Bariatric Surgery Is Gaining Ground as Treatment of Obesity After Heart Transplantation: Report of Two Cases

Bariatric surgery outcomes following organ transplantation: A review study

Weight gain is a frequent postoperative complication following a solid organ transplant which can be solved by bariatric surgery. The outcomes of bariatric surgery among patients with an organ transplant history are always a challengeable subject for surgeons and surgery candidates. In this review article, we aim to investigate the existence literature about the rates of morbidity and mortality, frequent complications in terms of graft function, remission in diabetes, hypertension, pulmonary and cardiovascular disorders, hepatic and renal functions, and immunosuppressive stability, as well as the safety of bariatric surgery among patients.

Bariatric Surgery and Solid-Organ Transplantation

Morbid obesity and being overweight are a growing problem worldwide. They also affect patients with end-stage solid-organ disease and patients after transplant. Bariatric surgery is the most effective available weight loss procedure. Bariatric surgery can be helpful for the treatment of some conditions, such as nonalcoholic fatty liver disease or nonalcoholic steatohepatitis, which may lead to transplant, and weight loss can improve or even reverse them. In other cases, morbid obesity is a limitation to accessing a transplant program, so bariatric surgery can serve as a conduit to transplant. After transplant, obesity and obesity-related comorbidities can be a significant health problem that may be treated, as in patients without a transplant, with bariatric surgery. There are some specific conditions and issues to be considered in patients with end-stage solid-organ disease who are candidates for bariatric surgery, such as increased morbidity and mortality. After transplant, immunosuppressant regimens and technical limitations may be also significant.

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.

Does Weight Loss Improve Clinical Outcomes in Overweight and Obese Patients with Heart Failure?

PURPOSE OF REVIEW

Obesity increases the risk of new onset heart failure (HF), and particularly HF with preserved ejection fraction (HFpEF). Despite the observations of favorable clinical outcomes in HF patients with obesity in general, sometimes referred to as the "obesity paradox," it is important to recognize that severe obesity is associated with worse clinical outcomes. This review summarizes the effects of obesity treatment on cardiovascular health and HF clinical outcomes.

RECENT FINDINGS

Treatment for obesity utilizes a variety of modalities to achieve purposeful weight loss including lifestyle intervention, medications, and bariatric surgery. There are a cluster of benefits of obesity treatment in terms of clinical outcomes in HF. The mechanisms of these benefits include both weight loss-dependent and weight loss-independent mechanisms. Obesity treatment is safe and associated with favorable clinical outcomes across the spectrum of the HF population. The potential benefits are facilitated through multiple mechanisms.

Bariatric Surgery Outcomes in Patients with Previous Organ Transplant: Scoping Review and Analysis of the MBSAQIP

BACKGROUND

Obesity is a major risk factor for transplant. Laparoscopic bariatric surgery (LBS) offers transplant patient benefits including improved comorbidities, graft function, and longevity. We completed a scoping review and analyzed the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to determine the risk-benefit profile of LBS after transplant. We also compared laparoscopic sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGB) following transplant.

METHODS

Univariate analysis determined between group differences with subgroup analysis comparing LSG versus LRYGB in transplant patients. Multivariable analysis assessed whether prior transplant was independently associated with major complications or mortality.

RESULTS

A total of 469 (0.1%) patients had previous transplant and had more comorbidities and more often underwent LSG. Operative time (93.9 min vs 83 min, p < 0.001) and length of stay were longer. Major complications were threefold higher in patients with a transplant history (9.6% vs 3.2%; p < 0.001. Previous transplant was the second greatest independent predictor for major complication (OR 2.14 [1.54-2.98], p = < 0.001) but was not predictive of death (OR 1.06 [0.14-8.13] p = 0.956). Amongst transplant patients, LRYGB demonstrated higher rates of leak (n = 1), VTE, AKI, unplanned intubation, and readmission.

CONCLUSIONS

The 30-day complication rate from LBS is three times higher amongst patients with a transplant. LSG is likely the best surgical approach. Despite risks, post-transplant patients incur important benefits from LBS. Surgeons must be aware of this risk-benefit profile when determining LBS candidacy.

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.

Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery

To ensure successful outcomes in pediatric patients with severe obesity who undergo metabolic and bariatric surgery (MBS), a number of pre-operative patient management options should be considered. This manuscript will review the indications and contraindications of MBS and special considerations for youth who might benefit from MBS. The treatment team conducts a thorough pre-operative evaluation, assessing risks and benefits of surgical intervention, and prepares patients and families to be successful with MBS by providing education about the surgical intervention and lifestyle changes that will be necessary. This article reviews the pre-operative considerations for adolescents with severe obesity who are being considered for MBS, based upon recent clinical practice guidelines.

Metabolic and Bariatric Surgery: An Effective Treatment Option for Obesity and Cardiovascular Disease

Obesity is a chronic and debilitating disease that has become a global epidemic. Especially severe in the Unites States, obesity currently affects almost 40% of the population. Obesity has a strong causal relationship with numerous serious comorbidities that impair quality of life, shorten life expectancy, and carry a major economic burden. Obesity has particular relevance to cardiologists because it contributes directly to several major cardiovascular diseases and, consequently, increases overall cardiovascular mortality. Multiple treatment options are available, but metabolic and bariatric surgery offers the most effective and durable treatment for obesity. Moreover, metabolic and bariatric operations alleviate and often completely eliminate numerous comorbidities, particularly type 2 diabetes and other cardiovascular risk factors, such as hypertension and dyslipidemia. With their low risk of complications and morbidity, metabolic and bariatric operations significantly improve quality of life and overall survival, particularly reducing death due to cardiovascular disease.

Bariatric Surgery in Immunocompromised Patients: Outcomes from One Year Follow-up

BACKGROUND

Recent Research evidences from across the world indicate the usefulness of bariatric surgery in improving the immunological co-morbidities in patients with morbid obesity.

AIM

The aim of the study was to evaluate the outcome from bariatric surgery in patients presenting with diabetes mellitus and or morbid obesity with immunological co-morbidities.

METHODS

It was a retrospective cross-sectional study. Study included patients with morbid obesity with immunological co-morbidities, and additional co- morbidity of type 2 diabetes mellitus in about one third of the cases, who had undergone bariatric surgery during the period 2014-2016 at our center. Patient demographics, preoperative data, and follow-up data were collected and analyzed. Patients were followed for assessing the outcome in terms of BMI and dependency on medications to evaluate the effectiveness of the procedure.

RESULTS

The study included 23 patients (52% female and 48% male). Bariatric surgery was effective in all the patients (except one) in weight reduction. Significant reduction in weight and BMI was observed (p < 0.05). The recent follow-up of these patients showed that the mean BMI of the study group decreased significantly, 34.4% patients had attained normal BMI ≤ 25 kg/m². Three-month follow-up indicated that 55.56% were not dependent on medications. At 1-year follow-up, 94.4% patients were without any dependency on immunosuppressive medications. Complications included a reversal of surgery and a case of mortality.

CONCLUSION

The results of our study have shown that immune-compromised patients can undergo bariatric surgery with good weight loss results and improvement in co-morbidities.