bariatric surgery pre, post and during...
TRANSCRIPT
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)
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There is a growing societal burden of NAFLD
Lazo and Clark, Semin Liver Dis, 2008
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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
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Wong et al Gastro 2015; 148: 547-55.
Indication for liver transplantation: US
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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
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• 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
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Development of fatty liver disease after liver transplant for cryptogenic cirrhois
Contos et al, Liver Transplantation, 2001, 7: 363-373
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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.
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• 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
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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
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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
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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
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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
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Acknowledgements: Dr. Julie Heimbach, Mayo Clinic, Dr. Arun Sanyal, VCU