Background

NASH is progressively becoming the leading cause of end-stage liver disease and liver transplantation. Of liver transplant recipients, 12.5% of are morbidly obese. Many patients are unsuitable for liver transplantation due to obesity. Despite evidence supporting bariatric surgery to prevent liver disease progression, bariatric surgery is rarely performed in patients with advanced liver disease. We present our pre-operative optimization protocol, surgical technique, and outcomes in patients with cirrhosis and portal hypertension who are liver transplant candidates.

Methods

Patients with MELD score>15, significant portal hypertension, and who were liver transplant candidates were identified and reviewed.

Results

Four patients were included. All patients were male. Median age was 56 years (42-63), mean BMI 41.6, mean MELD score 16.3 (15-18), and mean Childs B 7.2 (7-8). Calculated Vocal-Penn risk of 30-day mortality was 5.5%, 90-day decompensation was 25.3%. Three patients had previous esophageal variceal bleeding, one had previous sleeve gastrectomy. All patients were optimized by hepatology preoperatively. Three patients underwent laparoscopic sleeve gastrectomy, one patient sleeve to gastric bypass. Mean blood loss was 150 ml (20-450), median hospital stay was 3 days (2-4). 30-day and 90-day mortality and 90-day decompensation rate was 0%.

Conclusions

Despite the data on weight loss for prevention of liver disease progression and disease recurrence after transplantation, bariatric surgery is not being widely utilized. The timing of surgery is an area of discussion. Our findings support the literature, suggesting in pre-transplant bariatric surgery, there are low rates of surgery-related complications and peri-transplantation morbidity at 30 and 90 days.