De novo acute liver failure requiring urgent liver transplantation after sleeve gastrectomy: A case report

Introduction Bariatric surgery typically improves metabolic dysfunction-associated steatotic liver disease. We report a paradoxical case of de novo acute liver failure requiring super-urgent liver transplantation after sleeve gastrectomy. Presentation of Case A 46-year-old woman without pre-existing liver disease underwent uneventful sleeve gastrectomy, losing 20 kg over four months. She subsequently developed acute liver failure with encephalopathy and multi-organ failure. Extensive evaluation revealed no hepatotoxic trigger, alcohol use, or cirrhosis. Explant histopathology showed confluent necrosis involving 40% of the parenchyma. She underwent successful liver transplantation and has good graft function at nine months. Conclusion This is the first reported case of de novo acute liver failure requiring transplantation after sleeve gastrectomy without identifiable risk factors. It demonstrates that catastrophic liver injury can occur after restrictive procedures, highlighting a critical knowledge gap in individual susceptibility.