150 cm in 151 (33.9%), and not reported in 290 (65%) patients. OAGB was revised to normal anatomy in 126 (28.2%), sleeve gastrectomy in 46 (10.3%), Roux-en-Y gastric bypass in 41 (9.2%), and shortening of BPL length in 17 (3.8%) patients. One hundred fifty-one (33.8%) patients responded to treatment; ten (2.2%) did not respond and was not reported in 285 (63.9%) patients. Eight (0.02%) deaths were reported. Standardisation of the OAGB technique along with robust prospective data collection is required to understand this serious problem.

Perceptions of bariatric surgery in patients with type 2 diabetes: data from a self-administered questionnaire

BACKGROUND

Although bariatric surgery (BS) is recommended for patients with type 2 diabetes (T2D) and moderate to severe obesity, only approximately 2% of patients undergo surgery.

OBJECTIVE

To compare the knowledge and perception of BS with that of other treatments for diabetes among patients with diabetes.

SETTING

French social media platforms.

METHODS

A self-administered questionnaire was distributed from May 13 to June 3, 2020, via different French social media, including patients with T2D (main target), and patients with type 1 diabetes (control population). Different profiles of reluctance to BS were identified using a factorial analysis.

RESULTS

Of the 4481 responders (50.4% women, 33.9% aged over 65), 60% had T2D. Of the 1736 patients who had heard of BS (38.7%), 1493 declared they never addressed it with their physician. Among T2D patients, BS is the treatment that elicits the most negative response, with more than 10% showing reluctance. Four reluctance profiles were identified: (1) cluster 1 (43.4%), fear of consequences on their eating habits and irreversibility of the procedure; (2) cluster 2 (34.9%), fear of poorer diabetes control; (3) cluster 3 (9.3%), fear of surgical risk; and (4) cluster 4 (12.4%), fear of side effects. In all clusters, the opinion of their physician would be the most important factor to change their mind.

CONCLUSION

Bariatric surgery for T2D is rarely addressed in routine medical visits. Fear of operative risks and irreversibility of the procedure largely explains the reluctance to BS. Information and education campaigns on the benefit of metabolic surgery for patients with T2D remain necessary.

Comparison of single-anastomosis gastric bypass and sleeve gastrectomy on type 2 diabetes mellitus remission for obese patients: A meta-analysis of randomized controlled trials

Currently, the increasing numbers of one anastomosis gastric bypass (OAGB) brought this technique in the third position in order of frequency, behind sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). However, OAGB is still considered lack of evidence in reducing obesity- related comorbidities. Our study aimed to compare the efficacy for SG and OAGB improving type 2 diabetes mellitus (T2DM) remission and weight loss in obese patients. PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) comparing OAGB and SG. Review Manager 5.4.1 was used to analyze the data, and the right effect model was chosen based on heterogeneity. Five randomized controlled trials were included in the study. The remission of T2DM in the OAGB group was more efficient at 1 year and 5 years. Meanwhile, the OAGB group has a greater improvement than the SG group in terms of hypertension (HTN) and fasting plasma glucose (FPG). Although the percentage of excess BMI loss (%EBMIL) between the OAGB and SG groups was not significant at 6 months, the OAGB group had a conspicuous %EBMIL at 1 year. And 5 years after surgery, a higher percentage of excess weight loss (%EWL) was found in the OAGB group. Besides, the OAGB group showed a lower body mass index (BMI) at 5 years than the SG group, but the BMI at 6 months and 1 year were not significant. Finally, at 6 months, the OAGB group exhibited a more remarkable percentage of total weight loss (%TWL) than the SG group. In general, OAGB exhibited a better therapeutic effect in T2DM, HTN, and weight loss than SG in the medium-term follow-up period. To assess the long-term efficacy, clinics should be encouraged to continue longer-term follow-up studies and possibly RCTs.

Diabetic Markers, Five Years after Bariatric Surgery

Background: Bariatric surgery delivers substantial weight loss for obese patients with comorbidities like diabetes mellitus. We aimed to investigate the impacts of bariatric surgery on diabetic markers after 5 years of follow-up. Methods: This is a retrospective study on patients with diabetes and a history of bariatric surgery between 2016-2017. The diabetic markers before and 5 years following surgery, including a lipid profile, glucose level, and the required antidiabetic medications, were evaluated. Results: 34 consecutive patients were included, 30 (88.2%) women, with a mean age of 52.71±8.53 years. The majority (65%) of surgeries were Roux-en-Y gastric bypass (RYGB), and the remaining were one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG). The serum levels of diabetic markers reduced during follow-up (P=0.001), except for high-density lipoprotein levels and serum total cholesterol, which increased (P=0.011, P=0.838). Low-density lipoprotein levels reduced, but it was insignificant (P=0.194). Surgery types had affected the changes of diabetic markers (P>0.05). Demand for oral medication was reduced significantly, but insulin injection reduction was not significant (P=0.006 and P=0.099, respectively). Conclusion: Our study showed favorable bariatric surgery results on patients with diabetes in long-term follow-up. However, dyslipidemia is still a concern.

Towards precision medicine in bariatric surgery prescription

Obesity is a complex, multifactorial and chronic disease. Bariatric surgery is a safe and effective treatment intervention for obesity and obesity-related diseases. However, weight loss after surgery can be highly heterogeneous and is not entirely predictable, particularly in the long-term after intervention. In this review, we present and discuss the available data on patient-related and procedure-related factors that were previously appointed as putative predictors of bariatric surgery outcomes. In addition, we present a critical appraisal of the available evidence on which factors could be taken into account when recommending and deciding which bariatric procedure to perform. Several patient-related features were identified as having a potential impact on weight loss after bariatric surgery, including age, gender, anthropometrics, obesity co-morbidities, eating behavior, genetic background, circulating biomarkers (microRNAs, metabolites and hormones), psychological and socioeconomic factors. However, none of these factors are sufficiently robust to be used as predictive factors. Overall, there is no doubt that before we long for precision medicine, there is the unmet need for a better understanding of the socio-biological drivers of weight gain, weight loss failure and weight-regain after bariatric interventions. Machine learning models targeting preoperative factors and effectiveness measurements of specific bariatric surgery interventions, would enable a more precise identification of the causal links between determinants of weight gain and weight loss. Artificial intelligence algorithms to be used in clinical practice to predict the response to bariatric surgery interventions could then be created, which would ultimately allow to move forward into precision medicine in bariatric surgery prescription.

Remission of Type 2 Diabetes Mellitus (T2DM) after Sleeve Gastrectomy (SG), One-Anastomosis Gastric Bypass (OAGB), and Roux-en-Y Gastric Bypass (RYGB): A Systematic Review

Background and Objectives: The three most widely performed bariatric surgeries are Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and one-anastomosis gastric bypass (OAGB). Aside from the benefits of weight loss, current findings suggest that these procedures can also induce remission of T2DM (type 2 diabetes mellitus). There are limited data that directly compare these three procedures. This study aims to compare the short-term and long-term remission of T2DM after RYGB, SG, and OAGB. Materials and Methods: Three databases (Embase, PubMed, and Cochrane) were searched for randomised controlled trials, prospective studies, and retrospective studies that compared the effects of RYGB, SG, and OAGB on T2DM remission. Studies published between 2001 and 2022 were analysed. Only patients with T2DM and who had primary bariatric surgery were included. Results: After applying the inclusion and exclusion criteria, seven articles were included in the review. It was found that all three procedures had comparable T2DM remission. RYGB was noted to have the highest complication rate when compared to SG and OAGB. Importantly, it was noted that other predictive factors such as age, duration of diabetes, baseline HbA1c, BMI, and use of antidiabetic medication play a crucial role in T2DM remission. Conclusions: This systematic literature review confirms the existing data that all three bariatric surgeries induce remission of T2DM. Increasing in popularity, OAGB had comparable outcomes to RYGB and SG in inducing T2DM remission. In addition to the choice of bariatric surgery, there are other independent predictive factors that have an impact on T2DM remission. Further studies with larger sample sizes, longer follow-up periods, and studies that control confounding factors are required in this field.

Obesity surgery: Which procedure should we choose and why?

In the 70years that bariatric surgery has existed, many different surgical procedures have been developed. Four procedures are officially accepted by all learned societies: adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and bilio-pancreatic diversion (BPD). Gastric banding has the lowest short-term surgical risk, but it has the highest re-operation rate. Compared to SG, RYGB presents about twice the risk of early complications. Late complications seem equivalent between the two procedures but studies with follow-up>10years are rarer for SG. SG has become the most commonly performed bariatric procedure worldwide, followed by RYGB, which is still the standard. BPD remains very marginal but the omega gastric bypass, an alternative technique that is still under evaluation, now competes with RYGB. The effectiveness of these different procedures on weight loss remains difficult to compare. SG and RYGB seem to be equivalent for weight loss results and remission of type-2 diabetes (T2DM). Their results are superior to AGB. Procedures that result in greater lengths of intestinal bypass (bilio-pancreatic diversion, omega bypass) seem to have a greater weight-loss effect but are burdened by more side effects. In conclusion, the choice of a procedure is conditioned firstly by the benefit-risk ratio and in relation to patient-related parameters, particularly the body mass index (BMI) and co-morbidities. Long-term results are also linked to factors other than surgery and in particular patient behavioral factors. Obesity is a chronic disease that indicates the need for real long-term medical and surgical management.

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Women's Reasons to Seek Bariatric Surgery and Their Expectations on the Surgery Outcome - a Multicenter Study from Five European Countries

Purpose

Understanding patients’ reasons for having bariatric surgery and their expectation on surgery outcomes is important to provide the best clinical practice and reduce unrealistic expectations. It is unknown if reasons and expectations differ between countries. We aimed to investigate the reasons for seeking bariatric surgery and expectations of surgical outcomes among patients in five European countries.

Methods

In total, 250 women accepted for bariatric surgery were recruited: 50 women each from Finland, Germany, Norway, Sweden, and the Netherlands. Participants ranked 14 reasons for seeking surgery, and reported the three primary reasons. They also reported expectations on weight loss and impact of surgery vs. lifestyle on weight loss outcomes.

Results

Mean age and body mass index were 42.9 ± 11.5 years and 45.1 ± 6.2 kg/m², respectively. Weight loss and improved co-morbidity were ranked as the most important reasons. Participants expected to lose between 70.8 and 94.3% of their excessive weight. The expected impact of surgery as a driver of weight loss was higher in Germany and the Netherlands compared to in Finland, Norway, and Sweden where participants expected lifestyle changes to also have an impact.

Conclusion

Weight loss and improved co-morbidities were the main reasons for undergoing bariatric surgery. Expectations on weight loss were generally very high, but expectations of surgery vs. lifestyle as the main driver of weight loss differed between countries. While some patients understand the importance of lifestyle change and maintenance of a healthy lifestyle after surgery in order to obtain a successful weight loss, other may need additional counselling.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06280-w.

Nutritional Status after Roux-En-Y (Rygb) and One Anastomosis Gastric Bypass (Oagb) at 6-Month Follow-Up: A Comparative Study

Introduction: Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are two effective bariatric surgical procedures with positive outcomes in terms of weight loss, comorbidities remission, and adverse events profiles. OAGB seems to carry a higher risk of malnutrition, but existing data are controversial. The aim of this study is to objectively evaluate and compare malnutrition in patients undergoing RYGB and OAGB. Methods: Retrospective monocentric study of obese patients undergoing RYGB or OAGB between the 15 September 2020 and the 31 May 2021. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score and compared between groups. The primary outcome was the mean CONUT score at 6 months. The secondary outcomes included the incidence of malnutrition, comorbidities, including hypertension, insulin resistance and type II diabetes mellitus, and weight loss. Results: 78 patients were included: 30 underwent RYGB and 48 underwent OAGB. At 6-Month Follow-Up there was no difference between groups in the mean CONUT score nor in incidence of malnutrition. In both groups, the nutritional status significantly worsened 6 months after surgery (preoperative and postoperative score of 0.48 ± 0.9 and 1.38 ± 1.5; p = 0.0066 for RYGB and of 0.86 ± 1.5 and 1.45 ± 1.3; p = 0.0422 for OAGB). Type II Diabetes mellitus (DMII) and hypertension remission were significant in the OAGB group with a 100% relative remission in the DMII-OAGB group (p = 0.0265), and a 67% relative remission in the hypertension-OAGB group (p = 0.0031). Conclusions: No difference in nutritional status has been detected between patients undergoing RYGB or OAGB at the 6-Month Follow-Up. Both procedures may have significant mal-absorptive effects leading to decline in nutritional status. OAGB may be more efficacious in inducing DMII and hypertension remission. Larger prospective studies dedicated specifically to nutritional status after gastric bypass are needed to confirm the impact of different bypass procedures on nutritional status.

Comparison of mechanistic pathways of bariatric surgery in patients with diabetes mellitus: A Bayesian network meta-analysis

OBJECTIVE

Metabolic bariatric procedures are potentially efficacious treatment options in patients with type 2 diabetes mellitus (T2DM). Previous meta-analyses focused on individual operative approaches rather than the mechanistic pathways behind different bariatric procedures. This updated network meta-analysis aimed to synthesize new evidence and comparatively evaluate the efficacy of metabolic surgery against restrictive procedures and standard first-line treatment for patients with T2DM.

METHODS

Embase, MEDLINE, and trial registries were searched for randomized controlled trials on bariatric surgeries in patients with T2DM on September 3, 2021. A Bayesian network meta-analysis was conducted. The primary outcome was T2DM remission. Secondary outcomes included changes in BMI, lipoprotein levels, and blood pressure.

RESULTS

Thirty-two articles were included. Metabolic surgery was statistically superior to restrictive procedures (risk ratio [RR]: 2.57, 95% credibility intervals [CrI]: 1.36-5.43), medical therapy (RR: 35.29, 95% Crl: 10.56-183.23), and lifestyle intervention (RR: 40.51, 95% Crl: 5.32-402.59) in T2DM remission. Metabolic surgery significantly lowered BMI and blood pressure compared with other interventions. Restrictive procedures significantly increased high-density lipoprotein compared with metabolic surgery. Lifestyle intervention and metabolic surgery were statistically superior to restrictive procedures in reducing low-density lipoprotein.

CONCLUSIONS

The superiority in diabetes remission and favorable metabolic profile support the choice of metabolic surgery over restrictive bariatric procedures.

Clinical and Economic Impact of Bariatric Surgery Post Liver Transplantation: a Nationwide, Population-Based Retrospective Study

PURPOSE

Prevalence of obesity in liver transplant recipients is increasing with the overall epidemic augmentation of severe obesity, the effects of immunosuppressive drugs, and lifestyle changes which are responsible for de novo obesity development or aggravation of pre-existing obesity. The aim of this study is to analyze the differences in overall mortality, re-hospitalization rate, and hospitalization-related costs between patients undergoing bariatric surgery after liver transplantation and patients undergoing bariatric surgery alone.

MATERIALS AND METHODS

Twenty patients with history of liver transplantation who underwent bariatric surgery were analyzed from the French National Hospital Discharge Database. Overall mortality, re-hospitalization rate, length of stay for bariatric procedure, and the costs of bariatric surgery hospitalization and eventual re-hospitalizations were compared to a group of 360,846 patients who underwent bariatric surgery alone from 2010 to 2019. Furthermore, a 1:1 propensity score matching analysis was conducted.

RESULTS

Patients with a history of liver transplantation showed an increased risk of overall mortality (HR: 7.66, p = 0.0047) and increased costs of hospitalization for bariatric surgery (8250 ± 4822€ vs 5583 ± 3398€, p = 0.0005). No differences in length of stay, re-hospitalization rate, and costs were found after multivariate analysis. After propensity score matching analysis, a significant increased cost of hospitalization (8250 ± 4822€ vs 6086 ± 1813€, p = 0.0195) still resulted for the liver transplantation group.

CONCLUSION

Bariatric surgery represents the best treatment for obesity and its related associated medical problems. Our study highlights an increased risk of overall all-cause mortality and increased costs of hospitalization in this population compared to patients undergoing bariatric surgery alone.