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Ostojic A, Mahmud N, Reddy KR. Surgical risk stratification in patients with cirrhosis. Hepatol Int 2024; 18:876-891. [PMID: 38472607 DOI: 10.1007/s12072-024-10644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.
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Affiliation(s)
- Ana Ostojic
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA.
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2
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Sánchez-Pernaute A, Lasses B, Antoñanzas LL, Rubio MÁ, Marcuello C, Ferré NP, Torres A, Pérez-Aguirre E. Revisional surgery for malnutrition after SADI-S: prevalence, indications, techniques and outcomes. Updates Surg 2024:10.1007/s13304-024-01900-9. [PMID: 38805173 DOI: 10.1007/s13304-024-01900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/19/2024] [Indexed: 05/29/2024]
Abstract
KEY POINTS SADIS with short common limb (< 250 cm) is a malabsorptive operation. Reoperation is advised in patients requiring admission for severe malnutrition. Elongation of the common channel is the preferred revisional technique Introduction: Single-Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy (SADI-S) is a modification of the duodenal switch. Initial common channel's length was 200, and after malnutrition was detected in some patients, it was elongated to 250 or 300 cm. The present study analyzes presentation and treatment of malnutrition after SADI-S. MATERIALS Three hundred and thirty-three consecutive patients undergoing SADI-S between May 2007 and February 2019 were included. The common limb length was 200 cm in 50 cases, 250 cm in 211, 300 in 71 and 350 in 1. Thirty-one patients were admitted for severe hypoalbuminemia and 17 patients were submitted to revisional surgery, and constitute the series of our study. Mean weight before reoperation was 57 kg and mean body mass index (BMI) was 21 kg/m2. Mean number of daily bowel movements was 5,6. RESULTS Mean time to reoperation was 56 months. The limb was found shorter than expected in 6 cases. Revisional surgery was conversion into a Roux en Y duodenal switch in 3 cases, elongation of the common limb in 11 patients, duodeno-duodenostomy in 1 and duodeno-jejunostomy to the first jejunal loop in 2. Mean weight regain was 14 kg, and mean final BMI 26 kg/m2. Daily bowel movements were reduced to 1,3. Factors related to hypoalbuminemia were hypertension, poor-controlled diabetes, shorter common limb and liver-test alterations. CONCLUSION SADI-S is expected to be less malabsorptive than previous biliopancreatic diversions. However, caution must be taken with certain patients to avoid postoperative malnutrition. Adequate follow up with long-term supplementation is required.
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Affiliation(s)
- Andrés Sánchez-Pernaute
- Department of Surgery, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain.
| | - Bibiana Lasses
- Department of Surgery, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Leyre López Antoñanzas
- Department of Surgery, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Miguel Ángel Rubio
- Department of Endocrinology, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Clara Marcuello
- Department of Endocrinology, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Natalia Pérez Ferré
- Department of Endocrinology, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Antonio Torres
- Department of Surgery, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Elia Pérez-Aguirre
- Department of Surgery, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
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3
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Widmer J, Eden J, Abbassi F, Angelico R, Rössler F, Müllhaupt B, Dutkowski P, Bueter M, Schlegel A. How best to combine liver transplantation and bariatric surgery?-Results from a global, web-based survey. Liver Int 2024; 44:566-576. [PMID: 38082500 DOI: 10.1111/liv.15791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND AND AIMS Obesity is a growing healthcare challenge worldwide and a significant risk factor for liver failure as seen with non-alcoholic steatohepatitis (NASH). Combining metabolic-bariatric surgery (MBS) with liver transplantation (LT) appears as attractive strategy to treat both, the underlying liver disease and obesity. However, there is an ongoing debate on best timing and patient selection. This survey was designed to explore the current treatment practice for patients with NASH and obesity worldwide. METHODS A web-based survey was conducted in 2022 among bariatric and LT surgeons, and hepatologists from Europe, North and South America and Asia. RESULTS The survey completion rate was 74% (145/196). The average respondents were 41-50 years (38%), male (82.1%) and had >20 years of clinical experience (42.1%). Centres with a high LT-caseload for NASH were mainly located in the USA and United Kingdom. Almost 30% have already performed a combination of LT with MBS and 49% plan to do it. A majority of bariatric surgeons prefer MBS before LT (77.2%), whereas most of LT surgeons (52%) would perform MBS during LT. Most respondents (n = 114; 80%) favour sleeve gastrectomy over other bariatric techniques. One third (n = 42; 29.4%) has an established protocol regarding MBS for LT candidates. CONCLUSION The most experienced centres doing LT for NASH are in the USA and United Kingdom with growing awareness worldwide. Overall, a combination of MBS and LT has already been performed by a third of respondents. Sleeve gastrectomy is the bariatric technique of choice-preferably performed either before or during LT.
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Affiliation(s)
- Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Fariba Abbassi
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Roberta Angelico
- HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Fabian Rössler
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Beat Müllhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Marco Bueter
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
- Department of Surgery, Spital Männedorf, Männedorf, Switzerland
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
- Transplantation Center, Digestive Disease and Surgery Institute and Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, Milan, Italy
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4
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Núñez-Pizarro JL, Toapanta D, Montironi C, Zapatero J. Rapid weight loss and jaundice in an adult female. J Hepatol 2023; 79:e182-e184. [PMID: 37863546 DOI: 10.1016/j.jhep.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 10/22/2023]
Affiliation(s)
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Carla Montironi
- Pathology Department & Molecular Biology Core, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Juliana Zapatero
- Liver ICU, Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain.
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5
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Dumortier J, Erard D, Villeret F, Faitot F, Duvoux C, Faure S, Francoz C, Gugenheim J, Hardwigsen J, Hiriart JB, Houssel-Debry P, Bello AD, Lassailly G, Vanlemmens C, Saliba F, Altman C, Latournerie M, Dharancy S, Debs T. Bariatric surgery and liver transplantation, here we are now: A French nationwide retrospective study. Clin Res Hepatol Gastroenterol 2023; 47:102164. [PMID: 37352925 DOI: 10.1016/j.clinre.2023.102164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/25/2023]
Abstract
At the time of the growing obesity epidemic worldwide, liver transplantation (LT) and metabolic syndrome are closely linked: non-alcohol-related fatty liver disease (NAFLD) is one of the leading indications for liver transplantation, and metabolic syndrome can also appear after liver transplantation, in relation to immunosuppressive medications and weight gain, whatever was the initial liver disease leading to the indication of LT. Therefore, the role of bariatric surgery (BS) is important due to its longer-lasting effect and efficacy. We performed a retrospective review of all 50 adult French liver transplant recipients who had a history of bariatric surgery, including 37 procedures before transplantation, and 14 after. There were three significantly different characteristics when comparing pre-and post-LT BS: patients were older (at the time of BS), presented more frequently arterial hypertension (at the time of LT), and the proportion of NAFLD as initial liver disease leading to LT was lower, in the post-LT group. Regarding pre-LT BS, in one case BS was complicated by liver failure leading to the rapid indication of LT; it was the single patient for whom the delay between BS and LT was less than 1 year; there was no patient who specifically underwent BS for the purpose of LT listing.
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Affiliation(s)
- Jérôme Dumortier
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Pavillon L, 69437, Hospices Civils de Lyon, Cedex 03, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France.
| | - Domitille Erard
- Service d'hépatologie et de transplantation hépatique, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - François Villeret
- Université Claude Bernard Lyon 1, Lyon, France; Service d'hépatologie et de transplantation hépatique, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - François Faitot
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, CHRU Hautepierre, Strasbourg, France
| | | | - Stéphanie Faure
- Département D'hépatologie et Transplantation Hépatique, CHU Saint Eloi, Montpellier, France
| | - Claire Francoz
- Service d'Hépatologie et Transplantation Hépatique, Hôpital Beaujon, AP-HP, Clichy, France
| | - Jean Gugenheim
- Service de Chirurgie Digestive et de Transplantation Hépatique, CHU Archet II, Nice, France
| | - Jean Hardwigsen
- Service Chirurgie Générale et Transplantation Hépatique, Hôpital La Timone, AP-HM, Marseille, France
| | - Jean-Baptiste Hiriart
- Service de Chirurgie Hépatobiliaire et de Transplantation Hépatique, CHU Haut Lévêque, Bordeaux, France
| | - Pauline Houssel-Debry
- Service d'Hépatologie et Transplantation Hépatique, Hôpital Universitaire de Pontchaillou, Rennes, France
| | - Arnaud Del Bello
- Département de Néphrologie et Transplantation d'Organes, CHU Rangueil, Toulouse, France
| | - Guillaume Lassailly
- Service des Maladies de l'Appareil Digestif, Hôpital Claude Huriez, CHRU Lille, Lille, France
| | - Claire Vanlemmens
- Service d'Hépatologie et Soins Intensifs Digestifs, Hôpital Jean Minjoz, Besançon, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris Saclay, Unité Inserm 1193, AP-HP, Villejuif, France
| | - Clara Altman
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris Saclay, Unité Inserm 1193, AP-HP, Villejuif, France
| | - Marianne Latournerie
- Service D'hépatologie et de Gastro-Entérologie, CHU Dijon-Bourgogne, Dijon, France
| | - Sébastien Dharancy
- Service des Maladies de l'Appareil Digestif, Hôpital Claude Huriez, CHRU Lille, Lille, France
| | - Tarek Debs
- Service de Chirurgie Digestive et de Transplantation Hépatique, CHU Archet II, Nice, France
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6
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Sarno G, Schiavo L, Calabrese P, Álvarez Córdova L, Frias-Toral E, Cucalón G, Garcia-Velasquez E, Fuchs-Tarlovsky V, Pilone V. The Impact of Bariatric-Surgery-Induced Weight Loss on Patients Undergoing Liver Transplant: A Focus on Metabolism, Pathophysiological Changes, and Outcome in Obese Patients Suffering NAFLD-Related Cirrhosis. J Clin Med 2022; 11:jcm11185293. [PMID: 36142939 PMCID: PMC9503676 DOI: 10.3390/jcm11185293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/28/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Because of their condition, patients with morbid obesity develop several histopathological changes in the liver, such as non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver disease (ESLD). Hence, a liver transplant (LT) becomes an opportune solution for them. Due to many challenges during the perioperative and postoperative periods, these patients are recommended to lose weight before the surgery. There are many proposals to achieve this goal, such as intragastric balloons and many different bariatric surgery (BS) procedures in combination with a preparation diet (very-low-calorie diet, ketogenic diet, etc.). All the interventions focus on losing weight and keeping the continuity and functionality of the digestive tract to avoid postoperative complications. Thus, this review analyzes recent publications regarding the metabolic and pathophysiological impacts of BS in LT patients suffering from NAFLD-related cirrhosis, the effect of weight loss on postoperative complications, and exposes the cost-effectiveness of performing BS before, after, and at liver transplantation. Finally, the authors recommend BS before the LT since there are many positive effects and better outcomes for patients who lose weight before the procedure. Nevertheless, further multicentric studies are needed to determine the generalizability of these recommendations due to their impact on public health.
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Affiliation(s)
- Gerardo Sarno
- San Giovanni di Dio e Ruggi D’Aragona University Hospital, Scuola Medica Salernitana, 84131 Salerno, Italy
| | - Luigi Schiavo
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
- Correspondence: ; Tel.: +39-089-965062
| | - Pietro Calabrese
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
| | - Ludwig Álvarez Córdova
- Carrera de Nutrición y Dietética, Facultad de Ciencias Médicas, Universidad Católica De Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
| | - Evelyn Frias-Toral
- School of Medicine, Universidad Católica Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
- Universidad de Especialidades Espìritu Santo, Samborondòn 0901952, Ecuador
| | - Gabriela Cucalón
- Lifescience Faculty, ESPOL Polytechnic University, Escuela Superior Politécnica del Litoral (ESPOL), Campus Gustavo Galindo Km. 30.5 Vía Perimetral, Guayaquil 090615, Ecuador
| | | | | | - Vincenzo Pilone
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
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7
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Ahmed Z, Khan MA, Vazquez-Montesino LM, Ahmed A. Bariatric surgery, obesity and liver transplantation. Transl Gastroenterol Hepatol 2022; 7:25. [PMID: 35892056 PMCID: PMC9257534 DOI: 10.21037/tgh-2020-14] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/06/2020] [Indexed: 06/01/2024] Open
Abstract
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.
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Affiliation(s)
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, University of Alabama Birmingham, AL, USA
| | | | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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8
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Addeo P, Foguenne M, Michard B, Artzner T, Deridder M, Faitot F, Serfaty L, Bachellier P. Emergency reversal of a Roux-en-Y Gastric bypass to rescue liver graft from recurrent steatohepatitis. Clin Res Hepatol Gastroenterol 2022; 46:101971. [PMID: 35688376 DOI: 10.1016/j.clinre.2022.101971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/04/2022] [Accepted: 06/06/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France.
| | - Maxime Foguenne
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Baptiste Michard
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Thierry Artzner
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Mathilde Deridder
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - François Faitot
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
| | - Lawrence Serfaty
- Hepatogastroenterology department, Hôpital Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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9
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Hassen G, Singh A, Belete G, Jain N, De la Hoz I, Camacho-Leon GP, Dargie NK, Carrera KG, Alemu T, Jhaveri S, Solomon N. Nonalcoholic Fatty Liver Disease: An Emerging Modern-Day Risk Factor for Cardiovascular Disease. Cureus 2022; 14:e25495. [PMID: 35783879 PMCID: PMC9242599 DOI: 10.7759/cureus.25495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/30/2022] [Indexed: 11/05/2022] Open
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10
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Moolenaar LR, de Waard NE, Heger M, de Haan LR, Slootmaekers CPJ, Nijboer WN, Tushuizen ME, van Golen RF. Liver Injury and Acute Liver Failure After Bariatric Surgery: An Overview of Potential Injury Mechanisms. J Clin Gastroenterol 2022; 56:311-323. [PMID: 35180151 DOI: 10.1097/mcg.0000000000001662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The obesity epidemic has caused a surge in the use of bariatric surgery. Although surgery-induced weight loss is an effective treatment of nonalcoholic fatty liver disease, it may precipitate severe hepatic complications under certain circumstances. Acute liver injury (ALI) and acute liver failure (ALF) following bariatric surgery have been reported in several case series. Although rare, ALI and ALF tend to emerge several months after bariatric surgery. If so, it can result in prolonged hospitalization, may necessitate liver transplantation, and in some cases prove fatal. However, little is known about the risk factors for developing ALI or ALF after bariatric surgery and the mechanisms of liver damage in this context are poorly defined. This review provides an account of the available data on ALI and ALF caused by bariatric surgery, with emphasis on potential injury mechanisms and the outcomes of liver transplantation for ALF after bariatric surgery.
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Affiliation(s)
- Laura R Moolenaar
- Departments of Gastroenterology and Hepatology
- Department of Pharmaceutics, College of Medicine, Jiaxing University, Jiaxing, Zhejiang Province, P.R. China
| | | | - Michal Heger
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht
- Department of Pharmaceutics, College of Medicine, Jiaxing University, Jiaxing, Zhejiang Province, P.R. China
| | - Lianne R de Haan
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht
- Department of Pharmaceutics, College of Medicine, Jiaxing University, Jiaxing, Zhejiang Province, P.R. China
| | - Caline P J Slootmaekers
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | | | | | - Rowan F van Golen
- Departments of Gastroenterology and Hepatology
- Department of Pharmaceutics, College of Medicine, Jiaxing University, Jiaxing, Zhejiang Province, P.R. China
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11
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Aliseda D, Cienfuegos JA, Valenti V, Echeveste JI, Lujan J, Almeida A, Rotellar F. Liver transplantation for subacute hepatic necrosis and rapid liver failure following bariatric surgery. ANZ J Surg 2022; 92:620. [PMID: 35305072 DOI: 10.1111/ans.17373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/11/2021] [Accepted: 11/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Daniel Aliseda
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Javier A Cienfuegos
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.,Department of General Surgery, Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Spain
| | - Víctor Valenti
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.,Department of General Surgery, Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Spain
| | - José Ignacio Echeveste
- Department of Pathology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Juan Lujan
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Ana Almeida
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Fernando Rotellar
- Department of General Surgery, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain.,Department of General Surgery, Institute of Health Research of Navarra (IdisNA), Pamplona, Spain.,CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Spain
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12
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Liver Decompensation after Bariatric Surgery in the Absence of Cirrhosis. Obes Surg 2022; 32:1227-1235. [PMID: 35138516 DOI: 10.1007/s11695-022-05930-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/22/2022] [Accepted: 01/23/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Metabolic dysfunction-associated fatty liver disease-related cirrhosis is possible at the time of bariatric surgery, complicated by further liver decompensation. Hepatic decompensation can also occur in the absence of cirrhosis but the presentation is less clear. METHODS We analyze the clinical characteristics, histological findings, and management of patients without cirrhosis who developed hepatic decompensation after bariatric surgery in our single tertiary-care hospital. RESULTS From 2014 to 2019, 6 patients underwent a transvenous liver biopsy for liver decompensation after bariatric surgery. Mean age at diagnosis was 44 years. The time between bariatric surgery and the onset of symptoms varied widely (min. 8 months, max. 17 years). Mean % of weight loss was high at 43%. The clinical presentation was as follows: fatigue and jaundice (5/6), leg edema (3/6), and ascites (1/6). Blood test showed increased transaminases (mean ALT 53 UI/L, mean AST 130 UI/L), bilirubin (mean 6 mg/dL), and INR (mean 1.5) with a low albumin level (mean 27 mg/dL). The hepatic venous pressure gradient was high (mean 10 mmHg). Histology revealed steatosis, hepatocyte ballooning but also portal inflammation with polymorphonuclear cells, and bile duct alterations. Mean fibrosis score was 2. The clinical course was favorable with nutritional support with a mean follow-up of 36 months. CONCLUSION Liver decompensation in the absence of cirrhosis can occur after bariatric surgery with a highly variable delay. A special histological signature is present with the coexistence of steatosis, bile duct alterations, and portal inflammation. Substantial clinical improvement with appropriate nutritional support seems to be effective.
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13
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Finer N. Weight loss interventions and nonalcoholic fatty liver disease: Optimizing liver outcomes. Diabetes Obes Metab 2022; 24 Suppl 2:44-54. [PMID: 34622555 DOI: 10.1111/dom.14569] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
The growth in prevalence of obesity, type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) has become one of the most important global health challenges. The three chronic diseases are closely linked in their epidemiology and pathophysiology. Currently, weight loss is the most effective treatment for NAFLD (even in the minority of patients with NAFLD who do not have obesity) and is recommended in all national and international guidelines. Accumulating evidence has shown that weight loss, whether achieved by diet and lifestyle interventions, bariatric surgery or pharmacotherapy, can improve biomarkers of NAFLD, as well as prevent progression and, in some cases, reverse fibrosis. There is a dose dependency of weight loss with NAFLD improvement. Pharmacotherapy with antiobesity medications, alone or in combination with intensive lifestyle interventions or other weight-loss drugs, is closing the efficacy gap between diet and exercise and weight-loss surgery in efficacy at reversing obesity. Given the importance of providing effective weight-loss treatment to patients with NAFLD, weight management services need to be made increasingly available and embedded within hepatology services. This narrative review addresses the evidence that weight loss optimizes liver outcomes in people with NAFLD.
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Affiliation(s)
- Nick Finer
- National Centre for Cardiovascular Prevention and Outcomes, UCL Institute of Cardiovascular Science, London, UK
- Novo Nordisk A/S Vandtårnsvej, Søborg, Denmark
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14
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Mendoza YP, Becchetti C, Watt KD, Berzigotti A. Risks and Rewards of Bariatric Surgery in Advanced Chronic Liver Diseases. Semin Liver Dis 2021; 41:448-460. [PMID: 34243194 PMCID: PMC8492193 DOI: 10.1055/s-0041-1731705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The burden of obesity and metabolic syndrome has determined a sharp increase in bariatric surgery (BS) procedures, which lead to marked weight loss, improved metabolic syndrome, reduced cardiovascular risk, and even improvement in nonalcoholic steatohepatitis (NASH). Despite these promising results, BS in patients with chronic liver disease can rarely lead to worsening of liver function, progression to cirrhosis and its complications, and even liver transplantation. On the other hand, since obesity in patients with cirrhosis is a major cofactor for progression to a decompensated stage of the disease and a risk factor for hepatocellular carcinoma, BS has been used to achieve weight loss in this population. In this review, we critically analyze the existing data on outcomes of BS in patients with cirrhosis and the possible mechanisms leading to fibrosis progression and worsening liver function in patients undergoing BS. Finally, we propose a set of measures that could be taken to improve the multidisciplinary management of liver disease in patients undergoing BS, including early recognition of malnutrition and alcohol misuse.
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Affiliation(s)
- Yuly P. Mendoza
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland,Graduate School for Health Sciences (GHS), University of Bern, Switzerland
| | - Chiara Becchetti
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland
| | - Kymberly D. Watt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Annalisa Berzigotti
- Department of Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Switzerland,Address for correspondence Annalisa Berzigotti, MD, PhD Hepatology, University Clinic for Visceral Surgery and Medicine, Bern University Hospital, University of BernSwitzerland, Murtenstrasse 35, 3008 BerneSwitzerland
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15
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Iannelli A, Bulsei J, Debs T, Tran A, Lazzati A, Gugenheim J, Anty R, Petrucciani N, Fontas E. Clinical and Economic Impact of Previous Bariatric Surgery on Liver Transplantation: a Nationwide, Population-Based Retrospective Study. Obes Surg 2021; 32:55-63. [PMID: 34499293 PMCID: PMC8752569 DOI: 10.1007/s11695-021-05684-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023]
Abstract
Purpose The present study aims to determine the impact of previous bariatric surgery (BS) on the length of hospital stay; the incidence of mortality, re-transplantation, and re-hospitalization after LT; and the related economic costs, through the analysis of the French National Health Insurance Information System. Materials and Methods All patients aged > 18 years who underwent LT in France in the period from 2010 to 2019 were included. Thirty-nine patients with a history of BS (study group) were compared with 1798 obese patients without previous BS (control group). Results At the time of LT, patients with a history of BS were significantly younger than those of the control group and had lower Charlson comorbidity index. Female sex was significantly more represented in the study group. No significant differences were detected between the two groups regarding the postoperative mortality rate after LT (10.3% in the study group versus 8.0% in the control group), long-term mortality (0.038 versus 0.029 person-year of follow-up, respectively), re-transplantation (adjusted hazard ratio (HR) = 2.15, p = 0.2437), re-hospitalization (adjusted analysis, IRR = 0.93, p = 0.7517), and costs of LT hospitalization (73,515 € in the study group versus 65,878 € in the control group). After 1:2 propensity score matching, the duration of the LT hospital stay was significantly longer in the study group (58.3 versus 33.4 days, p = 0.0172). Conclusion No significant differences were detected between patients with previous BS versus obese patients without history of BS undergoing LT concerning the rates of mortality, re-LT, re-hospitalization after LT, and costs of hospitalization and re-hospitalizations. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05684-4.
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Affiliation(s)
- Antonio Iannelli
- Université Côte D'Azur, Nice, France. .,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France. .,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France.
| | - Julie Bulsei
- Centre Hospitalier Universitaire de Nice, Department of Clinical Research and Innovation, Université Côte D'Azur, Nice, France
| | - Tarek Debs
- Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France
| | - Albert Tran
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Andrea Lazzati
- Department of General Surgery, Centre Hospitalier Intercommunal de Creteil, Creteil, France
| | - Jean Gugenheim
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Rodolphe Anty
- Université Côte D'Azur, Nice, France.,Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Inserm, U1065, Team 8 "Hepatic Complications of Obesity and Alcohol", Nice, France
| | - Niccolo Petrucciani
- Centre Hospitalier Universitaire de Nice - Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, 151 Route Saint Antoine de Ginestière, BP 3079, Nice Cedex 3, France.,Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Eric Fontas
- Centre Hospitalier Universitaire de Nice, Department of Clinical Research and Innovation, Université Côte D'Azur, Nice, France
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16
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Lefere S, Onghena L, Vanlander A, van Nieuwenhove Y, Devisscher L, Geerts A. Bariatric surgery and the liver-Mechanisms, benefits, and risks. Obes Rev 2021; 22:e13294. [PMID: 34002452 DOI: 10.1111/obr.13294] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/18/2022]
Abstract
The prevalence of obesity and metabolic diseases such as type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) has risen dramatically over the past decades. At present, bariatric surgery is the most effective treatment for this global health problem, through effects on food intake, gut hormone secretion, metabolic signaling pathways, and adipose tissue dysfunction. The liver occupies a central role in carbohydrate, protein, and lipid metabolism. Notably, a reduction in hepatic fat content and an improvement in hepatic insulin resistance are among the earliest beneficial effects of bariatric surgery, which has therefore emerged as an attractive treatment option for NAFLD. However, as the scope and popularity of weight loss surgery have expanded, new questions have arisen regarding its safety in patients with liver cirrhosis, the outcome of liver transplantation in patients with a history of bariatric surgery, and over incidental reports of liver failure following surgery. Studies in humans and rodents have also linked bariatric surgery to an increased risk of developing alcohol use disorder, a major risk factor for liver disease. This review integrates data from clinical and translational research to delineate both the beneficial impact of bariatric surgery on the liver and the potential risks involved.
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Affiliation(s)
- Sander Lefere
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center Ghent, Ghent University, Ghent, Belgium.,Gut-Liver Immunopharmacology Unit, Department of Basic and Applied Medical Sciences, Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Louis Onghena
- Department of Gastrointestinal Surgery, Ghent University, Ghent, Belgium.,Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University, Ghent, Belgium
| | | | - Lindsey Devisscher
- Gut-Liver Immunopharmacology Unit, Department of Basic and Applied Medical Sciences, Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Anja Geerts
- Hepatology Research Unit, Department of Internal Medicine and Pediatrics, Liver Research Center Ghent, Ghent University, Ghent, Belgium
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17
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Clinical Impact of Antecedent Bariatric Surgery on Liver Transplant Outcomes: A Retrospective Matched Case-control Study. Transplantation 2021; 105:1280-1284. [PMID: 32590608 DOI: 10.1097/tp.0000000000003378] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bariatric surgery (BS) may be associated with significant malabsorption and nutritional deficiencies. METHODS Between March 1987 and January 2017, we performed 922 liver transplants (LT) at our institution; 33 had antecedent BS. We matched the BS cohort to LT recipients without BS (1:3 matching) based on exact matching for gender and cancer and inverse variance matching for age, LT body mass index, MELD score, and transplant date. RESULTS We analyzed outcomes in 132 LT recipients (33 BS; 99 non-BS). The BS cohort comprised 26 (79%) women with a mean age of 52.4 years. The BS procedures included 20 Roux-en-Y gastric bypass (61%), 6 jejunoileal bypass (18%), 3 gastric band (9%), 2 sleeve gastrectomy (6%), and 1 duodenal switch (3%). The primary indications for LT listing were alcoholic cirrhosis (9; 27%), nonalcoholic steatohepatitis (7; 21%), hepatitis C (8; 24%), and hepatocellular carcinoma (3; 9%). At LT, body mass index for the BS cohort was 29.6, and MELD was 24. Compared with matched controls, BS recipients did not have longer LT length of hospital stay (17.8 versus 15.7 d, P = 0.71), longer intensive care unit length of stay (5.3 versus 4.1 d, P = 0.16), or higher 30-day complication rate (76% versus 85%, P = 0.43). Overall patient survival was similar (1- and 3-y survival was 90.1% and 75.9% for BS; 90.9% and 76.4% for non-BS, P = 0.34). CONCLUSIONS A history of BS does not portend a deleterious effect on LT outcomes.
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18
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Haddad A. Reply: Severe Protein Malnutrition After Bariatric Surgery and Liver Failure: a Dangerous Sequence. Obes Surg 2021; 31:3862-3863. [PMID: 33876344 DOI: 10.1007/s11695-021-05409-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Ashraf Haddad
- Minimally Invasive & Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC)-Jordan Hospital, Queen Noor St., 4th Circle, Amman, P.O BOX 3073, Amman, 11181, Jordan.
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19
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Severe Protein Malnutrition After Bariatric Surgery and Liver Failure: a Dangerous Sequence. Obes Surg 2021; 31:3860-3861. [PMID: 33860463 DOI: 10.1007/s11695-021-05408-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 03/22/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
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20
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Finotti M, Auricchio P, Vitale A, Gringeri E, Cillo U. Liver transplantation for rare liver diseases and rare indications for liver transplant. Transl Gastroenterol Hepatol 2021; 6:27. [PMID: 33824931 DOI: 10.21037/tgh-19-282] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/12/2020] [Indexed: 12/13/2022] Open
Abstract
Liver transplantation (LT) is currently considered the gold standard treatment for end-stage liver failure. Compared to the first decades of its use, LT is associated with lower comorbidity and mortality, with a 5-year survival over 70%. Worldwide, liver cirrhosis and hepatocellular carcinoma represent the major indications to LT. However, almost 1% of LT is performed for rare diseases or rare indications, which include non-hepatocellular malignancy, vascular disorders, metabolic and congenital liver disorders. These diseases can lead to hepatocellular necrosis, biliary tree abnormality and/or hepatomegaly. Most of these diseases are not associated with liver failure but in highly selected patients, LT represent an effective therapy improving the overall survival and quality of life. Rare indications for LT often overlap with rare diseases. However, rare LT indications for non-rare diseases are rising in the last decades, especially for benign primary liver tumor, colon rectal liver metastasis, neuroendocrine liver metastasis, and cholangiocarcinoma (CCA). Non-rare diseases with rare indication for LT and rare adult disease with an indication for LT are categorized and discussed in detail, focusing on some disorders for which the literature provides a more definitive evidence base. Early referral to a transplant center is encouraged to provide an effective therapeutic option in these non-standard indications for LT.
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Affiliation(s)
- Michele Finotti
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Pasquale Auricchio
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Alessandro Vitale
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Enrico Gringeri
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
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21
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Aktas A, Gokler C, Sansal M, Karadag N, Kayaalp C. Acute Liver Failure following Sleeve Gastrectomy with Jejuno-Ileal Bypass. Obes Res Clin Pract 2021; 15:297-299. [PMID: 33766490 DOI: 10.1016/j.orcp.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/10/2021] [Accepted: 03/13/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric surgery in recent years, and some modifications have emerged to improve its efficacy. Melissas has described SG plus jejuno-ileal bypass (JIB), which has reported good results in a few studies. We performed this procedure in 21 cases and in one case, we observed acute liver failure (ALF) that has not been reported before. CASE PRESENTATION A 38-year-old female (BMI: 56.1 kg/m2) underwent laparoscopic SG plus JIB. There was no sign of diarrhea, malnutrition or liver failure for eight months and her BMI was 43.0 kg/m2. At the 9th month, she was hospitalized for abdominal pain, jaundice and ALF. The patient was treated by plasmapheresis and molecular absorptive recirculation system. She was planned to undergo liver transplantation but died of multiorgan failure on the 40th day of hospitalization. CONCLUSION ALF can be observed following SG plus JIB. JIB reversal before compromising liver functions should be taken into consideration.
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Affiliation(s)
- Aydin Aktas
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
| | - Cihan Gokler
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
| | - Mufit Sansal
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
| | - Nese Karadag
- Department of Pathology, Inonu University, Malatya, Turkey.
| | - Cuneyt Kayaalp
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey.
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22
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Abstract
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.
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23
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Haddad A, Bashir A, Fobi M, Higa K, Herrera MF, Torres AJ, Himpens J, Shikora S, Ramos AC, Kow L, Nimeri AA. The IFSO Worldwide One Anastomosis Gastric Bypass Survey: Techniques and Outcomes? Obes Surg 2021; 31:1411-1421. [PMID: 33517557 DOI: 10.1007/s11695-021-05249-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION One anastomosis gastric bypass (OAGB) has become one of the most commonly performed gastric bypass procedures in some countries. OBJECTIVES To assess how surgeons viewed the OAGB, perceptions, indications, techniques, and outcomes, as well as the incidence of short- and long-term complications and how they were managed worldwide. METHODS A questionnaire was sent to all IFSO members in all 5 chapters to study the pattern of practice and outcomes of OAGB. RESULTS Seven hundred and forty-two surgeons responded. The most commonly performed procedures were sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and OAGB. Preoperatively, 70% of the surgeons performed endoscopy routinely. In regards to weight loss, 83% (570 surgeons) responded that OAGB produces better weight loss than SG, and 49% (342 surgeons) responded that OAGB produces better weight loss than RYGB. The most common length of the biliopancreatic limb (BPL) utilized was 200 cm. Sixty-seven percent of surgeons did not measure the total length of the small bowel. In patients with reflux disease and history of smoking, 53% and 22% of surgeons respectively still offered OAGB as a treatment option. Postoperatively, leak was documented in 963 patients, and it was the leading cause for mortality. Leak management was conservative in 35%. Conversion to RYGB was performed in 31%. In 16% the anastomosis was reinforced, 6% of the patients were reversed, and other procedures were performed in 12%. Revision of OAGB for malnutrition/steatorrhea or severe bile reflux was reported at least once by 37% and 45% of surgeons, respectively (200 cm was the most commonly encountered biliopancreatic limb BPL in those revised for malnutrition). Most common strategy for revision was conversion to RYGB (43%), reversal to normal anatomy (32%), shortening of the BPL (20%), and conversion to SG (5%). Nevertheless, 5 out of 98 mortalities (5%) were due to liver failure/malnutrition. CONCLUSION There are infrequent but potentially severe specific complications including malnutrition, liver failure, and bile reflux that may require surgical correction after OAGB.
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Affiliation(s)
- Ashraf Haddad
- Minimally Invasive & Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC) -Jordan Hospital, Queen Noor St., 4th Circle, P.O BOX 3073, Amman, 11181, Jordan.
| | - Ahmad Bashir
- Minimally Invasive & Bariatric Surgery, Gastrointestinal Bariatric and Metabolic Center (GBMC) -Jordan Hospital, Queen Noor St., 4th Circle, P.O BOX 3073, Amman, 11181, Jordan
| | - Mathias Fobi
- Clinical Affairs and Research, Mohak Bariatric and Robotics, Indore, India
| | - Kelvin Higa
- Advanced Laparoscopic Surgery Associates, University of California San Francisco-Fresno, Fresno Heart and Surgical Hospital, Fresno, CA, USA
| | - Miguel F Herrera
- Endocrine and Bariatric Surgery, UNAM at INCMNSZ, Mexico City, México
| | - Antonio J Torres
- General and Bariatric Surgery, Complutense University of Madrid, Hospital Clinico "San Carlos", Madrid, Spain
| | - Jacques Himpens
- Metabolic-Bariatric Surgery, CHIREC Delta Hospital, Brussels, Belgium
- St Pierre University Hospital, Brussels, Belgium
| | - Scott Shikora
- Harvard Medical School, Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Almino Cardoso Ramos
- Gastro-Obeso-Center Institute of Metabolic Optimization, Bela Vista, São Paulo, SP, Brazil
| | - Lilian Kow
- Adelaide Bariatric Centre, 12 The Parade, Norwood, SA, 5067, Australia
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24
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Haddad A, Bashir A. The Hardship of Recovering a Patient from Liver Failure after One Anastomosis Gastric Bypass. Obes Surg 2021; 31:1395-1398. [PMID: 33417102 DOI: 10.1007/s11695-020-05210-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The one anastomosis gastric bypass (OAGB) was first described in 2001 as a safe and effective procedure that meets the criteria for the "ideal" weight loss operation. However, revisions for malnutrition and liver failure were reported. CASE REPORT We report a patient who was transferred to our institution with protein calorie malnutrition and liver failure after undergoing OAGB. METHODS A 42-year-old morbidly obese female patient underwent a laparoscopic sleeve gastrectomy (LSG) in 2012 followed by conversion to OAGB in 2018 for weight regain at another institution. Nine months after conversion, she was transferred to our institution with dehydration, vomiting, dysphagia, generalized edema, and steatorrhea (7 times/day). She had become wheelchair bound. On examination, there was gross edema, protein-calorie malnutrition, dermatitis, and muscle wasting. She had anemia (8 g/dl) reference range (11.5-15.5 g/dl), bilirubin (1.8 mg/dl) (0.2-1.2 mg/dl), hypoalbuminemia (1.4 g/dl) (3.5-5 g/dl), and elevated international normalized ratio (INR). The patient was admitted to the hospital and was started on total parenteral nutrition (TPN), with thiamine, vitamins, iron injections, and trace mineral replacement. Her course was complicated by multiple episodes of line sepsis and bacteremia. After 6 weeks, we succeeded in raising her albumin to 2.9 g/dl and proceeded with surgery. TECHNIQUE Laparoscopic exploration started with identifying the anatomy and measuring the biliopancreatic limb (BPL = 430 cm) and the common channel (CC = 380 cm). First, we restored the continuity of the small bowel. Then the long gastric pouch was trimmed. Finally, the patient was converted to a Roux-en-Y gastric bypass (RYGB) with a 30 cm BP limb and 70 cm Roux limb. The patient had an uneventful recovery and was discharged home on the fourth postoperative day. At 3 months of follow-up, her symptoms resolved, her laboratory work up normalized, and she regained mobility. CONCLUSION Malnutrition and liver failure after OAGB are not uncommon. It is encountered with configurations of longer BP limb. BPL length of 150 to 200 cm seems to reduce such complications. Preoperative nutritional optimization is key. Conversion to a proximal RYGB is a safe and feasible approach.
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Affiliation(s)
- Ashraf Haddad
- Gastrintestinal, Bariatric, and Metabolic Center (GBMC), Jordan Hospital, Queen Noor St., 4th Circle, P.O BOX 3073, Amman, 11181, Jordan.
| | - Ahmad Bashir
- Gastrintestinal, Bariatric, and Metabolic Center (GBMC), Jordan Hospital, Queen Noor St., 4th Circle, P.O BOX 3073, Amman, 11181, Jordan
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Frey S, Santarpia L, Chassang M, Schneck AS, Anty R, Gugenheim J, Iannelli A. A case report of liver transplantation following a biliopancreatic diversion: A friendly cohabitation? TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Histological grading evaluation of non-alcoholic fatty liver disease after bariatric surgery: a retrospective and longitudinal observational cohort study. Sci Rep 2020; 10:8496. [PMID: 32444690 PMCID: PMC7244764 DOI: 10.1038/s41598-020-65556-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/30/2020] [Indexed: 12/22/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a chronic disease with several degrees of histological features which may progress to cirrhosis. Obesity is an important risk factor and although NAFLD has no specific pharmacological treatment, bariatric surgery has been associated with NAFLD regression in severely obese patients. However, few longitudinal histological studies support this finding. Therefore, firstly, a retrospective study was performed including clinical and histological data of 895 obese patients who underwent bariatric surgery. In addition, histological analyses of 30 patient’s liver biopsies were evaluated at two timepoints (T1 and T2). The retrospective analysis of the total number of patients revealed that the average body mass index (BMI) was 35.91 ± 2.81 kg/m2. The liver biopsies during bariatric surgery showed that 53.52% did not present NAFLD, 30.16% had NASH, 15.98% isolated steatosis and 0.34% liver cirrhosis. The median BMI of the longitudinal cohort decreased from 37.9 ± 2.21 kg/m2 at the time of bariatric surgery (T1) to 25.69 ± 3.79 kg/m2 after 21 ± 22 months after the procedure (T2). The prevalence of NAFLD in T1 was 50%, and 16.67% in T2. The histological area of collagen fiber was lower in T2 compared to T1 (p = 0.0152) in the majority of patients, which was also illustrated by immunohistochemistry for Kupffer cell and myofibroblast formation markers. These findings confirmed the NAFLD regression after bariatric surgery and, for the first time, showed the amelioration of these features using more accurate histopathological techniques.
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Obesity in the Liver Transplant Setting. Nutrients 2019; 11:nu11112552. [PMID: 31652761 PMCID: PMC6893648 DOI: 10.3390/nu11112552] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022] Open
Abstract
The obesity epidemic has resulted in an increased prevalence of obesity in liver transplant (LT) candidates and in non-alcoholic fatty liver disease (NAFLD) becoming the fastest growing indication for LT. LT teams will be dealing with obesity in the coming years, and it is necessary for them to recognize some key aspects surrounding the LT in obese patients. Obesity by itself should not be considered a contraindication for LT, but it should make LT teams pay special attention to cardiovascular risk assessment, in order to properly select candidates for LT. Obese patients may be at increased risk of perioperative respiratory and infectious complications, and it is necessary to establish preventive strategies. Data on patient and graft survival after LT are controversial and scarce, especially for long-term outcomes, but morbid obesity may adversely affect these outcomes, particularly in NAFLD. The backbone of obesity treatment should be diet and exercise, whilst being careful not to precipitate or worsen frailty and sarcopenia. Bariatric surgery is an alternative for treatment of obesity, and the ideal timing regarding LT is still unknown. Sleeve gastrectomy is probably the procedure that has the best evidence in LT because it offers a good balance between safety and efficacy.
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