Obesity surgery in liver failure and patients needing liver transplants.

1. Laparoscopic bariatric surgeryLaparoscopic bariatric surgery
improves candidacy in morbidlyimproves candidacy in morbidly
obese patients awaitingobese patients awaiting
transplantation.transplantation.
Mark C. Takata, Guilherme M. Campos, RuxandraMark C. Takata, Guilherme M. Campos, Ruxandra
Ciovica, Charlotte Rabl, Stanley J. Rogers, John P.Ciovica, Charlotte Rabl, Stanley J. Rogers, John P.
Cello, Nancy L. Ascher, Andrew M. Posselt.Cello, Nancy L. Ascher, Andrew M. Posselt.
University of California, San Francisco, School of Medicine,University of California, San Francisco, School of Medicine,
San Francisco, CaliforniaSan Francisco, California

2. INTRODUCTION:INTRODUCTION:
 Obesity is associated with a greater peri-operativeObesity is associated with a greater peri-operative
morbidity and mortality after all major surgery.morbidity and mortality after all major surgery.
 Obesity is also associated with poorer short-term asObesity is also associated with poorer short-term as
well as long term outcomes after transplantation.well as long term outcomes after transplantation.
 A higher risk of infections and cardiovascularA higher risk of infections and cardiovascular
complications in the short term; and long termcomplications in the short term; and long term
higher incidence of cardiovascular and metabolichigher incidence of cardiovascular and metabolic
complications.complications.
 Thus, most transplant centers have an upper limit ofThus, most transplant centers have an upper limit of
BMI for transplantation, to justify the use of scarceBMI for transplantation, to justify the use of scarce
organs and resources.organs and resources.

3. MGMT OF OBESITY IN TRANSPLANTMGMT OF OBESITY IN TRANSPLANT
CANDIDATES:CANDIDATES:
 Attempts at pre-op weight loss have been seen toAttempts at pre-op weight loss have been seen to
result in higher mortality in the obese.result in higher mortality in the obese.
 Thus, weight loss just prior to liver transplantationThus, weight loss just prior to liver transplantation
might actually result in higher short-term mortality.might actually result in higher short-term mortality.
 Also, enforced weight loss prior to transplantationAlso, enforced weight loss prior to transplantation
does not prevent long-term post transplantationdoes not prevent long-term post transplantation
complications. Most post-transplant patients quicklycomplications. Most post-transplant patients quickly
regain their amount of pre-transplantation weightregain their amount of pre-transplantation weight
loss, with nothing having been done to treat theirloss, with nothing having been done to treat their
metabolic syndrome.metabolic syndrome.
 So, surgical weight-loss procedures afterSo, surgical weight-loss procedures after
transplantation may be the better/ preferredtransplantation may be the better/ preferred
treatment option.treatment option.

4. METHODS:METHODS:
 The BMI limits used at UCSFThe BMI limits used at UCSF::
- 40 kg/m- 40 kg/m22
for non-diabetic patients andfor non-diabetic patients and
- 35 kg/m- 35 kg/m22
for diabetic patients awaiting kidney tx,for diabetic patients awaiting kidney tx,
- 40 kg/m- 40 kg/m22
for patients awaiting lung transplantation,for patients awaiting lung transplantation,
- 40 kg/m- 40 kg/m22
(relative contraindication) and(relative contraindication) and
- 50 kg/m- 50 kg/m22
(absolute contraindication) for patients awaiting(absolute contraindication) for patients awaiting
liver tx.liver tx.
 They performed LRYGB in 7 patients with ESRD whoThey performed LRYGB in 7 patients with ESRD who
required hemodialysis & LSG in 6 patients with Child-Pughrequired hemodialysis & LSG in 6 patients with Child-Pugh
class A or B cirrhosis and 2 patients with end-stage lungclass A or B cirrhosis and 2 patients with end-stage lung
disease (ESLD).disease (ESLD).
 Cirrhotic patients with >/=2 grade varices, ascites notCirrhotic patients with >/=2 grade varices, ascites not
controlled by medications or portosystemic shunt,controlled by medications or portosystemic shunt,
uncontrolled encephalopathy, or severe coagulopathyuncontrolled encephalopathy, or severe coagulopathy
(INR>2.5) were excluded from the study.(INR>2.5) were excluded from the study.

5. Standard surgical procedures were used to perform theStandard surgical procedures were used to perform the
bariatric surgery. One patient with cirrhosis needed to be re-bariatric surgery. One patient with cirrhosis needed to be re-
explored for post-op bleeding. No conversions to open Sx.explored for post-op bleeding. No conversions to open Sx.
LRYGBLRYGB LSGLSG

6. OUTCOMES:OUTCOMES:
 13 patients for whom follow-up data of 3 months were13 patients for whom follow-up data of 3 months were
available reached the institution’s BMI limits foravailable reached the institution’s BMI limits for
transplantation.transplantation.
 Of the patients with ESLD, 1 underwent unilateral lungOf the patients with ESLD, 1 underwent unilateral lung
transplantation without any complications.transplantation without any complications.
 The obesity-related co-morbidities (hypertension, diabetes,The obesity-related co-morbidities (hypertension, diabetes,
and obstructive sleep apnea) had improved or resolved inand obstructive sleep apnea) had improved or resolved in
all patients with 6 months of follow-up.all patients with 6 months of follow-up.
 Diabetes had improved in 1 and completely resolvedDiabetes had improved in 1 and completely resolved
(defined as random blood glucose levels 200 mg/dL without(defined as random blood glucose levels 200 mg/dL without
therapy) in 2 of 3 patients who had undergone LRYGB.therapy) in 2 of 3 patients who had undergone LRYGB.
 All 3 diabetic patients who underwent LSG also hadAll 3 diabetic patients who underwent LSG also had
resolution of their diabetes.resolution of their diabetes.
 At 12 months after LSG, 1 patient with severe emphysemaAt 12 months after LSG, 1 patient with severe emphysema
and ESLD was able to discontinue home oxygen use andand ESLD was able to discontinue home oxygen use and
chronic corticosteroid therapy.chronic corticosteroid therapy.

7. RESULTS:RESULTS:
 Of the 15 patients, 7 with ESRD underwent LRYGBOf the 15 patients, 7 with ESRD underwent LRYGB
and 6 with cirrhosis and 2 with ESLD underwent LSG.and 6 with cirrhosis and 2 with ESLD underwent LSG.
 The preoperative laboratory data were significant forThe preoperative laboratory data were significant for
decreased albumin and platelet levels in patients withdecreased albumin and platelet levels in patients with
cirrhosis.cirrhosis.
 mean albumin 3.1g/L in cirrhosismean albumin 3.1g/L in cirrhosis versus 3.6 g/L andversus 3.6 g/L and
3.6 g/L in patients with ESRD/ ESLD, respectively;3.6 g/L in patients with ESRD/ ESLD, respectively;
 meanmean platelet count of 113x10platelet count of 113x1099
/L for cirrhotics/L for cirrhotics versusversus
266x10266x1099
/L and 244x10/L and 244x1099
/L in patients with ESRD or/L in patients with ESRD or
ESLD, respectively.ESLD, respectively.
 The patients with cirrhosis also had a mildly elevatedThe patients with cirrhosis also had a mildly elevated
INR (INR (mean INR 1.4mean INR 1.4) compared with patients with) compared with patients with
ESRD or ESLD (1.0).ESRD or ESLD (1.0).

8. OPERATIVE AND POST-OP OUTCOMES:OPERATIVE AND POST-OP OUTCOMES:
Variable ESRD (n=7) Cirrhosis
(n=6)
ESLD (n=2)
Operation LYRGB LSG LSG
Operative time:
Mean-
Range-
189
148-222
141
120-176
147
90-213
Mean estimated
blood loss (mL)
64 58 50
Post-op
complication
0 2 0
Hospital stay
(D):
Mean-
Range-
3.0
3-3
4.2
2-7
4.0
3-5

9. CHOICE OF SURGICAL PROCEDURE:CHOICE OF SURGICAL PROCEDURE:
 The LSG was selected instead of LRYGB in patientsThe LSG was selected instead of LRYGB in patients
with cirrhosis for the following reasons:with cirrhosis for the following reasons:
- some evidence has shown that the operative time- some evidence has shown that the operative time
and overall morbidity are reduced compared withand overall morbidity are reduced compared with
those with LRYGB.those with LRYGB.
- the remaining gastric tube remains endoscopically- the remaining gastric tube remains endoscopically
accessible in the case of variceal bleeding.accessible in the case of variceal bleeding.
- endoscopic access to the biliary system after liver- endoscopic access to the biliary system after liver
transplantation is preserved, andtransplantation is preserved, and
- it is expected that intake and absorption of critical- it is expected that intake and absorption of critical
medications will not be significantly altered.medications will not be significantly altered.

10. ? LAP-BAND:? LAP-BAND:
 Dis-adv of lap-bandDis-adv of lap-band::
- ascitic leak around the port tubing in patients- ascitic leak around the port tubing in patients
who develop ascites;who develop ascites;
- the presence of an intra-abdominal foreign body- the presence of an intra-abdominal foreign body
could predispose to the development of bacterialcould predispose to the development of bacterial
peritonitis and other infections inperitonitis and other infections in
patients receiving immunosuppression, andpatients receiving immunosuppression, and
- of technical issues with the port tubing when an- of technical issues with the port tubing when an
upper abdominal transverse incision is made forupper abdominal transverse incision is made for
liver transplantation.liver transplantation.

11. Postoperative BMI over time in patients with ESRD afterPostoperative BMI over time in patients with ESRD after
LRYGBP (n=7)LRYGBP (n=7)

12. Post-op BMI over time in patients with cirrhosis after LSG.Post-op BMI over time in patients with cirrhosis after LSG.
(n=6)(n=6)

13. Post-op BMI over time in patients with ESLD after LSG.Post-op BMI over time in patients with ESLD after LSG.
(n=2)(n=2)

14. ?!? THE IMPACT ON LIVER DISEASE:?!? THE IMPACT ON LIVER DISEASE:
 Kral et alKral et al [[Surgery. 2004;135:48-58Surgery. 2004;135:48-58..] described their findings] described their findings
in 104 patients who underwent repeat liver biopsy for ain 104 patients who underwent repeat liver biopsy for a
variety of reasons after a prior duodenal switch /variety of reasons after a prior duodenal switch /
biliopancreatic diversion (DS/BPD). Severe fibrosis hadbiliopancreatic diversion (DS/BPD). Severe fibrosis had
decreased in 28 patients, and 11 patients with confirmeddecreased in 28 patients, and 11 patients with confirmed
cirrhosis at the time of the DS/BPD showed decreasedcirrhosis at the time of the DS/BPD showed decreased
fibrosis and even disappearance of regenerative nodulesfibrosis and even disappearance of regenerative nodules
and bridging fibrosis.and bridging fibrosis.
 Other reports have questioned the role of mal-absorptiveOther reports have questioned the role of mal-absorptive
procedures in inducing liver disease. In a report by Baltasarprocedures in inducing liver disease. In a report by Baltasar
et al,[et al,[Obes Surg. 2004;14:77–83Obes Surg. 2004;14:77–83] 10 out of 470 patients who] 10 out of 470 patients who
had a DS/BPD developed clinically significant hepatichad a DS/BPD developed clinically significant hepatic
impairment, including one death from liver failure.impairment, including one death from liver failure.

15. TO CONCLUDE:TO CONCLUDE:
 LRYGB in patients with ESRD and LSGLRYGB in patients with ESRD and LSG
in patients with cirrhosis or ESLD isin patients with cirrhosis or ESLD is
safe, well tolerated, and improves theirsafe, well tolerated, and improves their
candidacy for transplantation.candidacy for transplantation.
 these patients experienced the samethese patients experienced the same
benefits of bariatric surgery as thebenefits of bariatric surgery as the
general population: sustained weightgeneral population: sustained weight
loss and improvement or resolution ofloss and improvement or resolution of
obesity-associated co-morbiditiesobesity-associated co-morbidities
without excessive morbidity, and nowithout excessive morbidity, and no
mortality.mortality.

16. THANK YOU!THANK YOU!