Bariatric Surgery Pre, Post and During LT

Kris V. Kowdley MD, FAASLDDirector, Liver Care Network and Organ Care Research

Swedish Medical CenterSeattle, WA

20-24.9%25-29.9%30-34.9%35+ %

Obesity rates: 9/21/15

• 3 states (AR,MS, WV) now have >35% of population with BMI>30

• 17% of children are obesehttp://stateofobesity.org/adult-obesity/

Rates of Obesity (BMI>30)

3

There is a growing societal burden of NAFLD

Lazo and Clark, Semin Liver Dis, 2008

NAFLD0

1

2

3

4

51986

2006

(hospital discharges)

n/1

00,0

00 p

op

ula

tio

n a

nn

uall

yKoebnick et al, J Pediatr Gastroenterol Nutr.2009;48:597-603.

There is a growing demand for OLT due to NASH-related cirrhosis

What do the trends tell us?

Charlton et al, Gastroenterology. 2011 Oct;141(4):1249-53

Indication for listing for liver transplantation in US

7

Wong et al Gastro 2015; 148: 547-55.

Indication for liver transplantation: US

8

Data 2002-2014

Pham et al Clin Liver Dis 2016 20: 403–417

Liver Transplantation 2009

Impact of obesity on outcome:• SRTR data 1987-2007

• 68,172 BMI 18.5-40, 1827 <18.5, and 1,447>40.

• Outcome worse high and low BMI patients (similar to previous report Nair et al 2002)

• No correction for ascites, small number of patients in each of the “extreme” groups

Dick, Liver Transpl. 2009:15;968-77.

Long term outcomes: NASH

10

• SRTR data analysis of transplant for NASH 1997-2010

Afzali et al, 2012, Liver Transpl 18:29-37.

Impact of recurrent NASH on outcomes

Unadjusted Post-LT Survival: NASH

vs. Not NASH, non-HCV

88.9%

83.7%

81.9%

91.1%

86.7%

84.6%

Log rank p<0.001

Courtesy, Dr. Danielle Brandyman- UNOS data

0 5 0 0 1 0 0 0 1 5 0 0 2 0 0 0

0

5 0

1 0 0

r e c u r r e n t

N A S H

r e c u r r e n t

fa tty live r

p = 0 .0 0 3 lo g r a n k te s t

F L /N A S H 1 1 /1 3 5 /7 2 /3 0 /12 7 /2 7

tim e f r o m O L T ( d a y s )

Pro

ba

bil

ity

of

be

ing

fre

e

of

NA

SH

or f

att

y l

ive

r (

%)

Development of fatty liver disease after liver transplant for cryptogenic cirrhois

Contos et al, Liver Transplantation, 2001, 7: 363-373

0 5 0 0 1 0 0 0 1 5 0 0 2 0 0 0 2 5 0 0 3 0 0 0

0

5 0

1 0 0

N A S H

P B C /P S C

p = 0 .0 3 lo g r a n k te s t

P B C

N A S H 2 7

1 2 7

5

4

2

1

0

1 1

1 1

tim e f r o m O L T ( d a y s )

pro

ba

bil

ity

of

be

ing

fre

e o

f

fatt

y l

ive

r a

fte

r O

LT

(%

)

De novo NAFLD post OLT versus recurrence of NAFLD

Contos et al, Liver Transplantation, 2001, 7: 363-373

Aggressive recurrence of NASH post OLT

Perisinusoidal fibrosis

Masson’s trichrome

• Usually in type diabetics• Consider underlying partial

lipodystrophy• Cumulative steroid use

Operations for weight loss

Adjustable band

gastroplastyProximal gastric

bypass

Vertical banded

gastroplasty

Bariatric surgery proceduresRestrictive• Lap band: reversible, low rate of

serious complications. Less effective weight loss, and >50% failure rate at 10 years. ? Access to distal varices

• Gastric sleeve: slower weight loss, low rate of complications, appears durable (early). Not reversible. Preserves access to biliary tree and varices.

Restrictive +Malabsorptive

• Roux-en-Y Gastric bypass: gold standard. Effective, long-term weight loss. Serious complication rate 0.5-2%. No access to distal varices. ? Rapid weight loss

• Duodenal switch: rarely used, reserved for very severe obesity. Not appropriate for patients with

liver disease.

17

• N=1236, (681 RYGB, 555 lap band). Biopsy available for 97% at baseline, 69% at 5 years. NAFLD, but not cirrhosis.

• All patients had improvement of NAFLD parameters.

• Improvement superior for RYGB compared to lap band, even though RYGB had higher BMI and worse NAFLD at surgery.

Caiazzo et al Ann Surg. 2014; 260:893-99

Bariatric Surgery in Cirrhosis Mosko and Nguyen: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:897–901

• Nationwide Inpatient Sample (NIS) between 1998 and 2007

• Patients identified as having bariatric surgery and compensated (n=3888); decompensated cirrhosis (n=62) or no cirrhosis (n=670,950).

• Diagnosis code of ascites or varices required to be classified as decompensated.

• In-hospital mortality 0.3% vs 0.9% and 16.3%, respectively; P <.0002). Higher in low volume centers (40%).

• LOS higher in cirrhosis: 3.2 and 4.4 d vs 6.7 d, respectively; P<.0001.

NASH: Surgical Approaches

NASH/Compensated cirrhosis

Goal attain >10% body weight loss to improve liver fibrosis,

metabolic complications

Consider lap sleeve gastrectomy (or LRYGB)

Decompensated cirrhosis

Transplant candidate?

Non-invasive attempt at weight loss (selected)

Sleeve gastrectomy (?during or after LT)

Lap. RYGB in patients with compensated cirrhosis Dallal et al. Obesity Surgery 2004;14:47-53

• Single center, retrospective review of 30 patients (of 2,119 total undergoing Lap RYGB) found to have cirrhosis (visual inspection– no biopsy).

• No deaths, no hepatic decompensation with mean f/u of 16 months (1-48 m).

• Conclude: possible in Child’s A, using lap. approach.

Bariatric surgery in patients with compensated Cirrhosis Shimizu et al Obesity Rel Dis (2013)9;1–6.

• Single center, retrospective, N=23, 2004-11, 22/23 “Child’s A”, 1 Child’s B, 2 with TIPS prior.

• LRYGB (14), LSG (8), lap band (1).

• Complications in 8 patients (leaks, strictures)

• 1 death at 9 months, no hepatic decompensation after surgery, 37 months f/u.

• Weight loss 67% of excess weight

• Conclude: LRYGB and LSG possible in Child’s A, and provides excellent weight loss.

Lap sleeve gastrectomy in patients with Cirrhosis Rebibo et al Obesity Rel Dis (2014)405-10

• Single center, 13 patients with Child’s A MELD 7-8 and LSG (2004-2013) matched 1:2 to non-cirrhotic LSG.

• No differences in perioperative complication rates (7.7 versus 7.7%), including major complications, no death, no hepatic decompensation.

• mean f/u of 24 months.

• Weight loss similar in both groups

• Conclude: LSG safe and effective in Child’s A,

Lap. Adjustable Band in patients with unexpected cirrhosis Woodford et al Obesity Surg (2015)1623-9

• N=14 patients, 1993-2014. Biopsied intra-operatively. No patients with

decompensation

• All underwent lap band.

• Complications in 2 patients (1 infection, 1 open re-op), no early deaths

• mean f/u of 64 months, 1 death from HCC.

• Weight loss 61% of excess weight at 1 year, then 39% at 5 years (mean BMI 38 to 32 to 34).

• Conclude: lap band safe in compensated cirrhosis

Bariatric Surgery in patients with cirrhosisPestana et al Mayo Clin. Proc. (2015)209-15.

• Single center, prospective, N=14, 2009-11. 4 had portal hypertension (1 with varices, 3 with portal hypertensive gastropathy). MELD 6-9.

• LSG (11), LRYGB (3).

• No surgical complications

• Weight loss 25% TBW at 1 year

• Conclude: bariatric surgery safe,

effective in compensated cirrhosis.

Bariatric surgery prior to TransplantTakata. Surg obes & Rel Dis 2008

• 6 ESLD (Childs A/B)– sleeve gastrectomy

– Excluded Grade 2+ varices, uncontrolled HE, ascites

– BMI>40

– Liver function remained stable,

– MS improved

– 24-40% excess weight lost

– 1 re-op for bleeding, 2 developed ascites, 1 re-admitted for encephalopathy. No deaths, no leaks

– Mean stay 4.2 days

– Mean follow-up 9 monthsTakata. Surg obes & Rel Dis 2008.

Sleeve gastrectomy prior to liver transplant

Lin et al, Surgery for Obesity and Related Diseases 9 (2013) 653–659

Rabl and Compos, Semin Liver Dis, 2012

Weight loss after bariatric surgery

Lin et al, Surgery for Obesity and Related Diseases 9 (2013) 653–659

• Option for selected patients who have not attained goal weight and have high enough MELD

• Gastric sleeve resection combined with liver transplantation

• No malabsorption, slower weight loss, technically easier

Heimbach et al AJT 2013

Combined LT and sleeve gastrectomy

• 37 non-invasive approach versus 7 combined sleeve with LT

• Since publication, 15 more patients (22 total), with 4 being liver+ kidney, and 1 re-transplant. NASH=18

31

characteristic N=37 LT N=7 LT+SG P-value

MELD at tx 19 (8-35) 32 (11-40) <0.001

O.R. time (mean) 4:21 (2:54-7:51) 4:59 (4:16-7:39) 0.59

Mean BMI at LT 33 (28-40) 48 (39-52) <0.001

% DM post LT 34% (12/35) 0% (0/7) 0.03

BMI at last f/u 36 (25-45) 28 (23-35 0.003

Noninvasive weight loss program

• The average BMI at enrollment was 40 kg/m2 (range 36–46)

• The mean BMI at transplant was 33 kg/m2 (range 30–37)

• There were three deaths in this group – severe porto-pulmonary hypertension – intraoperative bleeding– metastatic adenocarcinoma of unknown

primary at 2.5 months from transplantation

• three patients required retransplant(two for early graft dysfunction and one for chronic rejection).

• Remaining patients, 21 (60%) have a posttransplant BMI > 35 kg/m2,

• 35% of patients have posttransplantdiabetes mellitus

• 20% demonstrating steatosis on ultrasound

Am J Transplant 2013;13(2):363-368. ;

LT and Sleeve Gastrectomy

Combined LT and S. Gastrectomy

• 7 patients without weight loss• All seven patients alive with normal

allograft function• Significant weight loss (mean BMI =

28 kg/m2) • None of the patients currently

require insulin or oral hypo-glycemic treatment

• None of the patients has steatosis based on protocol ultrasound per-formed for all LT patients at 4 months and annually

• There was minimal additional operative time for LTSG patients

Weight loss: n=20 SG+LT

20

30

40

50

60

70

BMI attransplant

4 months 1 year 2 years 3 years 4 years 5 years

Mean BMI at TX=45, mean BMI at f/u=313 patients with BMI>35 at 3 year follow-up.

Post LT bariatric surgery• Lin et al: Lap gastric sleeve post LT n=9 patients

• Mean time from transplant 5.9 years, age=56, BMI=41,

• Mean f/u 6 months

• 3 patients required re-op in first 30 days: 1 conversion to RYGB, 1 bile leak, 1 dehiscence of concurrent hernia repair

Lin Surg Endo 2013: 27;81-85

Post LT bariatric surgery• Al-Nowaliti et al: open RYGB post LT n=7 patients

• Mean time from transplant 2.6 years, age=56, BMI=44, OR time 165 minutes (lysisof adhesions), hospital stay 5.6 days

• Mean f/u 5 years

• 2 patients died in first 1 year, and 1 reversal

36

Key Concepts: LT and SG• Standardized approach: specific nutritional,

activity, and weight loss goals

• Weight distribution/ascites important for technical considerations

• Close follow up (reflux excess weight loss, re-gain)

Issues after transplant in patients with a combined sleeve plus LT

• Reflux: twice daily PPI, Carafate

• Excessive weight loss: close follow-up, nutritional counseling, supplements, micronutrient replacement. Especially problematic in those with renal insufficiency.

• Early satiety: much more predominant in LT plus sleeve patients, versus sleeve alone. Eventually resolves.

• Weight re-gain

38

Bariatric surgery in Decompensated Cirrhosis

• Before transplant : not an option for patients with Child’s B/C cirrhosis

• An option to consider:

– After transplant

– Concurrent with transplantation

39

Acknowledgements: Dr. Julie Heimbach, Mayo Clinic, Dr. Arun Sanyal, VCU