Laparoscopic bariatric Laparoscopic bariatric surgery improves candidacy surgery improves candidacy in morbidly obese patients in morbidly obese patients awaiting transplantation.awaiting transplantation.

Mark C. Takata, Guilherme M. Campos, Ruxandra Mark 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

INTRODUCTION:INTRODUCTION:

Obesity is associated with a greater peri-operative Obesity 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 as Obesity 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 cardiovascular A higher risk of infections and cardiovascular complications in the short term; and long term complications in the short term; and long term higher incidence of cardiovascular and metabolic higher incidence of cardiovascular and metabolic complications.complications.

Thus, most transplant centers have an upper limit of Thus, most transplant centers have an upper limit of BMI for transplantation, to justify the use of scarce BMI for transplantation, to justify the use of scarce organs and resources. organs and resources.

MGMT OF OBESITY IN TRANSPLANT MGMT OF OBESITY IN TRANSPLANT CANDIDATES:CANDIDATES:

Attempts at pre-op weight loss have been seen to result Attempts at pre-op weight loss have been seen to result in higher mortality in the obese. in higher mortality in the obese.

Thus, weight loss just prior to liver transplantation might Thus, weight loss just prior to liver transplantation might actually result in higher short-term mortality.actually result in higher short-term mortality.

Also, enforced weight loss prior to transplantation does Also, enforced weight loss prior to transplantation does not prevent long-term post transplantation not prevent long-term post transplantation complications. Most post-transplant patients quickly complications. Most post-transplant patients quickly regain their amount of pre-transplantation weight loss, regain their amount of pre-transplantation weight loss, with nothing having been done to treat their metabolic with nothing having been done to treat their metabolic syndrome.syndrome.

So, surgical weight-loss procedures after transplantation So, surgical weight-loss procedures after transplantation may be the better/ preferred treatment option.may be the better/ preferred treatment option.

METHODS:METHODS: The BMI limits used at UCSFThe BMI limits used at UCSF: :

- 40 kg/m- 40 kg/m22 for non-diabetic patients and for 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 who required They performed LRYGB in 7 patients with ESRD who required hemodialysis & LSG in 6 patients with Child-Pugh class A or B hemodialysis & LSG in 6 patients with Child-Pugh class A or B cirrhosis and 2 patients with end-stage lung disease (ESLD).cirrhosis and 2 patients with end-stage lung disease (ESLD).

Cirrhotic patients with >/=2 grade varices, ascites not Cirrhotic patients with >/=2 grade varices, ascites not controlled by medications or portosystemic shunt, controlled by medications or portosystemic shunt, uncontrolled encephalopathy, or severe coagulopathy uncontrolled encephalopathy, or severe coagulopathy (INR>2.5) were excluded from the study.(INR>2.5) were excluded from the study.

Standard surgical procedures were used to perform the Standard 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

OUTCOMES:OUTCOMES:

13 patients for whom follow-up data of 3 months were 13 patients for whom follow-up data of 3 months were available reached the institution’s BMI limits for available reached the institution’s BMI limits for transplantation.transplantation.

Of the patients with ESLD, 1 underwent unilateral lung Of 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 in and 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 resolved Diabetes 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 had All 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 emphysema At 12 months after LSG, 1 patient with severe emphysema and ESLD was able to discontinue home oxygen use and and ESLD was able to discontinue home oxygen use and chronic corticosteroid therapy.chronic corticosteroid therapy.

RESULTS:RESULTS:

Of the 15 patients, 7 with ESRD underwent LRYGB and Of the 15 patients, 7 with ESRD underwent LRYGB and 6 with cirrhosis and 2 with ESLD underwent LSG.6 with cirrhosis and 2 with ESLD underwent LSG.

The preoperative laboratory data were significant for The preoperative laboratory data were significant for decreased albumin and platelet levels in patients with decreased 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 and versus 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;

mean mean platelet count of 113x10platelet count of 113x1099/L for cirrhotics/L for cirrhotics versus versus 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 elevated The patients with cirrhosis also had a mildly elevated INR (INR (mean INR 1.4mean INR 1.4) compared with patients with ESRD ) compared with patients with ESRD or ESLD (1.0).or ESLD (1.0).

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-

189148-222

141120-176

14790-213

Mean estimated blood loss (mL)

64 58 50

Post-op complication

0 2 0

Hospital stay (D):

Mean-Range-

3.03-3

4.22-7

4.03-5

CHOICE OF SURGICAL PROCEDURE:CHOICE OF SURGICAL PROCEDURE:

The LSG was selected instead of LRYGB in patients The 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 with and 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.

? 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 bacterial could predispose to the development of bacterial peritonitis and other infections inperitonitis and other infections in

patients receiving immunosuppression, and patients 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 for upper abdominal transverse incision is made for liver transplantation.liver transplantation.

Postoperative BMI over time in patients with ESRD afterPostoperative BMI over time in patients with ESRD afterLRYGBP (n=7)LRYGBP (n=7)

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)

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)

?!? 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 a in 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 had biliopancreatic diversion (DS/BPD). Severe fibrosis had decreased in 28 patients, and 11 patients with confirmed decreased in 28 patients, and 11 patients with confirmed cirrhosis at the time of the DS/BPD showed decreased cirrhosis at the time of the DS/BPD showed decreased fibrosis and even disappearance of regenerative nodules fibrosis and even disappearance of regenerative nodules and bridging fibrosis. and bridging fibrosis. 

Other reports have questioned the role of mal-absorptive Other reports have questioned the role of mal-absorptive procedures in inducing liver disease. In a report by Baltasar procedures 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 hepatic had a DS/BPD developed clinically significant hepatic impairment, including one death from liver failure. impairment, including one death from liver failure. 

TO CONCLUDE:TO CONCLUDE:

LRYGB in patients with ESRD and LSG in LRYGB in patients with ESRD and LSG in patients with cirrhosis or ESLD is safe, patients with cirrhosis or ESLD is safe, well tolerated, and improves their well tolerated, and improves their candidacy for transplantation.candidacy for transplantation.

these patients experienced the same these patients experienced the same benefits of bariatric surgery as the benefits of bariatric surgery as the general population: sustained weight general population: sustained weight loss and improvement or resolution of loss and improvement or resolution of obesity-associated co-morbidities obesity-associated co-morbidities without excessive morbidity, and no without excessive morbidity, and no mortality.mortality.

THANK YOU!THANK YOU!