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1
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Larson EL, Ellias SD, Blezek DJ, Klug J, Hartman RP, Ziller NF, Bamlet H, Mao SA, Perry DK, Nimma IR, Badurdeen D, Yang L, Leise MD, Watt KD, Diwan TS, Taner T, Rosen CD, Elli EF, Madura JA, Jadlowiec CC, Lizaola-Mayo B, Kellogg TA, Heimbach JK. Simultaneous liver transplant and sleeve gastrectomy provides durable weight loss, improves metabolic syndrome and reduces allograft steatosis. J Hepatol 2025:S0168-8278(25)00139-4. [PMID: 40089069 DOI: 10.1016/j.jhep.2025.02.030] [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: 08/14/2024] [Revised: 02/06/2025] [Accepted: 02/18/2025] [Indexed: 03/17/2025]
Abstract
BACKGROUND AND AIMS The prevalence of obesity and metabolic syndrome (MetS) is rising among liver transplant (LT) candidates, many of whom have Metabolic-Associated Steatotic Liver Disease (MASLD). Following LT, untreated obesity often causes recurrent MASLD. We treated patients with obesity with LT and concurrent sleeve gastrectomy (LTSG), aiming to determine long-term impact on obesity, MetS and recurrent MASLD after transplantation. METHODS A multicenter retrospective cohort study analyzed patients undergoing LTSG using a single clinical protocol (n=72), and patients with BMI >30 who underwent LT alone for MASLD (n=185). Follow-up duration was 4-153 (median 41) months for LTSG and 12-161 (median 75) months for LT. Outcomes included mortality, graft loss, BMI, MetS components, allograft steatosis and fibrosis. RESULTS Mortality and graft loss were not significantly different between LT and LTSG patients. Post-LTSG patients had significantly lower prevalence of diabetes for >8 years (p<0.05); hypertension decreased from 61.1% to 35.8% (p<0.01). LTSG patients, with average starting BMI of 45.5, had significant weight loss compared to baseline for >9 years (p<0.001). LT-alone patients, average starting BMI 34.0, experienced no significant change in BMI or diabetes. Development of allograft steatosis was significantly lower in LTSG vs LT patients (p=0.004). Fibrosis prevalence was reduced in LTSG vs LT patients 3-10 years postoperatively; although not statically significant, relative risk ratio was 0.46 (p=0.09). One LTSG patient had a gastric sleeve leak; one required hiatal hernia repair. Severe GERD occurred in 11.1% of LTSG patients; risk factors included pre-existing diabetes and GERD. CONCLUSIONS LTSG results in sustained weight loss, resolution of diabetes and hypertension, and reduced recurrence of steatosis and possibly fibrosis compared to LT alone. It confers no increase in mortality or graft loss.
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Affiliation(s)
- Ellen L Larson
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Samia D Ellias
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Daniel J Blezek
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Jason Klug
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Robert P Hartman
- Department of Radiology, Mayo Clinic College of Medicine Rochester MN USA
| | - Nickie Francisco Ziller
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Heather Bamlet
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Shennen A Mao
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Dana K Perry
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Induja R Nimma
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Dilhana Badurdeen
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Liu Yang
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Michael D Leise
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Kymberly D Watt
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Tayyab S Diwan
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Timucin Taner
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Charles D Rosen
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Enrique F Elli
- Department of Surgery, Division of General Surgery, Mayo Clinic Arizona
| | - James A Madura
- Department of Surgery, Division of General Surgery, Mayo Clinic Arizona
| | | | - Blanca Lizaola-Mayo
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Arizona
| | - Todd A Kellogg
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA
| | - Julie K Heimbach
- William Von Liebig Center for Transplantation Mayo Clinic College of Medicine Rochester MN USA.
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2
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Sugawara Y, Hibi T. Recent trends and new developments in liver transplantation. Biosci Trends 2024; 18:206-211. [PMID: 38945855 DOI: 10.5582/bst.2024.01176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Liver transplantation (LT) has been an established treatment for end-staged liver disease for acute, chronic, metabolic diseases and liver cancer. Advanced surgical techniques, refined indications and contraindications for LT, improvements of donor selection, prognostic scorings system and immunosuppressive regimens have contributed to the improved outcomes of liver transplantation. The etiologies of cirrhosis have been shifting from viral hepatitis to metabolic associated fatty liver disease. New indications include peripheral or mass forming bile duct cancer, metastases from bowel cancers or neuroendocrine tumors. Resection and partial liver segments 2-3 transplantation with delayed total hepatectomy has been performed to the limited cases, which was the explored technique of auxiliary partial orthotopic LT. Minimally invasive donor hepatectomy (laparoscopic or robotic) has been increasingly done. In this review are described the recent pressing topics in LT.
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Affiliation(s)
- Yasuhiko Sugawara
- Department of Transplantation/Pediatric Surgery, Postgraduate School of Life Science, Kumamoto University, Kumamoto, Japan
| | - Taizo Hibi
- Department of Transplantation/Pediatric Surgery, Postgraduate School of Life Science, Kumamoto University, Kumamoto, Japan
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3
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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: 17] [Impact Index Per Article: 5.7] [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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4
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de Barros F, Cardoso Faleiro Uba PH. Liver transplantation and bariatric surgery: a new surgical reality: a systematic review of the best time for bariatric surgery. Updates Surg 2021; 73:1615-1622. [PMID: 34118015 DOI: 10.1007/s13304-021-01106-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/26/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Fernando de Barros
- Professor of the Department of General Surgery, Fluminense Federal University, Niterói, RJ, Brazil. .,, Niteroi, Brazil, Rio de Janeiro.
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5
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Yemini R, Nesher E, Braun M, Cohen M, Carmeli I, Mor E, Keidar A. 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. Clin Transplant 2021; 35:e14374. [PMID: 34043840 DOI: 10.1111/ctr.14374] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/18/2021] [Accepted: 05/16/2021] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Renana Yemini
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eviatar Nesher
- Department of Transplant Surgery, Beilinson Medical Center, Petach-Tikva, Israel
| | - Marius Braun
- Liver Diseases Institute, Beilinson Medical Center, Petach-Tikva, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Cohen
- Liver Diseases Institute, Beilinson Medical Center, Petach-Tikva, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Idan Carmeli
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eytan Mor
- Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery B, Transplant Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Andrei Keidar
- Division of Surgery, Assuta University Medical Center Ashdod, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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6
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Lopez-Lopez V, Ruiz-Manzanera JJ, Eshmuminov D, Lehmann K, Schneider M, von der Groeben M, de Angulo DR, Gajownik U, Pons JA, Sánchez-Bueno F, Robles-Campos R, Ramírez-Romero P. Are We Ready for Bariatric Surgery in a Liver Transplant Program? A Meta-Analysis. Obes Surg 2021; 31:1214-1222. [PMID: 33225408 DOI: 10.1007/s11695-020-05118-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain.
| | - Juan José Ruiz-Manzanera
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Schneider
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland
| | | | - David Ruiz de Angulo
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ursula Gajownik
- Department of Hepatology, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Jose Antonio Pons
- Department of Hepatology, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Francisco Sánchez-Bueno
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Pablo Ramírez-Romero
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
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7
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Patrono D, Martini S, Romagnoli R. Liver Transplantation and NAFLD/NASH. NON-ALCOHOLIC FATTY LIVER DISEASE 2020:343-362. [DOI: 10.1007/978-3-319-95828-6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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8
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Yemini R, Keidar A, Nesher E, Mor E. Commentary: Peri-Transplant Bariatric Surgery. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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9
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Diwan TS, Rice TC, Heimbach JK, Schauer DP. Liver Transplantation and Bariatric Surgery: Timing and Outcomes. Liver Transpl 2018; 24:1280-1287. [PMID: 30080949 DOI: 10.1002/lt.25303] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Tayyab S Diwan
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
| | - Teresa C Rice
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
| | - Julie K Heimbach
- Division of Transplantation Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Daniel P Schauer
- Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati Collaborative on Obesity Research, Cincinnati, OH
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10
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The gastroenterologist's guide to management of the post-liver transplant patient. Am J Gastroenterol 2018; 113:819-828. [PMID: 29748558 DOI: 10.1038/s41395-018-0049-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/11/2018] [Indexed: 12/11/2022]
Abstract
The management of the post-liver transplant patient is complex and involves a large interdisciplinary team. After referral to a transplant center, evaluation and listing, and eventual transplantation, the patient is cared for closely by the transplant center. Once deemed ready for discharge, the patient returns to the primary care provider for ongoing management of the various issues that increase in incidence post transplant such as osteoporosis, cardiovascular, and renal diseases, as well as metabolic syndrome. The role of the gastroenterologist is not well defined, but certainly, he or she may be called upon for the initial evaluation and ongoing management of gastrointestinal as well as hepatobiliary issues. This includes but is not limited to the investigation of abnormal liver tests, non-specific gastrointestinal complaints such as nausea, vomiting, or diarrhea, biliary complications, and even recurrent hepatic disease. Having familiarity with post-transplant immunosuppressive agents, drug interactions, and potential infectious and malignancy-related complications of transplant is essential, as the primary gastroenterologist may be expected in some situations to field the initial work-up, if patient access to the transplant center is limited. The aim of this review is to summarize the gastroenterologist's role in the management of the post-liver transplant patient.
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11
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Dziodzio T, Biebl M, Öllinger R, Pratschke J, Denecke C. The Role of Bariatric Surgery in Abdominal Organ Transplantation-the Next Big Challenge? Obes Surg 2018; 27:2696-2706. [PMID: 28791580 DOI: 10.1007/s11695-017-2854-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Obesity is linked to inferior transplant outcome. Bariatric surgery (BS) is an established treatment of morbid obesity. We provide an overview on BS in the field of kidney (KT) and liver transplantation (LT). In end-stage renal disease (ESRD) and KT patients, BS seems safe and feasible. Complication rates were slightly higher compared to the non-transplant population, whereas weight loss and improvement of comorbidities were comparable. Sleeve gastrectomy (SG) was the preferred procedure before KT and superior to gastric bypass (GB) in regard to mortality and morbidity. If conducted after KT, both procedures showed comparable results. BS before LT was associated with high complication rates, in particular after GB. Albeit distinct complications, SG conducted after LT showed the best results. Immunosuppression (IS) changes after BS were rare.
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Affiliation(s)
- Tomasz Dziodzio
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany.
| | - Matthias Biebl
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
| | - Christian Denecke
- Department of Surgery, Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13352, Berlin, Germany
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12
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Spengler EK, O'Leary JG, Te HS, Rogal S, Pillai AA, Al-Osaimi A, Desai A, Fleming JN, Ganger D, Seetharam A, Tsoulfas G, Montenovo M, Lai JC. Liver Transplantation in the Obese Cirrhotic Patient. Transplantation 2017; 101:2288-2296. [PMID: 28930104 PMCID: PMC5762611 DOI: 10.1097/tp.0000000000001794] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Despite the rapidly increasing prevalence of obesity in the transplant population, the optimal management of obese liver transplant candidates remains undefined. Setting strict body mass index cutoffs for transplant candidacy remains controversial, with limited data to guide this practice. Body mass index is an imperfect measure of surgical risk in this population, partly due to volume overload and variable visceral adiposity. Weight loss before transplantation may be beneficial, but it remains important to avoid protein calorie malnutrition and sarcopenia. Intensive lifestyle modifications appear to be successful in achieving weight loss, though the durability of these interventions is not known. Pretransplant and intraoperative bariatric surgeries have been performed, but large randomized controlled trials are lacking. Traditional cardiovascular comorbidities are more prevalent in obese individuals and remain the basis for pretransplant cardiovascular evaluation and risk stratification. The recent US liver transplant experience demonstrates comparable patient and graft survival between obese and nonobese liver transplant recipients, but obesity presents important medical and surgical challenges during and after transplant. Specifically, obesity is associated with an increased incidence of wound infections, wound dehiscence, biliary complications and overall infection, and confers a higher risk of posttransplant obesity and metabolic syndrome-related complications. In this review, we examine current practices in the obese liver transplant population, offer recommendations based on the currently available data, and highlight areas where additional research is needed.
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Affiliation(s)
- Erin K Spengler
- 1 Division of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI.2 Division of Hepatology, Baylor University Medical Center, Dallas, TX.3 Center for Liver Diseases, University of Chicago Medicine, Chicago, IL.4 VA Pittsburgh Healthcare System, Department of Surgery, University of Pittsburgh, PA.5 Division of Digestive Diseases and The Emory Transplant Center, Emory University Hospital, Atlanta, GA.6 Division of Hepatology, Temple University Health System, Philadelphia, PA.7 Division of Gastroenterology and Hepatology, Department of Medicine, University of Arizona, Tucson, AZ.8 Department of Pharmacy, Medical University of South Carolina, Charleston, SC.9 Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL.10 Transplant Institute, Banner University of Arizona College of Medicine-Phoenix, Tucson, AZ.11 Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece.12 Division of Transplantation, Department of Surgery. University of Washington. Seattle, WA.13 Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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13
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Cazzo E, Gestic MA, Utrini MP, Chaim FDM, Callejas-Neto F, Pareja JC, Chaim EA. Bariatric surgery in individuals with liver cirrhosis: A narrative review. Rev Assoc Med Bras (1992) 2017; 63:190-194. [PMID: 28355381 DOI: 10.1590/1806-9282.63.02.190] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 06/26/2016] [Indexed: 02/08/2023] Open
Abstract
Introduction: Bariatric surgery has become the gold standard treatment for morbid obesity, but there is no consensus regarding its safety and efficacy among individuals with chronic liver diseases. Objective: To critically evaluate the existing evidence on literature about bariatric surgery in individuals with liver cirrhosis. Method: Narrative review performed by means of an online search in the MEDLINE and LILACS databases. Results: Bariatric surgery is safe and effective in individuals with chronic liver disease without clinical decompensation or significant portal hypertension. Individuals with severe liver function impairment present significantly higher surgical morbidity and mortality. Among candidates to liver transplantation, surgery may be performed before, after and even during transplantation, and there is a predominant trend to perform it after. Vertical sleeve gastrectomy seems to be the most adequate technique in this group of subjects. Conclusion: Bariatric surgery is safe and effective in individuals with compensated cirrhosis without significant portal hypertension, but presents higher morbidity. Among candidates to liver transplantation and/or individuals with severe portal hypertension, morbidity and mortality are significantly higher.
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Affiliation(s)
- Everton Cazzo
- MD, PhD, Assistant Lecturer, Department of Surgery, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
| | - Martinho Antonio Gestic
- MD, MSc, Assistant Lecturer, Department of Surgery, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
| | - Murillo Pimentel Utrini
- MD, Assistant Lecturer, Department of Surgery, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
| | - Felipe David Mendonça Chaim
- MD, MSc, Assistant Lecturer, Department of Surgery, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
| | - Francisco Callejas-Neto
- MD, MSc, Associate Professor, Department of Surgery, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
| | - José Carlos Pareja
- MD, PhD, Associate Professor, Department of Surgery, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
| | - Elinton Adami Chaim
- MD, PhD, Full Professor, Department of Surgery, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
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Kumar S, Khandelwal N, Kumar A, Yadav K, Sharma S, Sable S, Chauhan A, Kapoor S, Varma V, Palep J, Kumaran V. Simultaneous living donor liver transplant with sleeve gastrectomy for metabolic syndrome and NASH-related ESLD-First report from India. Indian J Gastroenterol 2017; 36:243-247. [PMID: 28560633 DOI: 10.1007/s12664-017-0753-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/24/2017] [Indexed: 02/07/2023]
Abstract
Nonalcoholic steatohepatitis (NASH) with morbid obesity and metabolic syndrome is now a common cause of end-stage liver disease (ESLD). These patients are high-risk candidates for liver transplant, and require bariatric surgery to prevent recurrent disease in the new liver. Data reports bariatric surgery after transplant, which maybe difficult because of adhesions between the stomach and liver in living donor liver transplant (LDLT) recipient. We report the first case of combined LDLT with sleeve gastrectomy (SG) from India. A morbidly obese diabetic woman with NASH-related ESLD was planned for combined right lobe LDLT with open SG, in view of failed diet therapy, musculo-skeletal complaints, and restricted mobility. Postoperatively, with liver graft functioning adequately, bariatric diet restrictions resulted in maximum reduction of 25% weight, achieving a target BMI below 30 kg/m2 within 2 months, along with complete cure of diabetes and better ambulation. Thus, combination of LDLT and bariatric surgery in the same sitting is safe and effective in management of metabolic syndrome and associated NASH-related ESLD.
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Affiliation(s)
- Suneed Kumar
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Nidhi Khandelwal
- Department of Metabolic and Bariatric Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Abhaya Kumar
- Department of Neurosurgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Kapildev Yadav
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Swapnil Sharma
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Shailesh Sable
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Ashutosh Chauhan
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Sorabh Kapoor
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Vibha Varma
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Jaydeep Palep
- Department of Metabolic and Bariatric Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India
| | - Vinay Kumaran
- Department of HPB and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Mumbai, 400 053, India.
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15
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Pisano G, Fracanzani AL, Caccamo L, Donato MF, Fargion S. Cardiovascular risk after orthotopic liver transplantation, a review of the literature and preliminary results of a prospective study. World J Gastroenterol 2016; 22:8869-8882. [PMID: 27833378 PMCID: PMC5083792 DOI: 10.3748/wjg.v22.i40.8869] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/27/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Improved surgical techniques and greater efficacy of new anti-rejection drugs have significantly improved the survival of patients undergoing orthotopic liver transplantation (OLT). This has led to an increased incidence of metabolic disorders as well as cardiovascular and cerebrovascular diseases as causes of morbidity and mortality in OLT patients. In the last decade, several studies have examined which predisposing factors lead to increased cardiovascular risk (i.e., age, ethnicity, diabetes, NASH, atrial fibrillation, and some echocardiographic parameters) as well as which factors after OLT (i.e., weight gain, metabolic syndrome, immunosuppressive therapy, and renal failure) are linked to increased cardiovascular mortality. However, currently, there are no available data that evaluate the development of atherosclerotic damage after OLT. The awareness of high cardiovascular risk after OLT has not only lead to the definition of new but generally not accepted screening of high risk patients before transplantation, but also to the need for careful patient follow up and treatment to control metabolic and cardiovascular pathologies after transplant. Prospective studies are needed to better define the predisposing factors for recurrence and de novo occurrence of metabolic alterations responsible for cardiovascular damage after OLT. Moreover, such studies will help to identify the timing of disease progression and damage, which in turn may help to prevent morbidity and mortality for cardiovascular diseases. Our preliminary results show early occurrence of atherosclerotic damage, which is already present a few weeks following OLT, suggesting that specific, patient-tailored therapies should be started immediately post OLT.
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16
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Patient Selection and Surgical Management of High-Risk Patients with Morbid Obesity. Surg Clin North Am 2016; 96:743-62. [DOI: 10.1016/j.suc.2016.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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17
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De Luca M, Angrisani L, Himpens J, Busetto L, Scopinaro N, Weiner R, Sartori A, Stier C, Lakdawala M, Bhasker AG, Buchwald H, Dixon J, Chiappetta S, Kolberg HC, Frühbeck G, Sarwer DB, Suter M, Soricelli E, Blüher M, Vilallonga R, Sharma A, Shikora S. Indications for Surgery for Obesity and Weight-Related Diseases: Position Statements from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). Obes Surg 2016; 26:1659-96. [PMID: 27412673 PMCID: PMC6037181 DOI: 10.1007/s11695-016-2271-4] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Maurizio De Luca
- Director Department of Surgery, Montebelluna Treviso Hospital, Montebelluna, Treviso, Italy.
| | | | - Jacques Himpens
- The European School of Laparoscopic Surgery, Brussels, Belgium
| | | | | | | | - Alberto Sartori
- Director Department of Surgery, Montebelluna Treviso Hospital, Montebelluna, Treviso, Italy
| | | | | | | | | | - John Dixon
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | | | | | | | | | - Michel Suter
- University Hospital of Lausanne, Lausanne, Switzerland
| | | | - Mattias Blüher
- Department of Medicine, University of Leipzig, Leipzig, Germany
| | | | - Arya Sharma
- Obesity Research Management, University of Alberta, Edmonton, Canada
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18
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Lazzati A, Iannelli A, Schneck AS, Nelson AC, Katsahian S, Gugenheim J, Azoulay D. Bariatric surgery and liver transplantation: a systematic review a new frontier for bariatric surgery. Obes Surg 2015; 25:134-42. [PMID: 25337867 DOI: 10.1007/s11695-014-1430-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This study aims to conduct a systematic review on bariatric surgery (BS) for patients in the setting of liver transplantation (LT). A literature review was conducted on the PubMed, Embase, and Cochrane Library databases. Studies in the English language on adults reporting on BS prior to, during, or after LT were included. Eleven studies with 56 patients were retrieved. Two studies reported on BS before, two during, and seven after LT. Sleeve gastrectomy was the most common procedure, followed by Roux-en-Y gastric bypass, biliopancreatic diversion, and gastric banding. The overall mortality rate was nil in the early postoperative period and 5.3 % in the first postoperative year. The reoperation rate was 12.2 %. Obesity surgery seems feasible in this population, but mortality and morbidity are higher.
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Affiliation(s)
- Andrea Lazzati
- Department of Digestive Surgery, Centre Hospitalier Intercommunal de Créteil, 40 avenue de Verdun, 94000, Créteil, France
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19
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Ayloo S, Armstrong J, Hurton S, Molinari M. Obesity and liver transplantation. World J Transplant 2015; 5:95-101. [PMID: 26421262 PMCID: PMC4580932 DOI: 10.5500/wjt.v5.i3.95] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/14/2015] [Accepted: 07/23/2015] [Indexed: 02/05/2023] Open
Abstract
The percentage of overweight and obese patients (OPs) waiting for a liver transplant continues to increase. Despite the significant advances occurred in bariatric medicine, obesity is still considered a relative contraindication to liver transplantation (LT). The main aim of this review is to appraise the literature on the outcomes of OPs undergoing LT, treatments that might reduce their weight before, during or after surgery, and discuss some of the controversies and limitations of the current knowledge with the intent of highlighting areas where future research is needed.
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20
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Reichman TW, Therapondos G, Serrano MS, Seal J, Evers-Meltzer R, Bohorquez H, Cohen A, Carmody I, Ahmed E, Bruce D, Loss GE. “Weighing the risk”: Obesity and outcomes following liver transplantation. World J Hepatol 2015; 7:1484-1493. [PMID: 26085908 PMCID: PMC4462687 DOI: 10.4254/wjh.v7.i11.1484] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 02/23/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Obesity is on the rise worldwide. As a result, unprecedented rates of patients are presenting with end stage liver disease in the setting of non-alcoholic fatty liver disease (NAFLD) and are requiring liver transplantation. There are significant concerns that the risk factors associated with obesity and the metabolic syndrome might have a detrimental effect on the long term outcomes following liver transplantation. In general, short term patient and graft outcomes for both obese and morbidly obese patients are comparable with that of non-obese patients, however, several studies report an increase in peri-operative morbidity and increased length of stay. Continued studies documenting the long-term outcomes from liver transplantation are needed to further examine the risk of recurrent disease (NAFLD) and also further define the role risk factors such cardiovascular disease might play long term. Effective weight reduction in the post liver transplant setting may mitigate the risks associated with the metabolic syndrome long-term.
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21
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Tariq N, Moore LW, Sherman V. Bariatric Surgery and End-Stage Organ Failure. Surg Clin North Am 2013; 93:1359-71. [DOI: 10.1016/j.suc.2013.08.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Al-Nowaylati AR, Al-Haddad BJS, Dorman RB, Alsaied OA, Lake JR, Chinnakotla S, Slusarek BM, Sampson BK, Ikramuddin S, Buchwald H, Leslie DB. Gastric bypass after liver transplantation. Liver Transpl 2013; 19:1324-9. [PMID: 24039124 DOI: 10.1002/lt.23734] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 08/01/2013] [Accepted: 08/12/2013] [Indexed: 02/06/2023]
Abstract
Few data are available for assessing the outcomes of bariatric surgery for patients who have undergone orthotopic liver transplantation (OLT). The University of Minnesota bariatric surgery database and transplant registry were retrospectively reviewed to identify patients who had undergone OLT and then open Roux-en-Y gastric bypass (RYGB) surgery between 2001 and 2009. Comorbidity-appropriate laboratory values, body mass indices (BMIs), histopathology reports, and immunosuppressive regimens were collected. Seven patients were identified with a mean age of 55.4 ± 8.64 years and a mean follow-up of 59.14 ± 41.49 months from the time of RYGB. The mean time between OLT and RYGB was 26.57 ± 8.12 months. The liver disease etiologies were hepatitis C (n = 4), jejunoileal bypass surgery (n = 1), hemangioendothelioma (n = 1), and alcoholic cirrhosis (n = 1). There were 2 deaths for patients with hepatitis C 6 and 9 months after bariatric surgery due to multiple-organ dysfunction syndrome and metastatic esophageal squamous carcinoma, respectively. One patient with hepatitis C required a reversal of the RYGB because of malnutrition and an inability to tolerate oral intake. Four of the 7 patients had type 2 diabetes mellitus (T2DM), 4 had hypertension, and 6 patients had dyslipidemia. All patients were on immunosuppressive medications, but only 4 were on corticosteroids. Glycemic control was improved in all surviving patients with T2DM. The mean BMI was 34.27 ± 5.51 kg/m(2) before OLT and 44.34 ± 6.08 kg/m(2) before RYGB; it declined to 26.47 ± 5.53 kg/m(2) after RYGB. In conclusion, in this case series of patients undergoing RYGB after OLT, we observed therapeutic weight loss, improved glycemic control, and improved high-density lipoprotein levels in the presence of continued dyslipidemia. RYGB may have contributed to the death of 1 patient due to multiple-organ dysfunction syndrome.
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Affiliation(s)
- Abdl-Rawf Al-Nowaylati
- Division of Gastrointestinal and Bariatric Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN
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23
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Heimbach JK, Watt KDS, Poterucha JJ, Ziller NF, Cecco SD, Charlton MR, Hay JE, Wiesner RH, Sanchez W, Rosen CB, Swain JM. Combined liver transplantation and gastric sleeve resection for patients with medically complicated obesity and end-stage liver disease. Am J Transplant 2013; 13:363-8. [PMID: 23137119 DOI: 10.1111/j.1600-6143.2012.04318.x] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/27/2012] [Indexed: 01/25/2023]
Abstract
Obesity is increasingly common before and after liver transplantation (LT), yet optimal management remains unclear. Our aim was to analyze the effectiveness of a multidisciplinary protocol for obese patients requiring LT, including a noninvasive pretransplant weight loss program, and a combined LT plus sleeve gastrectomy (SG) for obese patients who failed to lose weight prior to LT. Since 2006, all patients referred LT with a BMI > 35 were enrolled. There were 37 patients who achieved weight loss and underwent LT alone, and 7 who underwent LT combined with SG. In those who received LT alone, weight gain to BMI > 35 was seen in 21/34, post-LT diabetes (DM) in 12/34, steatosis in 7/34, with 3 deaths plus 3 grafts losses. In patients undergoing the combined procedure, there were no deaths or graft losses. One patient developed a leak from the gastric staple line, and one had excess weight loss. No patients developed post-LT DM or steatosis, and all had substantial weight loss (mean BMI = 29). Noninvasive pretransplant weight loss was achieved by a majority, though weight gain post-LT was common. Combined LT plus SG resulted in effective weight loss and was associated with fewer post-LT metabolic complications. Long-term follow-up is needed.
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24
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Watt KD. Reducing the load: the evolution and management of obesity and nonalcoholic steatohepatitis before liver transplantation. Liver Transpl 2012; 18 Suppl 2:S52-8. [PMID: 22821716 DOI: 10.1002/lt.23515] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
1. Obesity is common in patients with end-stage liver disease of any cause. 2. Obesity is associated with comorbidities that can affect liver transplant candidacy, such as metabolic syndrome (diabetes, hyperlipidemia, and hypertension), cardiovascular disease, pulmonary disorders (related to obstructive sleep apnea), renal dysfunction, and malignancies. 3. Nonalcoholic steatohepatitis is the only indication for transplantation that is increasing in frequency, and it may soon become the leading indication. 4. There is no set body mass index above which liver transplantation is contraindicated. Transplant candidacy and outcomes depend on the cumulative comorbidities of the individual patient. 5. Weight loss is an important component of metabolic syndrome management and is recommended before liver transplantation. 6. Bariatric surgery may be considered in carefully selected patients with well-compensated cirrhosis but is not recommended in patients with decompensated cirrhosis.
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Affiliation(s)
- Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA.
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25
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Kallwitz ER. Metabolic syndrome after liver transplantation: Preventable illness or common consequence? World J Gastroenterol 2012; 18:3627-34. [PMID: 22851856 PMCID: PMC3406416 DOI: 10.3748/wjg.v18.i28.3627] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 06/25/2012] [Accepted: 06/28/2012] [Indexed: 02/06/2023] Open
Abstract
The metabolic syndrome is common after liver transplant being present in approximately half of recipients. It has been associated with adverse outcomes such as progression of hepatitis C and major vascular events. As the United States population ages and the rate of obesity increases, prevention of the metabolic syndrome in the post-transplant population deserves special consideration. Currently, the metabolic syndrome after transplant appears at least two times more common than observed rates in the general population. Specific guidelines for patients after transplant does not exist, therefore prevention rests upon knowledge of risk factors and the presence of modifiable elements. The current article will focus on risk factors for the development of the metabolic syndrome after transplant, will highlight potentially modifiable factors and propose potential areas for intervention. As in the non-transplant population, behavioral choices might have a major role. Opportunities exist in this regard for health prevention studies incorporating lifestyle changes. Other factors such as the need for immunosuppression, and the changing characteristics of wait listed patients are not modifiable, but are important to know in order to identify persons at higher risk. Although immunosuppression after transplant is unavoidable, the contribution of different agents to the development of components of the metabolic syndrome is also discussed. Ultimately, an increased risk of the metabolic syndrome after transplant is likely unavoidable, however, there are many opportunities to reduce the prevalence.
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26
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Elli EF, Masrur MA, Giulianotti PC. Robotic sleeve gastrectomy after liver transplantation. Surg Obes Relat Dis 2012; 9:e20-2. [PMID: 22365186 DOI: 10.1016/j.soard.2012.01.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/15/2012] [Indexed: 12/11/2022]
Affiliation(s)
- E Fernando Elli
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois 60612, USA
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27
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Atkinson T, Fras A, Telehowski P. The influence of occupant anthropometry and seat position on ejection risk in a rollover. TRAFFIC INJURY PREVENTION 2010; 11:417-424. [PMID: 20730689 DOI: 10.1080/15389588.2010.485284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
PURPOSE During rollover crashes, ejection increases an occupant's risk of severe to fatal injury as compared to risks for those retained in the vehicle. The current study examined whether occupant anthropometry might influence ejection risk. Factors such as restraint use/disuse, seating position, vehicle type, and roll direction were also considered in the analysis. METHODS The current study examined occupant ejections in 10 years of National Automotive Sampling System (NASS) single-event rollovers of passenger vehicles and light trucks. Statistical analysis of unweighted and weighted ejection data was carried out. RESULTS No statistically significant differences in ejection rates were found based on occupant height, age, or body mass index. Drivers were ejected significantly more frequently than other occupants: 62 percent of unrestrained drivers were ejected vs. 51 percent unrestrained right front occupants. Second row unrestrained occupants were ejected at rates similar to right front-seated occupants. There were no significant differences in ejection rates for near- vs. far-side occupants. CONCLUSIONS These data suggest that assessment of ejection prevention systems using either a 50th or 5th percentile adult anthropomorphic test dummy (ATD) might provide a reasonable measure of system function for a broad range of occupants. They also support the development of ejection mitigation technologies that extend beyond the first row to protect occupants in rear seat positions. Future studies should consider potential interaction effects (i.e., occupant size and vehicle dimensions) and the influence of occupant size on ejection risk in non-single-event rollovers.
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Affiliation(s)
- Theresa Atkinson
- BIOS Consulting, LLC, Kettering University, Flint, Michigan 48504, USA.
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28
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Watt KDS, Charlton MR. Metabolic syndrome and liver transplantation: a review and guide to management. J Hepatol 2010; 53:199-206. [PMID: 20451282 DOI: 10.1016/j.jhep.2010.01.040] [Citation(s) in RCA: 155] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 01/06/2010] [Accepted: 01/09/2010] [Indexed: 12/15/2022]
Abstract
Metabolic syndrome is common among liver transplant recipients before and after transplantation. The components of metabolic syndrome are often exacerbated in the post-transplant period by transplant specific factors, such as immunosuppression, and are strong predictors of patient morbidity and mortality. Many aspects of the metabolic syndrome are modifiable. Early recognition, prevention and treatment of post-transplant hypertension, obesity, dyslipidemia and diabetes may impact long-term post-transplant survival. Further study into the prevention and management of these issues in the transplant patient are needed.
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Affiliation(s)
- Kymberly D S Watt
- Department of Gastroenterology and Hepatology, Mayo Clinic and Foundation, MN, USA
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29
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Abstract
Liver transplantation is currently the definitive treatment of end-stage liver disease. This article reviews the complex multidisciplinary care of the liver transplant recipient beginning immediately after transplantation but extending into the long term. The presentation, evaluation and treatment of common post-transplant complications are outlined. Importantly, immunosuppression strategies along with the issues of acute and chronic rejection are discussed in detail with an emphasis on how practice has evolved over time. The spectrum of infectious problems is systematically presented, based on the time since transplantation and the institution of immunosuppression. Finally, the substantial challenges of recurrent disease and long-term medical comorbidities are addressed as these are clearly the primary issues that threaten the longevity and wellbeing of the liver transplant recipient.
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Affiliation(s)
- Bruce Gelb
- Division of Transplantation, Department of Surgery, UCSF Medical Center, San Francisco, CA, USA
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30
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Pillai AA, Rinella ME. Non-alcoholic fatty liver disease: is bariatric surgery the answer? Clin Liver Dis 2009; 13:689-710. [PMID: 19818313 DOI: 10.1016/j.cld.2009.07.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As the worldwide obesity epidemic continues to increase, the prevalence of non-alcoholic fatty liver disease (NAFLD) and specifically non-alcoholic steatohepatitis (NASH) will become increasingly prominent. NASH will surpass chronic hepatitis C infection as the primary indication for orthotopic liver transplantation in the near future. With the evolution of surgical techniques, bariatric surgery is currently recognized as the most effective method for achieving sustained weight loss and reversing numerous comorbidities in severely obese individuals. This review focuses on the potential risks and benefits of bariatric surgery in subjects with NAFLD and explores its role in the management of NASH in the obese patient.
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Affiliation(s)
- Anjana A Pillai
- Department of Transplant Surgery, Northwestern University, Feinberg School of Medicine, 675 N. St. Clair Avenue, Galter 17-200, Chicago, IL 60611, USA
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31
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Dick AAS, Spitzer AL, Seifert CF, Deckert A, Carithers RL, Reyes JD, Perkins JD. Liver transplantation at the extremes of the body mass index. Liver Transpl 2009; 15:968-77. [PMID: 19642131 DOI: 10.1002/lt.21785] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Controversies exist regarding the morbidity and mortality of patients undergoing liver transplantation at the extremes of the body mass index (BMI). A review of the United Network for Organ Sharing database from 1987 through 2007 revealed 73,538 adult liver transplants. Patients were stratified into 6 BMI categories established by the World Health Organization: underweight, <18.5 kg/m(2); normal weight, 18.5 to <25 kg/m(2); overweight, 25 to <30 kg/m(2); obese, 30 to <35 kg/m(2); severely obese, 35 to <40 kg/m(2); and very severely obese, > or =40 kg/m(2). Survival rates were compared among these 6 categories via Kaplan-Meier survival curves with the log-rank test. The underweight and very severely obese groups had significantly lower survival. There were 1827 patients in the underweight group, 1447 patients in the very severely obese group, and 68,172 patients in the other groups, which became the control. Groups with extreme BMI (<18.5 and > or =40) were compared to the control to assess significant differences. Underweight patients were more likely to die from hemorrhagic complications (P < 0.002) and cerebrovascular accidents (P < 0.04). When compared with the control, the very severely obese patients had a higher number of infectious complications and cancer events (P = 0.02) leading to death. In 3 different eras of liver transplantation, multivariable analysis showed that underweight and very severe obesity were significant predictors of death. In conclusion, liver transplantation holds increased risk for patients at the extremes of BMI. Identifying these patients and instituting aggressive new policies may improve outcomes. Liver Transpl 15:968-977, 2009. (c) 2009 AASLD.
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Affiliation(s)
- André A S Dick
- Division of Transplantation, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA.
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32
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Mandell MS, Zimmerman M, Campsen J, Kam I. Bariatric Surgery in Liver Transplant Patients: Weighing the Evidence. Obes Surg 2008; 18:1515-6. [DOI: 10.1007/s11695-008-9712-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 09/12/2008] [Indexed: 12/23/2022]
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