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 body mass index (BMI) but also the presence and degree of sarcopenia, edema/ascites, clinically significant portal hypertension (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.
