Abstract

Background: The prevalence of obesity and metabolic syndrome (MS) is rising dramatically among liver transplant (LT) candidates, many of whom have NASH. Following LT, untreated MS often causes recurrent NAFLD and NASH. Several small case series describe bariatric surgery pre-, post-, or concurrently with LT as a treatment for MS. We reviewed our experience with LT and concurrent sleeve gastrectomy (LTSG) with aims to determine long-term safety, efficacy, and impact on progression of MS and liver disease after transplantation.

Methods: A multi-center retrospective analysis of all patients undergoing LTSG using a single clinical protocol (n = 73) was performed. Follow-up duration was 4 to 153 months. Outcomes assessed included morbidity and mortality, graft loss, BMI, evolution of MS, and development of allograft steatosis on ultrasound and fibrosis on magnetic resonance elastography. A comparison cohort included all 185 patients with BMI > 30 who underwent LT-only for NASH transplanted during the same time period.

Results: There was no significant difference in all-cause mortality or graft loss between LT and LTSG patients (Figure A, B). At last follow up, 20.3% and 23.4% of LTSG patients had steatosis and fibrosis, respectively, versus 40.4% and 37.3% of LT-only patients with steatosis and fibrosis respectively (p = 0.01 steatosis, p = 0.12 fibrosis). The prevalence of diabetes in LTSG patients decreased significantly from 42.2% at transplant to 20.3% at last follow up (p = 0.01), versus no significant change in diabetes prevalence in LT-only patients. The prevalence of hypertension in LTSG patients decreased from 61.1% to 35.8% (p < 0.01) and hyperlipidemia was not significantly changed (Figure C). LTSG patients, starting with an average BMI of 45.5, had significantly reduced BMI for at least 9 years following surgery (all p < 0.001). LT-only patients, with an average BMI of 34.0, had no significant change in BMI (Figure D). One LTSG patient (1.4%) had a gastric sleeve leak and one required hiatal hernia repair. None required revision. Severe gastric reflux occurred in 11.1% of LTSG patients; risk factors included male sex, pre-existing diabetes, and pre-existing GERD.

Conclusion: LTSG is an excellent option for those with BMI > 40; it confers no increase in mortality or graft loss even when compared to a less obese cohort. LTSG reduces recurrence of steatosis and trends toward less fibrosis when compared to LT alone, and leads to sustained weight loss and resolution of diabetes and hypertension.