Patients with cirrhosis and obesity who undergo bariatric surgery see survival benefits over 10 years that make the surgery cost-effective compared with people who only receive a lifestyle intervention, new research showed.
The study indicates that “for patients with obesity and compensated metabolic dysfunction–associated steatohepatitis (MASH) cirrhosis, bariatric surgery achieves the amount of weight loss needed to reduce steatohepatitis safely,” first author David E. Kaplan, MD, of the University of Pennsylvania Perelman School of Medicine, Philadelphia, told Medscape Medical News.
“While there is high initial cost [of the surgery], survival is improved, and over 10 years, initial costs are largely offset by reduced costs related to liver disease decompensation.”
This study was published in JAMA Surgery.
The prevalence of obesity-related MASH has been on the rise, and if the condition worsens to cirrhosis, decline to decompensation can be swift. Weight loss is the only treatment shown to be effective in such cases; however, efforts through conventional lifestyle modifications are notoriously challenging.
Bariatric surgery has been shown to be much more successful in achieving weight loss and improving survival; however, it comes with the significant burdens of cost, payer-mandated presurgery interventions, and other factors.
With data lacking on the efficacy and cost-effectiveness of surgery in patients with obesity and cirrhosis, Kaplan and his colleagues conducted the retrospective study, turning to data on patients with obesity in the US Veterans Health Administration database between 2008 and 2020.
Of the patients receiving bariatric surgery, 4301 underwent sleeve gastrectomy and 1906 had Roux-en-Y gastric bypass (RYGB) surgery.
The bariatric surgery patients were compared with a control group of 31,055 patients, also obese, who received only a structured lifestyle modification program (MOVE!), and not surgery.
In the three groups, a number of patients with cirrhosis were 64, 8, and 354, respectively. Their median age was 52 years, about three quarters (68.7%) were men, and their median body mass index was 41.0.
About half of the patients had type 2 diabetes at baseline, and more than 70% had hyperlipidemia. Patients with cirrhosis had a higher median age of 62 years, and all had mild cirrhosis, with 100% being Child-Turcotte-Pugh class A.
Over the 10-year study, those receiving bariatric surgery had a mean survival of 9.67 years compared with 9.46 years for control individuals. For those with cirrhosis, the median survival with bariatric surgery was 9.09 years vs 8.23 years with cirrhosis, but neither achieved statistical significance.
“The average survival increased 0.2 years, with an even greater benefit in the subset of patients with cirrhosis, 0.9 years,” the authors reported.
The study showed that the incremental cost-effectiveness ratio (ICER), reflecting the cost to increase each year of life with bariatric surgery after adjustment for the quality of life, was $132,207 for sleeve gastrectomy and $159,027 for RYGB in the overall cohort, whereas among those with cirrhosis, the ICER was $18,679 for sleeve gastrectomy and $44,704 for RYGB.
In general, “payors are willing to pay $100-200K per quality-of-life year gained by an intervention,” Kaplan noted, suggesting cost-effectiveness of the surgery.
“Cost of surgery has led to payor barriers that limit access,” he added. “This study demonstrates that bariatric surgery is cost-effective and possibly cost-saving in this patient population.”
“Bariatric surgery was found to be cost-effective at a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) among patients with cirrhosis.”
The current findings “support the expanded use of bariatric surgery in appropriately selected patients, including those with cirrhosis, to improve outcomes and reduce long-term health care costs,” the authors reported.
“Both RYGB and sleeve gastrectomy showed favorable outcomes regarding body weight loss and survival compared with the MOVE! program, aligning with findings from previous studies that demonstrate the long-term benefits of bariatric surgery in similar populations.”
Cirrhosis Associated With ‘Substantially’ Higher Healthcare Costs
Commenting on the study, Fasiha Kanwal, MD, of the section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, noted that “data from this study are encouraging. However, they are limited given the relatively small number of patients with cirrhosis.
“Despite these limitations, it is an important paper that will generate more research to address this important question,” she told Medscape Medical News.
In research published last year, Kanwal and her team reported on “substantially higher healthcare costs” among patients with cirrhosis than among control individuals without cirrhosis, with cirrhosis complications accounting for most of the excess cost.
While current guidelines recommend considering surgery in carefully selected patients with cirrhosis, “this [new] study provides additional support to the guidelines,” Kanwal said.
However, “we will need more evidence from multiple studies, and ideally randomized controlled trials, before more stronger recommendations can be made.”
Ultimately, the study’s “survival and quality-of-life benefits are noteworthy,” Kanwal added. “Despite the higher costs of surgery, it may be worth the investment.”
Kaplan reported grants from AstraZeneca, Gilead Sciences, Glycotest, Exact Sciences, and Bausch Health and personal fees from Roche-Genentech outside the submitted work. Kanwal had no disclosures to report.