Bariatric Surgical Practice Guide by Saravana Kumar & Rachel Maria Gomes

Author:Saravana Kumar & Rachel Maria Gomes
Language: eng
Format: epub
Publisher: Springer Singapore, Singapore

18.6 Bariatric Surgery After Liver Transplant in Cirrhotic Patients

Liver transplant recipients are at increased risk of developing or worsening obesity after transplantation [20, 21]. Of concern in an obese patient is the prevention of non-alcoholic steatohepatitis (NASH) and the treatment of recurrent NASH which has the associated risk of development of fibrosis [22]. The feasibility of bariatric surgery in a post-liver transplant setting has been reported in several small series. Duchini and Brunson reported two patients undergoing an open RYGB for recurrent steatohepatitis after liver transplant without complications with good weight loss and eventual resolution of steatohepatitis. Both did not require changes in tacrolimus or immunosuppression dosing [23]. Tichansky and Madan reported one patient with RYGB in a post–liver transplant patient whose BMI was 54 without complications with good weight loss [24]. Butte et al. reported a patient who was diagnosed intraoperatively at the time of bariatric surgery with cirrhosis with mild portal hypertension and a planned RYGB was deferred [25]. After few months he developed variceal bleeding and decompensated liver cirrhosis. He was listed and placed on intragastric balloon to qualify for transplantation with a loss of 18 kgs. He then underwent liver transplantation. He subsequently developed a biliary stricture that required a revision to a Roux-en-Y biliary bypass. He had by this time regained weight with a BMI of 37.9. He then underwent a simultaneous open biliary bypass and a sleeve gastrectomy uneventfully. Postoperatively, his BMI decreased to 29.8 at 6 months’ follow-up and no changes in post-operative cyclosporine levels were seen. A larger recent series by Lin and colleagues described SGs in 9 patients with prior liver transplantation [26]. There were three complications in three patients. One patient developed a bile leak from the liver surface, which subsequently resolved with drainage and argon-beam coagulation. Another patient had a simultaneous repair of a large incisional hernia and experienced a dehiscence on postoperative day two. The third patient had persistent dysphagia. Manometry was performed, which demonstrated aperistalsis of the esophagus, despite no significant anatomic or mechanical obstructions seen during upper endoscopy. The patient underwent a subsequent revision to a RYGB, whereby the symptoms resolved. Calcineurin inhibitor levels remained stable. There were no episodes of graft rejection. At 3 months liver function tests remained stable. Excess weight loss averaged 55.5 % at 6 months.

Though data is limited it can be concluded that bariatric surgery is feasible in a post-liver transplant setting and can be considered as a treatment option in patients with morbid obesity post liver transplant and as a treatment of reccurent steatohepatitis when conservative measures fail.

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