Survival and Cost-Effectiveness of Bariatric Surgery Among Patients With Obesity and Cirrhosis

Obesity and steatotic liver disease are associated with excess morbidity and mortality from cardiovascular, pulmonary, metabolic, and hepatic causes. Bariatric surgery has demonstrated long-term benefits in terms of weight loss and mortality rates, but barriers to its utilization persist. To evaluate the impact of bariatric surgery on outcomes and cost-effectiveness among patients with obesity, focusing on those with cirrhosis. This economic evaluation was a retrospective cohort study including US veterans older than 18 years with a body mass index (BMI) higher than 35 or with a BMI higher than 30 and more than 1 major metabolic comorbidity. These veterans were referred to a structured lifestyle modification program (MOVE!), and a subset proceeded to bariatric surgery, including sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2008 to 2020. Risk set matching was used to match bariatric surgery cases 1:5 with nonsurgical controls. Data were analyzed from September 2008 to September 2023. Bariatric surgery (SG or RYGB) or structured lifestyle intervention (MOVE!). The primary outcomes were the incremental cost-effectiveness ratio (ICER) of SG or RYGB vs MOVE! over 10 years. Secondary outcomes included overall survival, quality-adjusted survival, and weight loss achieved. The final cohort included 4301 SG, 1906 RYGB, and 31 055 MOVE! participants, among whom 64, 8, and 354, respectively, had cirrhosis. The median (IQR) age of the cohort was 52 (44-59) years; there were 25 581 male patients (68.7%) and 11 681 female (31.3%). Compared with MOVE!, bariatric surgery was associated with longer observed survival (9.67 years vs 9.46 years overall; 9.09 years vs 8.23 years in cirrhosis). The ICER was $132 207 for SG and $159 027 for RYGB in the overall cohort, and $18 679 for SG and $44 704 for RYGB in the cirrhosis cohorts. Bariatric surgery was cost-effective at a willingness-to-pay threshold of $100 000 per quality-adjusted life-year among patients with cirrhosis. Bariatric surgery was associated with improved survival and expected weight loss and was cost-effective. These 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.