Simultaneous Liver Transplantation and Sleeve Gastrectomy: First Reported Case in East Asia
Bariatric surgery has emerged as an effective treatment for patients with morbid obesity and its associated metabolic diseases. Among these, non-alcoholic fatty liver disease (NAFLD) is a common comorbidity linked to morbid obesity. Patients with non-alcoholic steatohepatitis (NASH), a severe form of NAFLD, are at a high risk of developing adverse outcomes such as cirrhosis and liver-related mortality. It is predicted that by 2025, liver function failure caused by NAFLD will become the most common reason for liver transplantation (LT) in the United States. Obesity is prevalent in 20% to 30% of LT recipients in the U.S., making weight management a critical factor in post-transplant outcomes. For patients with end-stage liver disease and morbid obesity, failure to control body weight after LT can lead to the recurrence of NAFLD in the donor liver. Simultaneous LT and sleeve gastrectomy (SG) have been proposed as a strategy to effectively manage post-operative body weight and metabolic disorders in these patients. This article presents the first reported case of simultaneous LT and SG in East Asia, highlighting the surgical approach, outcomes, and implications for future practice.
The patient in this case was a 42-year-old man with a height of 1.73 meters, body weight of 110 kilograms, and a body mass index (BMI) of 36.8 kg/m². He presented with hyperlipidemia and moderate obstructive sleep apnea syndrome but had no history of diabetes or hypertension. His primary clinical manifestation was end-stage liver disease, characterized by portal hypertension, severe hypoproteinemia, and refractory ascites, resulting from hepatitis B-induced cirrhosis. The patient also had a history of upper gastrointestinal hemorrhage and spontaneous bacterial peritonitis. Pre-operative clinical evaluation revealed an albumin level of 22.8 g/L, total bilirubin level of 69 mmol/L, prothrombin time of 17.6 seconds, Child grade C liver function, and a Model for End-stage Liver Disease (MELD) score of 30. Intraoperative findings included massive ascites, splenomegaly, gastric varices, and gastric wall edema.
The surgical procedure was conducted in two steps. First, a classic non-bypass orthotopic LT was performed, which significantly improved the patient’s liver function and associated complications. Following the LT, a sleeve gastrectomy was performed. The greater curvature of the stomach was dissected, and thick veins were ligated directly. The gastric resection began 6 cm from the pylorus, and five Echelon stapler reloads (Ethicon Endo-Surgery; Johnson & Johnson, NJ, USA) were used in the order of black, green, gold, blue, and blue. The black reload, which has the maximum staple height (open height of 4.2 mm and closed height of 2.3 mm), was used to minimize the risk of bleeding and tissue damage. The gastric tissue was compressed for one minute before resection to ensure proper stapling. No bleeding or blasting occurred along the staple line, which was subsequently reinforced with a running suture.
Post-operative recovery was generally favorable. The patient experienced transient renal insufficiency, which resolved quickly. Upper gastrointestinal radiography performed three days post-surgery showed no evidence of gastric leakage, and a liquid diet was initiated. The patient was discharged on the 14th post-operative day. At the three-month follow-up, his body weight had decreased to 88 kg, representing a total weight loss (TWL) of 20%. By the six-month follow-up, his weight had further reduced to 80 kg, with a TWL of 27.3%. Liver function remained stable during follow-up, indicating successful transplantation and weight management.
Patients with a BMI greater than 40 kg/m² are at a high risk of primary graft dysfunction and increased mortality, primarily due to cardiovascular complications. This often disqualifies obese patients from LT opportunities. For patients with morbid obesity and end-stage liver disease, LT alone is insufficient; effective weight control is also necessary. Bariatric surgery is currently the only treatment for severe obesity that has demonstrated significant and sustained weight loss. Combining LT with bariatric surgery offers a promising approach for these patients. However, there are no established guidelines regarding the timing or type of bariatric surgery for patients with cirrhosis.
Performing bariatric surgery before LT is associated with high morbidity and mortality due to complications such as portal hypertension, coagulation dysfunction, and gastric wall edema. Studies have shown that the major complication rate for SG before LT is as high as 17.9%. Conversely, performing bariatric surgery after LT is also challenging due to abdominal adhesions and the long-term use of immunosuppressants, which increase surgical risks. The major complication rate for SG after LT is reported to be up to 26.7%. A systematic review suggests that simultaneous LT and bariatric surgery have lower mortality and complication rates compared to staged procedures, whether bariatric surgery is performed before or after transplantation.
SG is the most frequently performed bariatric surgery worldwide, followed by Roux-en-Y gastric bypass (RYGB). Randomized controlled trials have shown that SG and RYGB are equally effective in long-term weight loss and metabolic disorder remission, but SG is associated with fewer complications. Heimbach et al. (2013) reported seven cases of simultaneous LT and SG, with an average BMI reduction from 48 kg/m² to 29 kg/m² after 17 months of follow-up. Zamora et al. (2018) conducted a three-year follow-up study of 13 patients who underwent simultaneous LT and SG, showing an average TWL of 34.8%, compared to 3.9% in the control group. Additionally, the combination surgery group demonstrated better control of hypertension, insulin resistance, and hepatic steatosis.
Despite these promising results, there are no clear indications or contraindications for simultaneous LT and SG. Candidates with severe obesity and obesity-related metabolic disorders may benefit from this combined approach. However, SG can exacerbate gastroesophageal reflux disease (GERD), making it unsuitable for patients with pre-existing symptomatic GERD or hiatal hernias larger than 4 cm. Pre-operative assessments, including computed tomographic angiography and gastroscopy, are recommended to evaluate the severity of perigastric varices. In this case, venous hypertension was alleviated after LT, and the use of a stapler with maximum height, along with tissue compression, minimized bleeding risks. Preservation of the gastric antrum was emphasized to avoid obstruction, and the staple line was reinforced with a running suture, although evidence suggests that suturing does not reduce the risk of gastric leakage.
To the best of our knowledge, this is the first reported case of simultaneous LT and SG in East Asia. This combined approach may offer an effective treatment for patients with end-stage liver disease and morbid obesity. To ensure patient safety, the procedure should be performed by experienced transplantation and bariatric surgery teams using mature surgical techniques. Further research with larger sample sizes and longer follow-up periods is needed to provide robust evidence for this combined surgical approach.
doi.org/10.1097/CM9.0000000000000421
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