Long‐term outcomes of patients undergoing simultaneous liver transplantation and sleeve gastrectomy

Zamora-Valdés, Daniel; Watt, Kymberly D.; Kellogg, Todd A.; Poterucha, John J.; Cecco, Sara R. Di; Francisco-Ziller, N.; Taner, Timuçin; Rosen, Charles B.; Heimbach, Julie K.

doi:10.1002/hep.29848

Cited by 98 publications

(84 citation statements)

References 42 publications

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“…An alternative strategy in morbidly obese LT candidates is to perform SG at the time of LT . Potential benefits of a combined operation include a single operation and recovery period in addition to avoiding the risk of complications or liver‐related morbidity in the pre‐LT period, which could delay or prevent LT.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

2019

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Morbid obesity (body mass index [BMI] ≥40 kg/m2) is a relative contraindication to liver transplantation (LT) at many transplant centers. The safety and efficacy of pre-LT bariatric surgery in morbidly obese LT candidates is unknown. Herein, we describe a cohort study of morbidly obese LT candidates who failed to achieve adequate weight loss through a medically supervised weight loss program and subsequently underwent sleeve gastrectomy (SG) at our institution. In total, 32 LT candidates with a median Model for End-Stage Liver Disease (MELD) score of 12 (interquartile range [IQR], 10–13) underwent SG. All LT candidates had a history of hepatic decompensation, but complications of liver disease were required to be well controlled at the time of SG. Median pre-SG BMI was 45.0 kg/m2 (IQR, 42.1–49.0 kg/m2). There were no perioperative deaths or liver-related morbidity. One patient experienced major perioperative morbidity secondary to a gastric leak, which was managed nonoperatively. Median weight loss at 6 and 12 months after SG was 22.0 kg (IQR, 18.9–26.8 kg) and 31.0 kg (IQR, 23.6–50.3 kg), respectively, corresponding to a percentage of excess body weight lost of 33.4% and 52.4%. Within 6 months after SG, 28 (88%) candidates were deemed eligible for LT. Our center’s experience highlights the potential option of SG in morbidly obese LT candidates with advanced liver disease who might otherwise be excluded from pursuing LT.

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Section: Discussionmentioning

confidence: 99%

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

2019

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“…This may further translate to better outcomes following LT, but this result remains unknown . The largest series on simultaneous LSG and LT by Zamora‐Valdes et al describes a %TWL of 33% at 12 months. They reported an overall complication rate nearing 50% and 2 postoperative deaths.…”

Section: Discussionmentioning

confidence: 99%

“…In patients with end‐stage liver disease, however, there is limited literature regarding outcomes after bariatric surgery. Small patient series have demonstrated the utility of bariatric surgery in patients with end‐stage liver disease, both simultaneously during LT and following LT . The optimal technique and timing of bariatric surgery remains undefined, and the safety and efficacy are uncertain.…”

mentioning

confidence: 99%

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

et al. 2019

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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.

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“…Patients with a BMI ≥35 kg/m 2 who underwent a sleeve gastrectomy during transplantation maintained greater weight loss and had fewer components of the metabolic syndrome. 16 Although this study did not specifically evaluate NASH patients, the predominant liver disease in this study was NASH, and almost 50% of the patients had NASH cirrhosis. Further studies are needed before this can be recommended in routine practice.…”

Section: Manag Ing Patients With Cirrhos Is and Na S Hmentioning

confidence: 91%

“…A new strategy including sleeve gastrectomy at the time of liver transplantation was recently reported. Patients with a BMI ≥35 kg/m 2 who underwent a sleeve gastrectomy during transplantation maintained greater weight loss and had fewer components of the metabolic syndrome . Although this study did not specifically evaluate NASH patients, the predominant liver disease in this study was NASH, and almost 50% of the patients had NASH cirrhosis.…”

Section: Managing Patients With Cirrhosis and Nashmentioning

confidence: 92%

Current management of non‐alcoholic steatohepatitis

Muthiah

Sanyal

2020

Liver International

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Non‐alcoholic steatohepatitis (NASH) is the most common cause of liver disease in Western populations, and its prevalence is increasing rapidly. It is part of a multisystem disease affecting other organs such as the kidneys, heart and blood vessels, and is closely associated with the components of the metabolic syndrome. Physicians managing patients with NASH should not only focus on the management of NASH, but also on associated comorbidities in individual patients. The approaches to treatment of NASH include either limiting energy surplus alone, or in combination with targeting of downstream pathways of inflammation and fibrosis. In this mini‐review, we discuss the currently available treatment options for NASH, as well as those in late‐stage clinical trials. We discuss the challenges of managing these patients with a limited number of approved therapies, as well as managing advanced‐stage patients with NASH and cirrhosis. We also discuss the specific management of comorbidities in NASH patients, in particular diabetes, hypertension, dyslipidaemia and cardiovascular diseases. Finally, we present the screening protocols for both hepatocellular carcinoma and extrahepatic malignancies in these patients.

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Long‐term outcomes of patients undergoing simultaneous liver transplantation and sleeve gastrectomy

Abstract: Whereas weight loss before transplantation was achieved by obese patients, weight regain was common in the LT cohort. Combined LT + SG resulted in more effective and more durable weight loss, as well as fewer metabolic complications at last follow-up. (Hepatology 2018).

Cited by 98 publications

References 42 publications

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

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

Current management of non‐alcoholic steatohepatitis

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