Baylor University Medical Center, Dallas, TX.
Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
Liver Transpl. 2019 Feb;25(2):217-227. doi: 10.1002/lt.25368.
Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End-Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention-to-treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1-year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2-15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8-13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105-141] cm versus 153 [131-191] cm ; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.
减重手术（BS）在治疗病态肥胖方面是有效的，但先前 BS 对肝移植（LT）候选资格的影响尚不清楚。我们研究了 78 例肝硬化合并先前 BS 的患者，并与 156 例同期患者进行了比较，这些患者按年龄、终末期肝病模型评分和基础肝病进行了匹配。我们比较了评估后移植拒绝率、在等待名单上除名率和 LT 后生存率。从 BS 到 LT 评估的中位时间为 7 年。Roux-en-Y 胃旁路术是最常见的 BS 手术（队列的 63%）。非酒精性脂肪性肝病是肝硬化的主要病因（47%）。BS 患者的除名/死亡在等待名单上的比例更高（33.3%比 10.1%；P=0.002），移植率更低（48.9%比 65.2%；P=0.03）。BS 队列与同期队列相比，从列入名单到 LT 后 1 年的意向治疗（ITT）生存率较低（1 年生存率，84%比 90%；P=0.05）。在调整分析中，BS 史与等待名单上死亡的风险增加相关（风险比[HR]，5.7；95%置信区间[CI]，2.2-15.1），但这种影响通过营养不良的存在而减弱（HR，4.9；95%CI，1.8-13.4）。当按性别与匹配对照组进行限制时，BS 引起的死亡率对女性不再具有统计学意义（P=0.37），但对男性仍具有统计学意义（P=0.046）。在一部分患者（n=49）中计算了骨骼肌指数表示的肌少症。BS 组的总骨骼表面积较低（127[105-141]cm 比 153[131-191]cm；P=0.005）。在列入名单后除名的患者中，肌少症的发生率更高（71.4%比 16.7%；P=0.04）。总之，BS 史与等待名单除名率升高以及 ITT 分析中从列入名单开始的生存率降低有关。BS 患者营养不良和肌少症的存在可能导致预后更差。
