Sleeve Gastrectomy After Liver Transplantation: Feasibility and Outcomes

Outcomes of Sleeve Gastrectomy in Patients With Organ Transplant-Related Immunosuppression

INTRODUCTION

Obesity is frequent among organ transplant recipients, increasing the risk of acute graft rejection and overall morbimortality. Laparoscopic sleeve gastrectomy (LSG) effectively improves graft survival and associated comorbidities. We first compared 30-d outcomes between chronic immunosuppressed (CI) and nonchronic immunosuppressed (non-CI) patients. Then, between organ transplant and non-organ transplant CI patients who underwent LSG.

METHODS

Patients who underwent LSG within the metabolic and bariatric surgery accreditation and quality improvement program 2017-2019 were included. Using 1:1 and 1:4 propensity score matching analysis, the cohorts were matched for 30 characteristics. We then compared 30-d outcomes between CI and non-CI (analysis 1) and between organ transplant and non-organ transplant CI patients who underwent LSG (analysis 2).

RESULTS

A total of 486,576 patients were included. The matched cohorts in analysis 1 (n = 8978) and analysis 2 (n = 1152, n = 371) had similar preoperative characteristics. Propensity score matching in analysis 1 showed that patients in the CI group had significantly higher rates of renal complications (0.4% versus 0.2%, P = 0.006), unplanned intensive care unit admission (1.1% versus 0.7%, P = 0.003), blood transfusions (1.1% versus 0.7%, P = 0.003), readmissions (4.6% versus 3.5%, P < 0.001), reoperations (1.4% versus 1.0%, P = 0.033), interventions (1.3% versus 1.0%, P = 0.026), and postoperative bleeding (0.6% versus 0.4%, P = 0.013). In analysis 2, patients with organ transplant CI had a higher rate of pulmonary complications (1.1% versus 0.3%, P = 0.043), renal complications (2.4% versus 0.2%, P < 0.001), blood transfusions (6.5% versus 1.3%, P < 0.001), and readmissions (10.0% versus 4.6%, P < 0.001).

CONCLUSIONS

Patients with transplant-related CI who underwent LSG have higher 30-d postoperative complication rates compared to nontransplant-related CI patients; however, there were no differences in terms of mortality, intensive care unit admissions, staple line leaks, or bleeding. LSG is safe and feasible in this high-risk population.

The Impact of Metabolic Health and Obesity on Liver Transplant Candidates and Recipients

Poor metabolic health and obesity have significant impacts on the outcomes of patients suffering from chronic liver disease, particularly those with metabolic dysfunction-associated steatotic liver disease. Patients with such comorbidities who require liver transplant evaluation for advancing liver disease or liver failure require special consideration due to increased risk of cardiovascular disease, renal dysfunction, sarcopenic obesity, and cancer. Those who have had a history of prior bariatric surgery pose specific anatomical constraints and may also be at increased risk of alcohol use disorder. Pre-operative risk assessment as well as strict control of metabolic risk factors are essential to reduce intra-operative and post-liver transplant complications. As immunosuppressive therapy exacerbates metabolic dysfunction and risk for cancer, post-liver transplant care must focus on balancing the need to prevent rejection and the impact of progressive metabolic dysfunction in this unique, but growing, patient population.

The Role Bariatric Surgery and Endobariatric Therapies in Nonalcoholic Steatohepatitis

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Disease spectrum varies from steatosis, steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Currently, there are no approved medical therapies, and weight loss through lifestyle modifications remains a mainstay of therapy. Bariatric surgery is the most effective therapy for weight loss and has been shown to improve liver histology. Recently, endoscopic bariatric metabolic therapies have also emerged as effective treatments for patients with obesity and NAFLD. This review summarizes the role of bariatric surgery and endoscopic therapies in the management of patients with NAFLD.

Liver transplantation for non-alcoholic fatty liver disease: indications and post-transplant management

Non-alcoholic fatty liver disease (NAFLD) is currently the fastest growing indication to liver transplantation (LT) in Western Countries, both for end stage liver disease and hepatocellular carcinoma. NAFLD/non-alcoholic steatohepatitis (NASH) is often expression of a systemic metabolic syndrome; therefore, NAFLD/NASH patients require a multidisciplinary approach for a proper pre-surgical evaluation, which is important to achieve a post-transplant outcome comparable to that of other indications to LT. NAFLD/NASH patients are also at higher risk of post-transplant cardiovascular events, diabetes, dyslipidemia, obesity, renal impairment and recurrent NASH. Lifestyle modifications, included diet and physical activity, are key to improve survival and quality of life after transplantation. A tailored immunosuppressive regimen may be proposed in selected patients. Development of new drugs for the treatment of recurrent NASH is awaited.

Impact of Chronic Immunosuppression on Short-, Mid-, and Long-Term Bariatric Surgery Outcomes

INTRODUCTION

Bariatric surgical outcomes depend heavily on proper healing of gastrointestinal anatomy, metabolic alterations, and patient lifestyle modifications which are all negatively impacted by immunosuppression and underlying inflammatory diseases. There is a lack of literature exploring how patients with diseases requiring immunosuppression respond to bariatric surgical intervention in the long term.

METHODS

A retrospective analysis of chronically immunosuppressed patients who underwent primary bariatric surgeries at Mayo Clinic was conducted (2008-2020). Data collected included patient demographics, BMI, underlying disease, and immunosuppression regimen and complications at 3, 6, 12, 24, and 60 months.

RESULTS

We identified a total of 89 (RYGB = 49, SG = 34, BPD/DS = 6) patients on chronic immunosuppression who underwent bariatric surgery at our center. RYGB (N = 49), 38.2% had a SG (N = 34) and 6.7% had a BPD/DS (N = 6). Rheumatoid arthritis and renal transplantation were the most underlying condition at 20.22% each (N = 18). There were a total of 2 (2.25%) intraoperative complications. In the immediate post-operative period, there were 15 (16.5%) minor complications. In follow-up, 6.1% of RYGB patients experienced marginal ulcerations, while no gastrointestinal leaks occurred. The mean pre-surgical BMI was 48.29 kg/m² (SD = 18.41). Percent total weight loss (%TWL) and BMI reduction were 30.89% and 14.83 kg/m² (SD = 9.07) at 12 months and 29.48% and 14.43 kg/m² (SD = 13.46) at 60 months, respectively. The mean follow-up time was 30.49 months.

CONCLUSIONS

Bariatric surgery remains safe and effective therapy for chronically immunosuppressed patients with excellent long-term outcomes for patients with moderate to severe obesity.

Clinical and Economic Impact of Bariatric Surgery Post Liver Transplantation: a Nationwide, Population-Based Retrospective Study

PURPOSE

Prevalence of obesity in liver transplant recipients is increasing with the overall epidemic augmentation of severe obesity, the effects of immunosuppressive drugs, and lifestyle changes which are responsible for de novo obesity development or aggravation of pre-existing obesity. The aim of this study is to analyze the differences in overall mortality, re-hospitalization rate, and hospitalization-related costs between patients undergoing bariatric surgery after liver transplantation and patients undergoing bariatric surgery alone.

MATERIALS AND METHODS

Twenty patients with history of liver transplantation who underwent bariatric surgery were analyzed from the French National Hospital Discharge Database. Overall mortality, re-hospitalization rate, length of stay for bariatric procedure, and the costs of bariatric surgery hospitalization and eventual re-hospitalizations were compared to a group of 360,846 patients who underwent bariatric surgery alone from 2010 to 2019. Furthermore, a 1:1 propensity score matching analysis was conducted.

RESULTS

Patients with a history of liver transplantation showed an increased risk of overall mortality (HR: 7.66, p = 0.0047) and increased costs of hospitalization for bariatric surgery (8250 ± 4822€ vs 5583 ± 3398€, p = 0.0005). No differences in length of stay, re-hospitalization rate, and costs were found after multivariate analysis. After propensity score matching analysis, a significant increased cost of hospitalization (8250 ± 4822€ vs 6086 ± 1813€, p = 0.0195) still resulted for the liver transplantation group.

CONCLUSION

Bariatric surgery represents the best treatment for obesity and its related associated medical problems. Our study highlights an increased risk of overall all-cause mortality and increased costs of hospitalization in this population compared to patients undergoing bariatric surgery alone.

Bariatric surgery, obesity and liver transplantation

The obesity epidemic has profoundly impacted the epidemiology and trends of liver disease. In the current era, non-alcoholic fatty liver disease (NAFLD) progressing to non-alcoholic steatohepatitis (NASH) has emerged as the second leading indication for liver transplant (LT) and has been associated with the rising rates of hepatocellular carcinoma (HCC) with and without underlying cirrhosis. Obesity has been associated with poor post-transplant outcomes including lower patient and graft survival; higher risk of post-operative metabolic complications; poor wound healing; and higher infection rates. Bariatric surgery is currently the most effective management of morbid obesity and has been offered to patients both in the pre and post LT setting. The techniques attempted in LT recipients most commonly include sleeve gastrectomy (SG), gastric bypass surgery with few cases of gastric banding and biliopancreatic diversion. However, there is lack of evidence-based data on the optimal management for patients with obesity and who are liver transplant candidates and/or recipients. In the following discussion, we present the highlights from a review of the literature.

Bariatric Surgery in NAFLD

Currently, there are no approved medications to treat patients with nonalcoholic steatohepatitis (NASH) with fibrosis or cirrhosis. Although the management goal in these patients is weight reduction by 7-10% with lifestyle modifications, only less than 10% of patients achieve this target at 1-year, and fewer maintain the weight loss at 5 years. Bariatric surgery is an option that may be considered in those who fail to lose weight by lifestyle changes. Bariatric surgery has been shown to improve liver histology including fibrosis secondary to NASH, in addition to other benefits including an improvement or resolution of type 2 diabetes mellitus, dyslipidemia, and hypertension, and a reduction of cardiovascular morbidity or mortality. There are no guidelines of bariatric surgery indications for the management of NASH. The purpose of this review is to critically appraise the current knowledge of the role of bariatric surgery and the potential mechanisms for its perceived benefits in the management of patients with NASH-related liver disease.

Bariatric surgery in transplant recipients: A narrative review

Morbidity and mortality rates are increased due to obesity after organ transplantation; in this regards, bariatric surgery (BS) is believed to be an effective treatment for posttransplant obese patients. Nevertheless, some studies are doubtful in terms of the effectiveness of BS, the most suitable bariatric procedure, and management of immunosuppressant drugs in some kinds of organ transplants. We evaluated nonsurgical therapies, weight reduction, adjustment of immunosuppressants, comorbidities, and the recommended surgical procedures for posttransplant BS for different types of organ transplantations.

Current and Evolving Indications for Simultaneous Liver Kidney Transplantation

This review will discuss the etiologies of kidney disease in liver transplant candidates, provide a historical background of the prior evolution of simultaneous liver-kidney (SLK) transplant indications, discuss the current indications for SLK including Organ Procurement and Transplantation Network policies and Model for End Stage Liver Disease exception points, as well as provide an overview of the safety net kidney transplant policy. Finally, the authors explore unanswered questions and future research needed in SLK transplantation.

Liver transplantation and bariatric surgery: a new surgical reality: a systematic review of the best time for bariatric surgery

Non-alcoholic fatty liver disease has increased in parallel with the obesity. This situation represents a new reality for patients with an indication for liver transplant (LT) and bariatric surgery (BS). We undertook a systematic review of BS and LT using the terms 'liver transplant', 'obesity' and 'bariatric surgery'. The variables analyzed were number of patients, technique and timing of BS, surgical complications, follow-up and mortality. A total of 190 papers were identified and, 28 articles were discussed (6 papers with BS before a LT, 6 with both procedures simultaneously and 16 studies with BS after a LT). In the last 7 years, 22 of the 28 papers (78.6%) were published on this subject. A total of 144 patients had both procedures: 27 (18.8%) before, 42 (29.1%) simultaneously and 75 (52.1%) after. Sleeve gastrectomy was the most performed BS (121 cases-84%) followed by a Roux-en-Y gastric bypass (20 cases-13.9%). The number of publications has increased substantially in recent years. The majority papers of BS after LT could be explained because of commodity of the flow of these patients. The best moment to perform BS in these patients has yet to be established.

Long-term outcomes of Roux-en-Y gastric bypass or sleeve gastrectomy in patients with cirrhosis; before, during or after liver transplantation: A single center's experience

BACKGROUND

The increasing prevalence of morbid obesity (MO) results in parallel growth of obesity-associated liver diseases necessitating liver transplantation (LT).

OBJECTIVE

To examine the feasibility and safety of Roux-en-Y gastric bypass or sleeve gastrectomy in the setting of LT.

METHODS

This retrospective chart review included the data on all the MO candidates before and after LT who underwent bariatric surgery (BS) in our institution between 04/2013-09/2016. The reported outcomes were weight change and early and late postoperative complications (mean follow-up: 43 ± 11.1 months).

RESULTS

Eighteen MO peri-LT patients (10 females, 8 males, average age 48 years) were included in the study. Ten had cirrhosis (mean Model of End-stage Liver Disease [MELD] score of 12.5 ± 6.42), three underwent concurrent LT and BS (mean MELD score 23.7 ± 0.58), and five had LT (mean of 56 months from LT). The mean percentage of total and excess weight loss was 31% and 81%, respectively. Six of the eight patients with type 2 diabetes mellitus became normoglycemic after BS. Three patients sustained perioperative complications. Two cirrhotic patients died 1 and 4.5 years after BS with decompensation.

CONCLUSIONS

Bariatric surgery appears to effectively address obesity in cirrhotic and LT patients. The surgical risk is higher than that of the regular BS population.

Bariatric Surgery Outcomes in Patients with Prior Solid Organ Transplantation: an MBSAQIP Analysis

Introduction

Obesity is a risk factor for poor patient outcomes after organ transplantation (TXP). While metabolic and bariatric surgery (MBS) is safe and effective in treating severe obesity, the role of MBS in transplant patients continues to evolve.

Methods

A retrospective analysis was performed of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients in the 2017 Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database. Propensity and case-control matching, and multivariable logistic regression were performed for 30-day post-operative outcomes.

Results

A total of 336 transplant patients were compared with 157,413 patients without transplant. Propensity and case-control matching reveal no significant differences in mortality (p > 0.2). However, case-control matching revealed longer operative time (104 min versus 76 min, p < 0.001), increased length of stay (2 days versus 1 day, p < 0.05), perioperative transfusions (2% versus 0.22%, p = 0.009), and leak rates (2.2% versus 0.55%, p = 0.02) in the transplant cohort. On multivariable regression analysis, prior transplantation was associated with higher rates of overall (OR 1.6, p = 0.007) and bariatric-related morbidity (OR 1.78, p = 0.004), leak (OR 3.47, p = 0.0027), and surgical site infection (OR 3.32, p = 0.004). Prior transplantation did not predict overall (p = 0.55) nor bariatric-related mortality (p = 0.99).

Conclusion

MBS in prior solid organ transplantation patients is overall safe, but is associated with increased operative time and length of stay, as well as higher rates of some post-operative morbidity.

Pre-transplant bariatric surgery is associated with increased fungal infection after liver transplant

AIM

The impact of pre-transplant (pre-TXP) bariatric surgery (BS) on outcomes after liver transplant (LTX) has not been completely elucidated. Roux-en Y gastric bypass (RYGB) is one of the most common BS procedures. The primary objective of this study was to identify the risk of infection in LTX recipients with pre-TXP RYGB.

METHODS

Adult patients with LTX between 1/1/2001 and 9/30/2018 at our center were screened for pre-TXP RYGB; patients with gastrectomy via sleeve or banding were excluded. Patients with no history of BS pre- or post-transplant were placed in a comparator group, matched 2:1 via incidence density sampling on age epoch.

RESULTS

There were 16 LTX recipients with pre-TXP RYGB matched to 32 controls. Median time from RYGB to transplant was 11.7 years. Mean weight loss was 66 ± 19 kg. There were significantly more women with pre-TXP RYGB than in the matched control (RYGB:68.8% vs control:25%, P = .009). Demographics were otherwise similar between groups. Pre-TXP RYGB did not significantly increase hospital or ICU length of stay (P = .5, P = .3) but was associated with a significantly increased rate of fungal infection at 1 year (RYGB:33.4% vs control:9.7%, P = .01), and a numerical trend to increased bacterial infection (RYGB:56.2% vs control:32.2%, P = .09).

CONCLUSION

Despite the substantial weight loss attributed to BS, patients with pre-TXP RYGB demonstrated increased rates of fungal infection after transplant and trended toward increased bacterial infection. While the anatomical complexity associated with LTX surgery after RYGB did not appear to significantly affect ICU or hospital length of stay, it may have contributed to overall infectious risk, and possibly to impaired survival. Additionally, bypass of the host natural barrier defenses of the stomach could also have contributed to infectious risk. Our findings highlight the complexity of this patient population. Future prospective studies are needed to investigate risk of infection after LTX in the setting of pre-Txp BS. Potential modification in fungal prophylaxis protocols to include pre-TXP RYGB may be warranted.

Are We Ready for Bariatric Surgery in a Liver Transplant Program? A Meta-Analysis

BACKGROUND

Obesity-related non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are two main causes of end-stage liver disease requiring a liver transplantation. Studies exploring bariatric surgery in the liver transplantation setting have increased in recent years; however, a systematic analysis of the topic is lacking to date. This meta-analysis was conducted to explore the perioperative and long-term outcomes of bariatric surgery in obese patients undergoing liver transplantation.

METHODS

Electronic databases were systematically searched for studies reporting bariatric surgery in patients undergoing liver transplantation. The primary outcomes were postoperative complications and mortality. We also extracted data about excess weight loss, body mass index, and improvement of comorbidities after bariatric surgery.

RESULTS

A total of 96 patients from 8 articles were included. Bariatric surgery-related morbidity and mortality rates were 37% (95% CI 0.27-0.47) and 0.6% (95% CI 0.02-0.13), respectively. Body mass index at 24 months was 31.02 (95% CI 25.96-36.09) with a percentage excess weight loss at 12 and 24 months of 44.08 (95% CI 27.90-60.26) and 49.2 (95% CI 31.89-66.66), respectively. After bariatric surgery, rates of improvement of arterial hypertension and diabetes mellitus were 61% (95% CI 0.45-0.75) and 45% (95% CI 0.25-0.66), respectively. In most patients, bariatric surgery was performed after liver transplant and the most frequent technique was sleeve gastrectomy.

CONCLUSIONS

Bariatric surgery can be performed safely in the setting of liver transplantation resulting in improvement of obesity-related comorbidities. The optimal timing and technique require further studies.

Obesity Management of Liver Transplant Waitlist Candidates and Recipients

Obesity is increasing in prevalence in liver transplant candidates and recipients. The rise in liver transplantation for nonalcoholic steatohepatitis reflects this increase. Management of obesity in liver transplant candidates can be challenging due to the presence of decompensated cirrhosis and sarcopenia. Obesity may increase peritransplant morbidity but does not have an impact on long-term post-transplant survival. Bariatric surgery may be a feasible option in select patients before, during, or after liver transplantation. Use of weight loss drugs and/or endoscopic therapies for obesity management ultimately may play a role in liver transplant patients, but more research is needed to determine safety.

Successful Outcome of Bariatric Surgery in Living Donor Liver Transplant Recipients With Multidisciplinary Approach: A Preliminary Experience

INTRODUCTION

Liver transplant recipients may develop weight gain, metabolic syndrome, and subsequent nonalcoholic steatohepatitis of the transplanted liver which impairs graft function. Bariatric surgery is an effective modality for management of morbid obesity and metabolic syndrome. Our aim is to review the role of bariatric surgery in such high-risk posttransplant patients not responding to medical management and highlight the important considerations.

METHODOLOGY

We review the management of two cases with posttransplant metabolic syndrome not responding to medical management and discuss the literature available on bariatric surgery in organ transplant patients.

RESULTS

The first patient was a 51-year-old man who underwent living donor liver transplantation 3 years prior, and follow-up ultrasound and fibroscan was suggestive of steatohepatitis of the graft. After liver transplantation, he had gained 30 Kg weight and was on oral hypoglycemic agents with HbA1c of 8%. The second patient was a 65-year-old man, who gained 30 Kg weight with risk of graft impairment 4 years after of combined liver and kidney transplant. Both patients were evaluated thoroughly preoperatively for risk stratification including an upper gastro-intestinal (GI) endoscopy. The immunosuppression was reduced and monitored closely perioperatively. Both patients underwent laparoscopic sleeve gastrectomy (LSG) and were discharged on postoperative day 3. The first patient was evaluated a year after surgery with body mass index (BMI) reduction from 42 to 34 and second at 2 months with BMI reduction from 38 to 33; both patients were free of diabetes and had stable graft functions.

CONCLUSION

Bariatric surgery in liver transplant recipients has significant challenges with higher complication rates as patients are on immunosuppression which often impairs wound healing. LSG is safe and effective in such patients which often requires good coordination between the bariatric team and liver transplant team.

Perioperative risks of bariatric surgery among patients with and without history of solid organ transplant

Bariatric surgery is effective among patients with previous transplant in limited case series. However, the perioperative safety of bariatric surgery in this patient population is poorly understood. Therefore, we assessed the safety of bariatric surgery among previous-transplant patients using a database that captures >92% of all US bariatric procedures. All primary, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures between 2017 and 2018 were identified from the MBSAQIP dataset. Patients with previous transplant (n = 610) were compared with patients without previous transplant (n = 321 447). Primary outcomes were 30 day readmissions, surgical complications, medical complications, and death. Multivariable logistic regression with predictive margins was used to compare outcomes. Previous transplant patients experienced higher incidence of readmissions (8.0% vs 3.5%), surgical complications (5.0% vs 2.7%), and medical complications (4.3% vs 1.5%). There was no difference in incidence of death (0.2% vs 0.1%). Among individual complications, there no statistical differences in intraabdominal leak, unplanned reoperation, myocardial infarction, or infectious complications. Baseline estimated glomerular filtration rate was found to be a strong moderator of primary outcomes, with the highest risk of complications occurring at the lowest baseline estimated glomerular filtration rate. Given the many long-term benefits of bariatric surgery among patients with previous transplant, our findings should not preclude this patient population from operative consideration.

Obesity, transplantation, and bariatric surgery: An evolving solution for a growing epidemic

The increasing obesity epidemic has major implications in the realm of transplantation. Patients with obesity face barriers in access to transplant and unique challenges in perioperative and postoperative outcomes. Because of comorbidities associated with obesity, along with the underlying end-stage organ disease leading to transplant candidacy, these patients may not even be referred for transplant evaluation, much less be waitlisted or actually undergo transplant. However, the use of bariatric surgery in this population can help optimize the transplant candidacy of patients with obesity and end-stage organ disease and improve perioperative and postoperative outcomes. We review the impact of obesity on kidney, liver, and cardiothoracic transplant candidates and recipients and explore potential interventions to address obesity in these populations.

Medical management of metabolic and cardiovascular complications after liver transplantation

Liver transplantation represents the only curative option for patients with end-stage liver disease, fulminant hepatitis and advanced hepatocellular carcinoma. Even though major advances in transplantation in the last decades have achieved excellent survival rates in the early post-transplantation period, long-term survival is hampered by the lack of improvement in survival in the late post transplantation period (over 5 years after transplantation). The main etiologies for late mortality are malignancies and cardiovascular complications. The latter are increasingly prevalent in liver transplant recipients due to the development or worsening of metabolic syndrome and all its components (arterial hypertension, dyslipidemia, obesity, renal injury, etc.). These comorbidities result from a combination of pre-liver transplant features, immunosuppressive agent side-effects, changes in metabolism and hemodynamics after liver transplantation and the adoption of a sedentary lifestyle. In this review we describe the most prevalent metabolic and cardiovascular complications present after liver transplantation, as well as proposing management strategies.

Minimally Invasive Sleeve Gastrectomy as a Surgical Treatment for Nonalcoholic Fatty Liver Disease in Liver Transplant Recipients

BACKGROUND

Obesity is a major public health burden that affects the transplant community because of its key role in fatty liver disease and transplantation outcomes.

OBJECTIVES

To evaluate the role of sleeve gastrectomy in treating recurrent and de novo nonalcoholic fatty liver disease (NAFLD) in liver transplant recipients.

SETTING

A university hospital.

METHODS

We describe 2 obese liver transplant recipients with recurrent and de novo NAFLD who underwent minimally invasive metabolic and bariatric surgery.

RESULTS

The surgery was performed successfully, with much of the operative time consumed by enterolysis. There were no intraoperative or postoperative complications. At last follow-up appointment (16 months postoperatively), there was a mean reduction in weight (31.98 kg), body mass index (10.2 kg/m²), glycosylated hemoglobin (1.05%), alanine aminotransferase (38 IU/L), steatosis score (0.34), and fibrosis score (0.05). The mean decrease in 6-month postoperative hepatic fat quantification was 6%.

CONCLUSIONS

These cases show that metabolic and bariatric surgery in obese, posttransplant recipients with recurrent and de novo nonalcoholic steatohepatitis lead to improved steatosis and reduced obesity and obesity-associated comorbidities.

Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience

Obesity has become an epidemic in the United States over the past decade, and recent studies have shown this trend in the liver transplantation (LT) population. These patients may be candidates for laparoscopic sleeve gastrectomy (LSG) to promote significant and sustained weight loss to prevent recurrence of nonalcoholic steatohepatitis. However, safety remains a concern, and efficacy in this setting is uncertain. A single-institution database from 2014 to 2018 was queried for patients undergoing LSG following LT. The selection criteria for surgery were consistent with National Institutes of Health guidelines, and patients were at least 6 months after LT. A total of 15 patients (median age, 59.0 years; Caucasian, 86.7%; and female, 60%) underwent LSG following LT. Median time from LT to LSG was 2.2 years with a median follow-up period of 2.6 years. The median hospital length of stay (LOS) was 2 days after LSG. Mortality and rate of liver allograft rejection was 0, and there was 1 postoperative complication (a surgical site infection). Following LSG, body mass index (BMI) decreased from 42.7 to 35.9 kg/m² (P < 0.01), and in 12 patients with at least 1 year of follow-up, the total body weight loss was 20.6%. Following LSG in patients with diabetes, the median daily insulin requirements decreased from 98 (49-118) to 0 (0-29) units/day (P = 0.02), and 60% discontinued insulin. Post-LT patients had a similar decrease in BMI and reduction in comorbidities at 1 year compared with a matched non-LT patient cohort. In the largest patient series to date, we show that LSG following LT is safe, effective, and does not increase the incidence of liver allograft rejection. Larger longer-term studies are needed to confirm underlying metabolic changes following LSG.

Liver Transplantation and Bariatric Surgery: Timing and Outcomes

Nonalcoholic steatohepatitis (NASH) is projected to become the leading indication for liver transplantation (LT) in the next decade in the United States. Strategies to treat the underlying etiology of NASH, which is almost always obesity, are being pursued. One such strategy is the utilization of bariatric surgery (BS) in the peritransplant period. The use of BS prior to LT could prevent the progression of NASH and abrogate the need for LT. BS at the time of LT or postoperatively has the potential to not only improve obesity-associated conditions such as diabetes, but also the potential to influence the incidence of NASH in the post-LT setting. However, there continues to be no consensus on the use and timing of BS in this patient population. This review aims to discuss the current literature and possible future action.

Consensus document. Management of non-alcoholic fatty liver disease (NAFLD). Clinical practice guideline

Non-alcoholic fatty liver disease (NAFLD) is the main cause of liver diseases in Spain and the incidence is raising due to the outbreak of type 2 diabetes and obesity. This CPG suggests recommendation about diagnosis, mainly non-invasive biomarkers, and clinical management of this entity. Life-style modifications to achieve weight loss is the main target in the management of NAFLD. Low caloric Mediterranean diet and 200 minutes/week of aerobic exercise are encouraged. In non-responders patients with morbid obesity, bariatric surgery or metabolic endoscopy could be indicated. Pharmacological therapy is indicated in patients with NASH and fibrosis and non-responders to weight loss measures. NAFLD could influence liver transplantation, as a growing indication, the impact of steatosis in the graft viability, de novo NAFLD rate after OLT and a raised cardiovascular risk that modify the management of this entity. The current CPG was the result of the First Spanish NAFLD meeting in Seville.