**6. Conclusion**

With the epidemic of obesity, there will be steep rise in performing bariatric surgery on NAFLD patients. Multiple cohort studies suggest that bariatric surgeries are extremely effective in lowering significant amount of body weight and in improving the metabolic syndrome and histology of NAFLD. Bariatric surgery helps NAFLD in achieving significant and durable weight loss, decreasing insulin resistance, ameliorating dyslipidemia, and improving metabolic hormone profile. As most of the patients with NAFLD die from cardiovascular diseases and malignancy, bariatric surgery should be considered in otherwise obese individuals with NAFLD. The commonly used bariatric surgeries include laparoscopic RYGB, laparoscopic sleeve gastrectomy, and LAGB. According to cohort studies, bariatric surgeries can be performed safely in patients with compensated Child's A cirrhosis attributed to NAFLD. But at the present time, AASLD does not recommend bariatric surgery in patients with cirrhosis attributed to NAFLD because of the lack of randomized controlled trial. Prospective randomized controlled trials are also needed in morbidly obese patients with end-stage liver disease attributed to NAFLD to find out whether performing simultaneous orthotopic liver transplantation and bariatric surgery are safe and effective.

**69**

**Author details**

Monjur Ahmed

provided the original work is properly cited.

Thomas Jefferson University, Philadelphia, PA, USA

\*Address all correspondence to: monjur.ahmed@jefferson.edu

*Non-alcoholic Fatty Liver Disease and Surgery DOI: http://dx.doi.org/10.5772/intechopen.86146*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Non-alcoholic Fatty Liver Disease and Surgery DOI: http://dx.doi.org/10.5772/intechopen.86146*

*Liver Disease and Surgery*

weight loss (including decreasing the risk of cardiovascular diseases and malignancy) and candidacy for liver transplantation may overweigh the risks. The AASLD guidelines published in January 2018 do not recommend bariatric surgery to patients with cirrhosis of the liver attributed to NAFLD as the type, safety, and efficacy of bariatric surgery are not yet established in this group of patients [60].

Some transplant centers have a strict criteria of not performing orthotopic liver transplantation with BMI > 35. Orthotopic liver transplantation in morbidly obese patients is technically difficult and can be associated with increased bleeding, postoperative complications, morbidity, and mortality [61]. The longevity of morbidly obese transplanted patients is also shortened. Pretransplant bariatric surgery is considered in these patients to reach the BMI goal for liver transplantation. Lin et al. did a retrospective study in pretransplant morbidly obese patients and found that laparoscopic sleeve gastrectomy was safe and successful in causing significant weight loss and improving candidacy for liver transplantation [62]. On the other hand, one third of post-liver transplant patients become obese, and some of them become morbidly obese due to increased appetite, increased calorie intake, sedentary lifestyle, and corticosteroid therapy. A proportion of these patients may develop metabolic syndrome and NAFLD in the transplanted liver. Both RYGB and laparoscopic sleeve gastrectomy have been found to be safe and feasible in post-liver transplant morbidly obese patients [63, 64]. Another small study showed combined liver transplantation and sleeve gastrectomy in morbidly obese patients led to effective weight loss and less metabolic complications. There was no mortality or graft loss in those patients [65]. So bariatric surgery has been found to be safe before, during, and after liver transplantation in selected patients in small studies although

With the epidemic of obesity, there will be steep rise in performing bariatric surgery on NAFLD patients. Multiple cohort studies suggest that bariatric surgeries are extremely effective in lowering significant amount of body weight and in improving the metabolic syndrome and histology of NAFLD. Bariatric surgery helps NAFLD in achieving significant and durable weight loss, decreasing insulin resistance, ameliorating dyslipidemia, and improving metabolic hormone profile. As most of the patients with NAFLD die from cardiovascular diseases and malignancy, bariatric surgery should be considered in otherwise obese individuals with NAFLD. The commonly used bariatric surgeries include laparoscopic RYGB, laparoscopic sleeve gastrectomy, and LAGB. According to cohort studies, bariatric surgeries can be performed safely in patients with compensated Child's A cirrhosis attributed to NAFLD. But at the present time, AASLD does not recommend bariatric surgery in patients with cirrhosis attributed to NAFLD because of the lack of randomized controlled trial. Prospective randomized controlled trials are also needed in morbidly obese patients with end-stage liver disease attributed to NAFLD to find out whether performing simultaneous orthotopic liver transplantation and

**5. Bariatric surgery and orthotopic liver transplantation**

there is no consensus about the optimal timing yet.

bariatric surgery are safe and effective.

**6. Conclusion**

**68**
