Bariatric surgery in liver transplant patients: weighing the evidence.

In developed nations, physicians must modify their practices in order to provide good medical care to an increasing number of patients who suffer from obesity [1]. Transplant surgeons have especially struggled to adapt their practices as an increasing number of obese patients compete for a scarce supply of donor organs [2]. Generally, patients are considered transplant candidates if they have a reasonable chance of surviving for 5 years following surgery. Patient selection is complicated when this principle is combined with the paradoxical approach of prioritizing patients with the greatest severity of liver disease [3]. Under these circumstances, the survival statistics for obese patients has been very disappointing [4, 5]. Far more obese patients suffer from early death and donor graft loss than other transplant recipients. Early deaths are clearly caused by complications due to obesity. The death rate due to cardiovascular and pulmonary disease and complications of insulin resistance mirrors the higher rate of medical problems in obese patients in general. Previously, many obese and virtually all morbidly obese patients were denied access to transplantation [6]. However, the solution is not that easy anymore. It has become increasingly difficult to dismiss a growing segment of the patient population. In addition to treating more patients with obesity, nonalcoholic fatty liver disease (NAFLD) caused by obesity-associated insulin resistance has recently emerged as the third most common cause of liver disease in the USA [7]. Epidemiologists project that it will be the most prevalent cause of liver failure requiring transplantation in this next decade. The transplant community now thinks about the obese candidates differently. The question is not if we should transplant obese patients but rather how do we improve their outcome. Behavioral weight loss programs are usually the first line of treatment for obesity [8]. While many healthy patients have problems with compliance, these programs are usually unrealistic in patients who are ill and often have insulin resistance as part of their disease process. The disappointing results of behavioral programs as a single intervention brought attention to bariatric surgery as an adjunct means to achieve long-term weight loss. If bariatric surgery is that effective, then why not use it in liver transplant candidates? In fact, a new report of bariatric surgery in a transplant recipient appeared in the August issue of this journal [9]. That case report which described adjustable gastric banding during liver transplantation raised a number of interesting and important questions. At the very foundation of weight loss intervention is the pervasive question: how much weight does the patient have to lose to improve outcome. The growing number of patients with NAFLD makes this an urgent problem to solve. The American Gastroenterological Association suggests that patients with NAFLD should reduce their weight by 10% [10]. However, no one actually knows if this goal will work equally well for all patients with NAFLD or if it will have any effect in other types of liver disease? OBES SURG (2008) 18:1515–1516 DOI 10.1007/s11695-008-9712-7