Combined Liver Transplant and Sleeve Gastrectomy in the Same Surgical Time - Abstract
Introduction: According to the National Health Survey, 75.2% of Mexicans are overweight and obese. One of the main complications related to obesity is Nonalcoholic fatty liver disease (NAFLD). Some individuals with NAFLD can develop nonalcoholic steatohepatitis (NASH), which is marked by liver inflammation and may progress to cirrhosis and liver failure. NASH is currently the most common chronic liver disease worldwide and it’s estimated that between 30 and 40% of patients with NASH-related cirrhosis will require liver transplantation. On the other hand, obesity, particularly when it exceeds 40 kg/m2 of body mass index (BMI), increases the mortality rate after liver transplantation, in fact most transplant programs exclude obese patients from their transplant list a priori. Options for obese liver transplant candidates include bariatric surgery before or during transplantation, and in terms of the type of bariatric procedure, sleeve gastrectomy (SG) appears to offer some advantages. Although limited, the initial results of bariatric surgery at the time of transplantation are encouraging with the maintenance of weight loss, the resolution of hypertension and diabetes, and the absence of reported mortality. Objective: To analyze 3 patients who underwent Sleeve Gastrectomy (SG) and Liver transplant (LT) in the same surgical time at the National Institute of Medical Sciences and Nutrition “Salvador Zubirán” (INCMNSZ), with particular attention to the development of complications. Methods: This is a retrospective study of three obese patients and liver transplant candidates. Liver transplantation was programmed as the initial procedure and once it was finished, SG was performed. Their general characteristics, details of the operation, postoperative complications at 30 and 90 days, as well as their evolution until their last follow-up were reviewed. Results: The demographic characteristics and comorbid phenomena of the three patients at the time of the surgical procedure are shown in Table 1. All patients presented cirrhosis secondary to NASH. Patient #2 underwent a kidney transplant at the same time. The surgical technique used in all the procedures was the standard one, with open SG being performed on a #34 F bougie and staple line reinforcement with continuous suture using 3-0 monocryl. The total surgical time was 8 h 30 min, 10 h 54 min and 7 h 35 min and the gastric sleeve time was 30 min, 60 min and 35 min respectively for patients 1,2 and 3. Complications were documented per patient: on the third postoperative day Patient 1 presented unstable angina with intermediate TIMI risk, so cardiac catheterization was performed without further complications. A sub capsular hepatic hematoma ruptured at 4 days in Patient 2 that required surgical reintervention, and Patient 3 a portal stenosis of 50% with occlusion of the inferior vena cava at the hepatic level and thrombosis of the inferior vena cava with extension to the left iliac, in relation to a direct complication of liver transplantation, six months after surgery. There were no complications related to the bariatric procedure and there was no mortality. The follow-up time is 36 months for patient 1 and 12 months for patient 2 and 3; percentage of excessive weight loss (%EWL) at 6 months is 73.62%, 45% and 75%, respectively. The current BMI of Patient 1 is 32 kg/m2 ; patient 2 and 3, BMI of 26 kg/m2 and 31 kg/m2 respectively. Other complications reported have been nutritional, with hypovitaminosis D for the all patients, as well as iron deficiency anemia for patients 1 and 2. Conclusion In carefully selected obese patients who are candidates for Liver transplant, performing SG during the same surgical time as transplantation is an option that in our short experience seems to have good results.