Obesity Surgery, 17, 1517-1519
Case Report
Sleeve Gastrectomy as Treatment for Severe Obesity after Orthotopic Liver Transplantation Jean M. Butte, MD1; Nicolás Devaud, MD1; Nicolás P. Jarufe, MD1,3; Camilo Boza, MD1; Gustavo Pérez, MD1; Javiera Torres3; Rosa M. Pérez-Ayuso, MD2,4; Marco Arrese, MD2,4; Jorge Martínez, MD1,4
Departments of 1Digestive Surgery, 2Gastroenterology, 3Pathology, and 4Liver Transplantion Unit, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile Obesity is highly prevalent in both liver transplant candidates and recipients, and can have a significant impact on perioperative morbidity and mortality and the overall cost of transplantation. Herein, we describe an obese patient who was managed sequentially with an intragastric balloon in the pre-transplant setting and a gastric sleeve following transplantation, with good long-term results. Sleeve gastrectomy is a non-malabsorptive bariatric procedure with potential benefit for liver transplant patients due to its lack of influence on the absorption of immunosuppressive agents.
Key words: Bariatric surgery, morbid obesity, liver transplantation, sleeve gastrectomy
Introduction Obesity is reaching epidemic proportions in the Western world, with an estimated prevalence of 20 to 30% in the United States.1, 2 Following the trend in the general population, obesity is highly prevalent in both liver transplant candidates and recipients. It has been estimated that between 20 and 30% of patients with end-stage cirrhosis referred for liver transplantation (LT) evaluation and 30 to 70% of LT
recipients exhibit some degree of obesity.3 Thus, while pre-existing obesity may impact on perioperative morbidity and mortality and influence the overall cost of transplantation,4,5 post-LT obesity poses the risk of cardiovascular complications and diabetes and increased late morbidity and mortality.6 Moreover, obesity may also be involved in the development/recurrence of nonalcoholic fatty liver disease (NAFLD) after liver transplantation.7 NAFLD is one of the main indications for LT, is closely related to obesity and metabolic syndrome, and has the potential to progress to cirrhosis in both the pre- and post-transplant setting.7-9 Therefore, management of obesity in the context of LT is a complex matter where all available resources should be carefully evaluated. In the present article, we report a multidisciplinary approach for managing a patient with severe obesity and terminal NAFLD who was selected for LT. He was treated sequentially using an intragastric balloon preoperatively and a sleeve gastrectomy following liver replacement.
Case Report Correspondence to: Jorge Martínez, MD, Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 367, 833-0024 Santiago, Chile. Email:
[email protected]
© Springer Science + Business Media, Inc.
A 61-year-old morbidly obese male patient weighing 140 kg [body mass index (BMI) 47 kg/m2] was Obesity Surgery, 17, 2007
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referred to our bariatric surgery team in June 2003 after medical treatment for his obesity had failed. His previous medical history included type 2 diabetes and arterial hypertension as associated comorbidities. He was initially scheduled for a Rouxen-Y gastric bypass (RYGBP). However, at the beginning of the surgical procedure, a previously undiagnosed liver cirrhosis with associated portal hypertension was discovered; therefore the RYGBP was not done.10 Further analysis established that the patient probably had a “burned-out” non-alcoholic steatohepathitis (NASH), which is considered the terminal stage of NAFLD.11 A few months after surgery, the patient suffered an episode of variceal hemorrhage and deterioration of both hepatic excretory and synthetic function, and was placed on the national waiting list for liver transplantation. In order to achieve weight loss prior to LT, placement of an intragastric balloon was carried out in August 2003, and the patient achieved a weight reduction of 18 kg (weight 122 kg, BMI 41.3 kg/m2). In October 2005, the patient underwent an orthotopic liver transplantation with a cadaveric graft using a piggy-back side-to-side cavo-caval technique with an end-to-end donor common bile duct anastomosis. The early postoperative period was uneventful, and the patient started a standard cyclosporinebased immunosuppressive regimen. However, 60 days after the transplantation, biochemical evidence of cholestasis was found in liver function tests, and magnetic resonance (MR) cholangiography showed a partial stenosis of the common bile duct anastomosis. This complication was initially treated with repeated endoscopic dilations and stenting of the biliary anastomotic stenosis; 12 however, results were unsatisfactory, with the persistence of cholestasis and morphological evidence of biliary stenosis. Therefore, a Roux-en-Y biliary diversion reconstruction was planned. In addition, a permanent surgical procedure for morbid obesity was planned to be performed together with the biliary procedure, because the weight reduction achieved preoperatively was progressively lost and the patient reached a weight of 112 kg (BMI 37.9 kg/m2) despite dietary treatment. Thus, an open sleeve gastrectomy and a Roux-en-Y biliary reconstruction (Figure 1) were performed in August 2006. The gastric sleeve was constructed using a linear stapler which removed the greater curvature including the complete fundus, 1518
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Figure 1. Schematic representation of a combined Rouxen-Y biliary drainage reconstruction and gastric sleeve performed in a liver transplant patient.
and up to the angle of His together with the major part of the corpus and antrum, thereby reducing the stomach to a narrow gastric tube over a 30-Fr bougie, which was used to avoid stenosis. The postoperative period was uneventful and the patient was discharged after 6 days. An intraoperative liver biopsy revealed a normal liver with minimal steatosis. At 6 months after the combined procedure, the patient is currently in good general condition, and has achieved a weight reduction of 28 kg (weight 88 kg, BMI 29.8 kg/m2). He has normal liver function tests and stable trough levels of cyclosporine.
Discussion Obesity is a common problem faced by physicians managing liver transplant patients. A multimodal approach that addresses diet, physical activity, and behavioral issues is generally used, but results are often disappointing. In this scenario, surgical approaches have emerged as useful alternatives with good short- and long-term results in the treatment of
Sleeve Gastrectomy after Liver Transplantation
severely obese patients.13 In the case discussed herein, we present an obese patient with chronic liver disease successfully managed with an intragastric balloon in the pre-transplant setting and with a sleeve gastrectomy following LT. Information on the use of both gastric balloon and bariatric surgery in the context of LT is either lacking or very limited,14,15 and to our knowledge, this is the first report on the use of both procedures in a liver transplant patient. The use of the intragastric balloon achieved a significant weight reduction (18 kg) in the pre-transplant setting and served as a short-term temporary aid in the control of obesity in our patient. After the liver transplant, the sleeve gastrectomy was chosen as a weight-reducing procedure in this patient by the bariatric team due to its restrictive and non-malabsorptive nature. This is relevant considering the potential interference of a malabsorptive procedure such as the RYGBP with the absorption of immunosuppressive drugs. In fact, cyclosporine dosage did not have to be adjusted in our patient to achieve stable blood serum levels of the drug; therefore, this operation appears to be an attractive option for obese patients following liver transplantation. The significant weight reduction observed after 6 months of surgery may be considered as a very successful result, considering that the etiology of the liver disease of our patient was NAFLD. Recurrence of NAFLD following liver transplantation has been increasingly recognized, particularly in subjects who remain above their ideal body weight after surgery.7, 16 Various studies indicate that recurrent NAFLD after liver transplantation may not be a benign condition, because it may progress to end-stage disease and require retransplantation.7,17 Thus, control of obesity in liver transplant patients is an important goal to achieve. Although sleeve gastrectomy is a relatively new bariatric procedure which is still under evaluation,18 the case presented herein indicates that this procedure may be considered as a useful option in this setting.
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