Bariatric Surgery For Patients With End-Organ Failure

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1 Bariatric Surgery For Patients With End-Organ Failure Arnold D. Salzberg, M.D. Andrew M. Posselt, M.D., PhD Divisions of Transplant and Minimally Invasive Surgery University of California, San Francisco Does Obesity Actually Have a Detrimental Impact on Transplant Patients? Evidence Against 1 Dialysis Outcomes and Practice Patterns Study (Leavey, et.al.) Dialysis patients with a BMI of > had a relative risk of death of.77 compared with patients with a normal reference BMI of. Easier to delay position on recipient lists Not covered by insurers P e r c e n t o f P o p u l a t i o n 1 1 Prevalence of Obesity in Patients Awaiting Liver or Kidney Transplant at UCSF - 7 Liver < > BMI 18 1%> 1%> UNOS 1996: 1% BMI> % BMI> 8 P e r c e n t o f P o p u l a t i o n 1 1 Kidney < > BMI 18 9%> 11%> 8 1

2 Increase in Prevalence Friedman, et.al.: >8, ESRD Pts for transplant 11.6% BMI > from 1987 to % BMI > from to % increase!! Does Obesity Affect Outcomes after Transplantation? KIDNEY Wound Infections More blood transfusions Higher rates of delayed graft function Higher rates of early graft loss Higher rates of acute rejection Higher rates of overall graft failure Gore JL, et al. Am J of Transplantation 6 LIVER Intra-op complications and transfusion requirements similar More post-op wound, pulmonary and cardiovascular complications Higher PNF rates (6% vs. 1%) Longer length of stay % higher cost of hospitalization Nair, S, et al. AJG 1, Hepatol Sawyer, RG, et al. Clin Trans 1999 BMI and Graft Survival after Kidney Transplant BMI < BMI > Gore JL, et al. Am J of Transplantation 6

3 Hasse, J: Nutrition in Clin Pract Oct 7 Segev, et.al., J Am Soc Nephrol, 8 BMI and Survival after Liver Transplant BMI > BMI - BMI < Segev, et.al., J Am Soc Nephrol, 8 Hasse, S, Nutr Clin Pract 7

4 Survival after Liver Transplant according to MELD and BMI Goals of Obesity Management in Transplant Patients Improve candidacy Improve preoperative co-morbid condition Decrease postoperative complications Decreasing Wound infections Control: BMI 18.- Very Severely Obese: BMI > Avoid worsening underlying process Dick, A, et al. Liver Transplant 9 Open Gastric Bypass in Patients with ESRD JW Alexander et al., Transplantation 19 pts with ESRD Mean preop BMI = 8 yr postop BMI = pts received Txps Significant decrease in BP and BP med use Significant decrease in Insulin/OHA requirements Stable Albumin, Vitamin levels Management of Obese Transplant Candidates at UCSF BMI > considered a relative contraindication to liver transplantation BMI > considered absolute contraindication BMI > 8 (non-diabetic), > (diabetic) are contraindications to kidney transplantation Weight loss requirements outlined to pt Patients referred to weight loss programs through their PCP's

5 Lap Gastric Bypass in Patients with ESRD - UCSF Demographic and Preoperative Laboratory Data ESRD (n=7) Age (range) 6 (6 6) BMI (range) ( 7) Gender 7/7 female Albumin (range).6 (..8) T bilirubin (range) - INR (range) 1. (.9 1.1) Platelets (range) 66 (161 1) 9 n= 1 Lap Gastric Bypass in Patients with ESRD - UCSF Operation Operative and Perioperative Outcomes ESRD (n=7) LGBP Operative time, min (range) 189 (18-) Mean EBL, ml 6 Complications Mean LOS, days (range). ( - ) Follow-up Information %EWL at > 6 months, (range) ( 7) Comorbidities / off insulin 1/ decreased insulin Transplant candidate at > 6 months / Underwent transplant / Lap GBP in Patients with ESRD B M I 6 Preop 1 Mo Mos 6 Mos 9 Mos 1 Mos Time since Surgery BMI Cutoff for TXP

6 Bariatric Surgery in Patients with Cirrhosis Brolin RE, et al. (Arch Surg 1998) 1 pts. with cirrhosis discovered intraoperatively 91 (7%) underwent planned surgery % -day mortality (sepsis, FHF) 8% late mortality (all due to disease progression) Risks: ascites, coagulopathy, EBL>1cc Surgeon Questionnaire: 9% favored VBG, % GBP, % DS, % do nothing Dallal RM, et al. (Obesity Surg ) pts. with Child-Pugh class A underwent LRYGBP Mean BMI Operative time min, EBL 9cc, Hospital Stay d (-18) No deaths, % early complication rate (ATN, leak, resp decompensation) What is the Best Procedure for the Cirrhotic Patient? Lap GBP Pros: effective, longest experience Cons: complex, potential for nutritional deficiencies, difficulty in taking meds, may affect absorption of meds, EGD/ERCP impossible LAGB (lap band) Pros: short OR time, "reversible" Cons: less weight loss, intensive follow-up, difficulty in taking meds, foreign body, EGD/ERCP difficult DS Pros: rapid weight loss Cons: complex, rapid weight loss, malnutrition, exacerbation of liver disease Laparoscopic Sleeve Gastrectomy Sleeve Gastrectomy in High-Risk Patients Pros: technically easy, no anastomoses, short OR time does not compromise med/nutrient intake allows full endoscopic evaluation, beneficial effect on gut hormones Cons: less weight loss long-term efficacy? Mean preop BMI = 6 6 mos. after LSG Cottam, D, et al. Surg Endo 6 6

7 Post-operative Weight Loss Post-operative UGI Lap Sleeve Gastrectomy Lap R-Y Gastric Bypass Weight Lost (lbs) VG Band GBP DS BMI VG Band GBP DS GEJ Antrum Sleeve GEJ Roux Limb Pouch Time Post-op (months) Time Post-op (months) Lee, C., et al. ASBS Mtg Weight Loss and Endocrine Changes after Sleeve Gastrectomy Patient Selection and Timing BMI > or > w/ severe comorbidities, failed supervised weight loss program Childs A or B Minimal or no ascites Grade 1- esophageal varices Transplant workup completed before surgery Langer, FB, Obesity Surg 7

8 Bariatric Surgery in ESLD Demographic Data Bariatric Surgery in ESLD Perioperative Outcomes Cirrhosis (n=1) Post-transplant (n = ) Cirrhosis (n=1) Post-transplant (n=) Mean Age (y) Mean BMI (range) 9 (6 9) ( ) Gender 8/1 female / female Mean Follow-Up (m) 1. (-6) (1-) Etiology ESLD HCV 8 NASH ALD HCV NASH Number transplanted n/a Procedure LSG LSG (), OGBP () Operative time, min (range) 11 (9-176) 1 (1-18) Mean EBL, ml 1 Liver biopsy histology all stage fibrosis 8/8 grade - steatohepatitis / grade 1- steatosis / stage - fibrosis Complications (UTI, TF, Enceph, Leak) 1 (conversion) Mean LOS, days (range) (-1) (-7) Weight Loss in Cirrhotics after Bariatric Surgery Weight Loss in Post-transplant Patients 6 6 Pt # 1 Pt # Pt # Pt # BMI BMI 1 Pre 1m m 6m 9m 1m 18m m 1 Pre 1 m m 6 m 9 m Time (months) Time (months) 8

9 Metabolic Parameters in Cirrhotics Pre-GBP Current Metabolic Parameters in Post-transplant Patients Cr Albumin Total Bil INR 8 6 MELD Score Awaiting Txp Pre-Tx Pre-GBP Current 18 Pre-GBP 1 Pre-Tx Current Received Txp Cr Albumin Total Bil INR MELD Score 1 6 Cr Albumin Total Bil INR MELD Score NAFLD after Gastric Bypass Steatosis Inflammation GBP after Liver Transplant Pre 1 Yr after GBP Stage Fibrosis (1 pts): -7 regressed to stage -1 to stage 1-1 to stage - 1 no change Dixon, et al. Hepat Open RYGBP, patients Mean BMIs: 9 (pre), 9 (>1. y post) Recurrent NASH resolved in both Duchini, A, et al. Transplantation 1 9

10 Conclusions Thank you! Morbid obesity is common in patients with end-stage liver or kidney disease and compromises transplant outcomes and patient survival Lap Gastric Bypass and Lap Sleeve Gastrectomy are well tolerated by patients with ESRD or ESLD and improve transplant candidacy Bariatric surgery is possible and effective and well tolerated in liver transplant recipients Long-term effects on post-transplant course are not yet known but seem very favorable from our preliminary data at UCSF 1