Published online Dec 18, 2025. doi: 10.5500/wjt.v15.i4.110957
Revised: July 28, 2025
Accepted: September 19, 2025
Published online: December 18, 2025
Processing time: 152 Days and 18 Hours
Malabsorptive bariatric surgery, including Roux-en-Y gastric bypass and duodenal switch, are known to be more metabolically effective than restrictive surgery. However, the permanent alteration of gastrointestinal anatomy from these operations has been shown to alter the kinetics of drug absorption and may make subsequent surgeries more technically challenging.
To evaluate perioperative liver transplant outcomes and rates of acute cellular rejection in recipients with prior malabsorptive bariatric surgery.
Patients who underwent liver transplantation at a single institution between 2005-2024 with a history of malabsorptive bariatric surgery were identified. Matched controls were selected based on age, sex, listing model for end-stage liver disease (MELD), and primary liver diagnosis.
A total of 12 liver transplant patients with prior malabsorptive surgery and 25 controls were included. The mean age in the malabsorptive group was 50.5 years at the time of transplant and 92% were female. The mean MELD at the time of transplant was 27.6 and mean body mass index was 28. There were no significant differences in length of stay, post operative complications, or 1 year survival between the controls and malabsorptive patients. However, the malabsorptive group was significantly more likely to experience biopsy-proven and clinically treated acute cellular rejection than the controls (24% vs 66.7%, P = 0.012), more frequent rejection episodes (0.28 ± 0.53 vs 1.0 ± 0.91, P = 0.006), and earlier time to first rejection episode (P = 0.002).
Previous malabsorptive bariatric surgery in liver transplant recipients did not increase the risk of perioperative complications or mortality but significantly increased the rate and frequency of acute cellular rejection.
Core Tip: This study compares perioperative outcomes and episodes of acute cellular rejection between liver transplant recipients with a history of malabsorptive bariatric surgery and controls. Patients with malabsorptive anatomy have higher rates, frequency, and earlier rejection, but no differences in perioperative or 1 year survival outcomes. The mechanism of increased acute cellular rejection is unknown but may be due to altered drug absorption following intestinal bypass. Therefore, this cohort may require meticulous drug-level monitoring or specified postoperative protocols to reduce rejection risk.