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Transplantation and bariatric surgery

Combined liver transplant/LSG results in effective weight loss

Combined procedure results in fewer post-transplant metabolic complications

Patients who had a combined liver transplant and laparoscopic sleeve gastrectomy achieved effective weight loss, according to a study published in the American Journal of Transplantation.

The paper also revealed that patients who underwent the combined procedure had fewer post-transplant metabolic complications, compared with patients who had a liver transplantation after enrolling in a non-invasive pre-transplant weight loss programme but did not have a sleeve gastrectomy.

The researchers write that the obesity epidemic could be the primary cause of liver disease or at least a contributing factor in the patient's liver disease. Current weight loss programmes for obese patients who require a liver transplant include a non-invasive approach of dietary and lifestyle changes before and after a liver transplant. However, this may not be successful for patients with long-standing severe obesity.

They also note that post-transplant bariatric surgery can result in long-term immunosuppression from the adhesions and complications, related to two separate major operations.


The researchers wanted to analyse the effectiveness of a multidisciplinary protocol for obese patients requiring liver transplantation. As a result, they developed a programme offering a combined liver transplant and sleeve gastrectomy procedure for patients who were unsuccessful in attaining sufficient weight loss in the non-invasive pre-transplant weight loss programme.

A total of 37 patients who achieved their weight goal had a liver transplant, while seven patients who did not achieve their pre-transplant target weight had a combined liver transplant and sleeve gastrectomy procedure.

There were three deaths in the transplant only group and three patients who required re-transplant (two for early graft dysfunction and one for chronic rejection). Of the remaining transplant patients, 60% had a post-transplant BMI>35, 35% of patients have post-transplant diabetes mellitus and 20% demonstrating steatosis on ultrasound.

Combined procedure

The combined procedure involved a caval sparing hepatectomy and a duct to duct biliary anastomosis. The sleeve procedure was performed by a bariatric surgeon after the transplant using a 9mm endoscope placed along the lesser curve of the stomach. The operators used a combination of 45mm 4.8 and 60mm 3.5 Covidien Endo-GIA staple loads to resect the antrum and greater curve. The surgeons left a small amount of cardia in place in order to avoid injury to the oesophagus.  A running 3–0 PDS suture was used to over-sew the staple line, visualised from the lumen of the stomach to ensure hemostasis.

There were no deaths from the patients in the combined procedure group; all patients had normal allograft function and significant weight loss with a mean BMI of 28. None of the patients require insulin or oral hypo-glycaemic treatment.

Complications in the combined procedure group included one patient with severe early graft dysfunction who developed a leak from his gastric staple line, resulting in multiple re-operations and an extended hospital stay. A second patient developed a large groin haematoma, which was managed conservatively. A third patient had one episode of steroid-resistant rejection, which required treatment with thymoglobulin.

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