Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

Abstract

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.

Obesity in the Liver Transplant Setting

“…Potential benefits of BS are being listed for LT in places where a specific BMI cutoff point precludes candidacy to LT, and improving the control of comorbidities associated with obesity, including NAFLD, in which even regression of fibrosis can be achieved [56,59,60,61,62]. Amongst the risks of BS in the pre-LT setting is that sarcopenia, a predictor of mortality in cirrhosis, may worsen [63,64], and patients may become malnourished.…”

“…In our opinion, BS should only be considered in the context of LT when BMI is an obstacle for getting listed, and it should be preferentially done laparoscopically and in centers with expertise in this area. SG seems to be the best alternative [53,60] because it has a lower perioperative risk, lower risk of nutritional status worsening, it allows one to preserve access to the biliary tree via endoscopy, it does not interfere with immunosuppression pharmacokinetics, and it does not restrict access to the stomach in case there is gastric variceal bleeding [59]. Six-month and one-year weight loss with SG in these patients is around 18–28% and 25–34%, respectively [62] (Reibibo L, 2014).…”

“…Based on information from Sharpton [59], García-Sesma [60], Diwan [53]. LT: Liver transplant; BMI: Body mass index; BS: Bariatric surgery.…”

Obesity: Weighty Challenges for the Liver Transplant Community

“…(1) Nonalcoholic steatohepatitis (NASH)-related liver cirrhosis, a well-described complication of obesity, is currently the second most common indication for liver transplantation (LT) and will become the leading indication for transplantation within the next decade. (2) In the current issue of Liver Transplantation, Sharpton et al (3) report on the safety and efficacy of pre-LT sleeve gastrectomy (SG) in a cohort study of 32 morbidly obese patients with advanced liver disease who were not eligible for LT based on a body mass index (BMI) ≥40 kg/m 2 . They had failed to achieve weight loss with medical management, and all had well-controlled complications of liver disease.…”

“…In the current issue of Liver Transplantation , Sharpton et al report on the safety and efficacy of pre‐LT sleeve gastrectomy (SG) in a cohort study of 32 morbidly obese patients with advanced liver disease who were not eligible for LT based on a body mass index (BMI) ≥40 kg/m 2 . They had failed to achieve weight loss with medical management, and all had well‐controlled complications of liver disease.…”