In the Journals

Sleeve gastrectomy with liver transplantation improves outcomes for obesity

Simultaneous liver transplantation and sleeve gastrectomy improved weight loss and led to decreased rates of metabolic complications among obese patients compared with liver transplantation alone, according to recently published data.

“The multidisciplinary management of obese patients with decompensated liver disease before, during and after [liver transplantation (LT)] has become an important challenge,” Daniel Zamora-Valdés, MD, from the Mayo Clinic, Minnesota, and colleagues wrote. “Weight reduction through lifestyle modifications has been shown to benefit obese patients with [nonalcoholic steatohepatitis (NASH)]; however, this is difficult to achieve and sustain, particularly for patients with longstanding, severe medically-complicated obesity (MCO).”

As part of a larger study, Zamora-Valdés and colleagues enrolled 74 adult patients listed for LT since 2006 with BMI of 35 kg/m2 or higher and at least one follow-up visit in an aggressive weight management protocol.

At baseline, patients whose BMI decreased to less than 35 kg/m2 (n = 36) underwent LT alone and those with BMI of 35 kg/m2 or higher (n = 13) underwent combined LT with sleeve gastrectomy.

Patients were kept on a calorie count after surgery with a minimum goal of 600 calories to 800 calories and 60 grams to 80 grams of protein per day.

Overall, while the LT-alone cohort showed no significant difference between BMI at listing and 3 years follow-up (40.06 vs. 38.53 kg/m2), BMI among patients who underwent combined LT and sleeve gastrectomy decreased significantly between baseline and follow-up (49 vs. 30.9 kg/m2; difference, –18.08; P = .001).

Total body weight loss was higher in the LT-alone cohort at time of transplantation (17.7%; 95% CI, 14.1-21.3) compared with patients who underwent the combined procedure (9.1%; 95% CI, 4.5-13.7). However, patients who underwent combined LT and sleeve gastrectomy had statistically higher total body weight loss at 4 months (20.9% vs 29.6%; P = .038), 1 year (12.1% vs. 36.3%; P < .001), 2 years (4% vs. 34.4%; P < .001) and 3 years (3.9% vs. 34.8%; P < .001).

At follow-up, patients in the LT-alone cohort also had a higher prevalence of hypertension (63.9% vs. 23.1%; P = .021), higher insulin levels (20.1 vs. 8.6; P < .001) and higher prevalence of hepatic steatosis (66.7% vs. 23.1%; P = .01) compared with those who underwent the combined procedure.

“Mortality after LT in patients with obesity before transplant has been associated with cardiovascular events. Based on these data and concern for technical challenges related to exposure, weightloss prior to LT is recommended by many centers,” the researchers wrote. “Given that obesity-related liver disease is now one of the most common indications for LT, a structured approach for obese transplant candidates is of increased importance. The combination of LT [with sleeve gastrectomy] is effective at achieving durable weight loss and improved metabolic parameters.” – by Talitha Bennett

Disclosure: Healio.com/Hepatology was unable to determine relevant financial disclosures at the time of publication.

Simultaneous liver transplantation and sleeve gastrectomy improved weight loss and led to decreased rates of metabolic complications among obese patients compared with liver transplantation alone, according to recently published data.

“The multidisciplinary management of obese patients with decompensated liver disease before, during and after [liver transplantation (LT)] has become an important challenge,” Daniel Zamora-Valdés, MD, from the Mayo Clinic, Minnesota, and colleagues wrote. “Weight reduction through lifestyle modifications has been shown to benefit obese patients with [nonalcoholic steatohepatitis (NASH)]; however, this is difficult to achieve and sustain, particularly for patients with longstanding, severe medically-complicated obesity (MCO).”

As part of a larger study, Zamora-Valdés and colleagues enrolled 74 adult patients listed for LT since 2006 with BMI of 35 kg/m2 or higher and at least one follow-up visit in an aggressive weight management protocol.

At baseline, patients whose BMI decreased to less than 35 kg/m2 (n = 36) underwent LT alone and those with BMI of 35 kg/m2 or higher (n = 13) underwent combined LT with sleeve gastrectomy.

Patients were kept on a calorie count after surgery with a minimum goal of 600 calories to 800 calories and 60 grams to 80 grams of protein per day.

Overall, while the LT-alone cohort showed no significant difference between BMI at listing and 3 years follow-up (40.06 vs. 38.53 kg/m2), BMI among patients who underwent combined LT and sleeve gastrectomy decreased significantly between baseline and follow-up (49 vs. 30.9 kg/m2; difference, –18.08; P = .001).

Total body weight loss was higher in the LT-alone cohort at time of transplantation (17.7%; 95% CI, 14.1-21.3) compared with patients who underwent the combined procedure (9.1%; 95% CI, 4.5-13.7). However, patients who underwent combined LT and sleeve gastrectomy had statistically higher total body weight loss at 4 months (20.9% vs 29.6%; P = .038), 1 year (12.1% vs. 36.3%; P < .001), 2 years (4% vs. 34.4%; P < .001) and 3 years (3.9% vs. 34.8%; P < .001).

At follow-up, patients in the LT-alone cohort also had a higher prevalence of hypertension (63.9% vs. 23.1%; P = .021), higher insulin levels (20.1 vs. 8.6; P < .001) and higher prevalence of hepatic steatosis (66.7% vs. 23.1%; P = .01) compared with those who underwent the combined procedure.

“Mortality after LT in patients with obesity before transplant has been associated with cardiovascular events. Based on these data and concern for technical challenges related to exposure, weightloss prior to LT is recommended by many centers,” the researchers wrote. “Given that obesity-related liver disease is now one of the most common indications for LT, a structured approach for obese transplant candidates is of increased importance. The combination of LT [with sleeve gastrectomy] is effective at achieving durable weight loss and improved metabolic parameters.” – by Talitha Bennett

Disclosure: Healio.com/Hepatology was unable to determine relevant financial disclosures at the time of publication.