Lower survival and higher rates of cirrhosis in patients with ROUX-EN-Y gastric bypass hospitalised with alcohol-associated hepatitis | BMJ Open Gastroenterology

Introduction

The prevalence of alcohol-associated liver disease (ALD) is increasing, notably in women and patients with low socioeconomic status, and ALD is now the leading indication for liver transplantation in the USA.1-3 Alcohol-associated hepatitis (AH) is defined by the American Association for the Study of Liver Diseases (AASLD) as a clinicopathologic syndrome of jaundice (onset within 8 weeks), associated with elevated liver enzymes (hepatocellular pattern with AST/ALT> 1.5; AST and ALT <400 IU/L) occurring in an individual with ongoing/recent alcohol use.4 AH represents a major cause of morbidity, mortality and healthcare utilisation, particularly within the first year of diagnosis.5 The incidence of AH increased by 30% over an 8-year period in 2013 and is expected to increase further due to the spike of ALD observed in the context of the recent COVID-19 global pandemic.6 7

The obesity epidemic is a public health crisis in the USA, directly impacting the incidence of diabetes mellitus (DM), coronary artery disease (CAD) and cerebrovascular disease.8 Weight loss surgery (WLS) is the most effective intervention for the management of obesity by inducing rapid, durable weight loss and has also been shown to improve long-term survival.9 10 Roux-en-Y gastric bypass (RYGB) surgery—division of the stomach into a small pouch with formation of an anastomosis to the jejunum—was the standard of care in WLS until 2013 with the advent of the sleeve gastrectomy.11 12 RYGB results in significant loss of body weight, improvement of hepatic steatosis and can treat hypertension and type 2 DM.13-15 However, long-term studies have shown that RYGB is also associated with gastrointestinal ulcers, dumping syndrome and chronic nutritional deficiencies, which can result in high rates of hospitalisations and the need for repeat surgery.16-18

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WLS is associated with alcohol use disorder (AUD) and ALD.19-21 Prospective studies show that patients with WLS have an increased risk for the development of AUD, particularly patients with RYGB.22 23 Furthermore, patients with a history of RYGB are at increased risk of mortality from alcohol and drug use.24 While the relationship between AUD and WLS is well established, the impact of RYGB surgery on clinical outcomes specifically in patients with AH remains largely unknown. In patients hospitalised for AH, two database studies have shown that the presence of RYGB results in a higher risk of 30-day hospital readmission.25 26

We aimed to evaluate the impact of RYGB on mortality, hospital readmissions and diagnosis of cirrhosis following an initial hospitalisation for AH. Due to the increased risk of mortality related to AUD and long-term complications associated with RYGB, we hypothesised that patients with a history of RYGB admitted to hospital for AH would have lower inpatient and overall survival, more frequent readmissions and higher instances of cirrhosis following discharge from hospital.

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