Timing is everything: sleeve gastrectomy and liver transplantation.

The obesity epidemic has presented new and unique challenges in the transplant population. In 2015, NASH became the second leading cause of liver disease among waitlist candidates in the United States and has remained in this position since, with an increasing incidence annually.1 While some reports have shown no difference in patient or graft survival between obese and nonobese liver transplant recipients,2,3 other studies have demonstrated an increased risk of biliary complications, infection, and wound dehiscence in obese patients4 as well as decreased 5-year patient and graft in those patients with body mass index >40 kg/m2.5 Not only does obesity possibly play a direct role in outcomes, but evidence also suggests a combined effect of obesity and its associated conditions, for example, cardiovascular disease and diabetes, that may contribute to poor outcomes.6 Weight loss has been shown to improve both steatosis and fibrosis in patients with fatty liver disease and NASH.7 As such, bariatric surgery has emerged as a potential treatment strategy for obese patients with NAFLD. Among different surgical bariatric procedures, sleeve gastrectomy is likely a more favorable option in the setting of liver transplant because it allows access to the biliary system and has lower complication rates than Roux-en-Y gastric bypass. Several studies have evaluated bariatric surgery performed before, at the time of, and after liver transplant, and while the optimal timing not established, it is important to recognize that bariatric surgery before liver transplantation is only feasible in well-selected patients with compensated cirrhosis. Specifically, sleeve gastrectomy at the time of transplant has been shown to be safe and result in more durable weight loss after transplant and lower rates of allograft steatosis, diabetes, and hypertension compared with noninvasive weight loss programs,8 while sleeve after transplant has been shown to have similar outcomes to nontransplant patients.9 In this issue of Liver Transplantation, Tariq and colleagues report on their single-center experience performing sleeve gastrectomy at the time of liver transplantation as a part of a brief-interval staging protocol.10 The authors describe a two-staged approach to liver transplant in the event of instability. In these instances, the abdomen is packed and closed temporarily, and the biliary reconstruction performed as a planned return to the operating room after a period of resuscitation in the ICU. The authors retrospectively describe outcomes in a cohort of 14 patients who underwent the two-staged approach, but also qualified for bariatric surgery so had their sleeve gastrectomy performed at the time of biliary reconstruction. There were no significant differences in hospital or ICU length of stay, unplanned reoperation within 30 days, need for dialysis, or 1-year graft survival in the sleeve gastrectomy patients compared with controls. There was a significantly higher rate of tracheostomy in sleeve gastrectomy patients. Among the sleeve gastrectomy patients, none required unplanned return to the operating room for sleeve-related complications. The timing of sleeve gastrectomy in this study is unique compared with previous reports on this topic. The results suggest that sleeve gastrectomy performed at this brief interval is safe and feasible. An important distinction is that the brief interval staging was not implemented for the sake of performing sleeve gastrectomy; rather, sleeve gastrectomy was incorporated into a previously practiced operative strategy for those patients who were hemodynamically unstable at the initial operation. The patients in the case and control groups had significantly lower blood product requirements, vasopressor requirement, and peak lactate levels during the second stage, demonstrating objective evidence of the improved clinical stability of the patients. Performing the sleeve gastrectomy in this more hospitable environment may serve to reduce the risk of staple line complications in these previously tenuous patients. These data also demonstrate a feasible strategy for performing sleeve gastrectomy in patients who would benefit but may be too unstable at the index operation. However, it is important to consider the cost of a second operation as a standard approach as in the current series, rather than for selected unstable patients. Overall, the patients undergoing sleeve gastrectomy had higher percentages of excess and total weight loss with a reduction in body mass index from 47 kg/m2 to 31 kg/m2. The authors provide an important contribution to the growing literature on the role of bariatric surgery in liver transplantation recipients. Their results demonstrate the safety and efficacy of sleeve gastrectomy performed as a part of brief-interval staging at the time of liver transplantation. Although weight reduction is an important early marker of success, the true goal of combining sleeve gastrectomy with liver transplantation is to impact long-term outcomes by reducing obesity-related complications and possible recurrent fatty liver disease in the liver allograft. The time point at which bariatric surgery should be offered to these patients is not yet established and is likely not a “one-size-fits-all” scenario. In our opinion, the program that is able to offer a more comprehensive approach to bariatric surgery in this very complicated patient population, for example bariatric surgery preliver, simultaneous, and postliver transplantation, will be the one that will have the greatest impact on patient outcomes.