AbstractFactors and outcomes associated with decompensation of liver disease and liver failure in obese patients who underwent modern bariatric surgery are unclear. We present here a cohort of seventeen consecutive patients referred because of decompensation of liver disease following laparoscopic bariatric surgery. All patients showed signs of malnutrition (sarcopenia in 76.5%). In ten (58.8%), decompensation was associated with alcohol ingestion, which started after bariatric surgery in six patients. One patient died and three patients required liver transplantation, in one case preceded by transjugular intrahepatic portosystemic shunt (TIPS). However, thirteen patients achieved stabilization or full re-compensation with medical therapy and nutritional support. Our cases underline the risk of alcohol intake and malnutrition after laparoscopic bariatric surgery as causes of severe liver decompensation and underline the need for careful interdisciplinary care of these patients after surgery to early identify and treat alcohol misuse, malnutrition, and liver disease.