BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) affects up to 75% of patients with obesity. Despite its clinical relevance, NAFLD is often underdiagnosed, as non-invasive methods may lack sensitivity for detecting early-stage disease. Intraoperative liver biopsy (ILB) provides an opportunity for accurate diagnosis and staging, however concerns about its safety have limited its use during bariatric surgery. Our study aimed to compare 30-day outcomes in patients who underwent sleeve gastrectomy (SG) with versus without concurrent ILB.

METHODS: We analyzed patients who underwent SG using the 2023 MBSAQIP database. Concurrent ILB was identified using CPT codes (47001). We performed a Propensity Score Matching (PSM) analysis with 25 preoperative characteristics and comorbidities. Subsequently, we compared the 30-day postoperative outcomes and bariatric-specific complications for patients who underwent SG versus SG with concurrent ILB (Analysis 1). Then, a subgroup analysis was conducted among patients with pre-existing liver disease comparing those who underwent SG versus SG with concurrent ILB (Analysis 2).

RESULTS: A total of 126,165 SG cases were analyzed using the 2023 MBSAQIP database, of which 2,272 (1.8%) included concurrent ILB. Propensity-matched outcomes in Analysis 1 (1:1 PSM Analysis, n=2,272) showed no significant differences in 30-day mortality (0.2% vs. 0.2%, p=0.754), unplanned ICU admissions (0.3% vs. 0.4%, p=0.466), blood transfusions (0.8% vs. 0.5%, p=0.143) or postoperative bleeding (0.4% vs. 0.4%, p=1.000) compared to SG alone. Propensity-matched outcomes in Analysis 2 (1:4 PSM Analysis, n=549, n=2,192) showed that patients with liver disease who had concurrent ILB had higher rates of interventions (1.1% vs. 0.4%, p=0.032). There were no differences in blood transfusions (1.1% vs. 0.8%, p=0.541) or postoperative bleeding (0.2% vs. 0.5%, p=0.479) compared to SG alone.

CONCLUSION: Concurrent ILB during SG is safe and not associated with increased perioperative mortality or major morbidity. Although patients with pre-existing liver disease who undergo SG with concurrent ILB may experience a modest increase in interventions rates, we observed no differences in blood transfusion or postoperative bleeding.  Therefore, ILB still remains a valuable diagnostic tool that can be safely integrated into SG, even in patients with liver disease.