Laparoscopic Sleeve Gastrectomy (LSG) Is Safe, Well Tolerated and Improves Candidacy in Morbidly Obese Patients Awaiting Liver Transplantation

Abstract

Introduction: Morbid obesity is a relative contraindication to liver transplantation due to higher risks of perioperative morbidity and worse long-term outcomes. We evaluated the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a strategy for achieving long-lasting weight loss and improving transplant candidacy in morbidly obese patients with end stage liver disease (ESLD) awaiting liver transplantation. Methods: We collected data on patients with ESLD who were not eligible for transplantation due to morbid obesity and underwent LSG at our institution between 2006 -2011. Parameters included demographics, operative details, complications, percent excess weight loss (EWL), laboratory data, and transplant candidacy. Results: 20 patients with ESLD (8 NASH, 8 HCV, 2 Alcohol, and 2 autoimmune hepatitis) underwent LSG (Table 1). Mean age was 56 6y, 60% of the cohort was female, and mean follow-up was 2.5 1.7y. Mean preop body mass index (BMI) was 46 5 kg/m2 (range 38-55). There were 5 postop complications: 2 superficial wound infections, 1 staple line leak, 1 with transient encephalopathy, 1 temporary renal insufficiency, but no mortalities. Serum albumin and other nutritional parameters 12 months or later after surgery were similar to preop levels and were stable. Mean EWL was 45% at 12 mos. 19/20 patients reached our institution's BMI limit for transplantation (BMI< 40) within 6 mos of LSG and were activated on the waitlist. They have all maintained stable weight loss for the duration of the follow-up period. One patient was lost to followup. To date, 3 patients have received liver transplants and 1 underwent a combined liver and kidney transplant. All are doing well with stable graft function.Conclusion: This is the largest case series involving pre-transplant candidates and LSG. We demonstrate that LSG in selected patients with ESLD is safe, well tolerated, and improves candidacy for transplantation. Given the poor results achieved with non-surgical methods of weight loss, LSG can be safely integrated into a treatment program for morbidly obese patients with ESLD awaiting transplantation.