Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA.
Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI, USA.
Transpl Infect Dis. 2021 Apr;23(2):e13484. doi: 10.1111/tid.13484. Epub 2020 Oct 15.
The impact of pre-transplant (pre-TXP) bariatric surgery (BS) on outcomes after liver transplant (LTX) has not been completely elucidated. Roux-en Y gastric bypass (RYGB) is one of the most common BS procedures. The primary objective of this study was to identify the risk of infection in LTX recipients with pre-TXP RYGB.
Adult patients with LTX between 1/1/2001 and 9/30/2018 at our center were screened for pre-TXP RYGB; patients with gastrectomy via sleeve or banding were excluded. Patients with no history of BS pre- or post-transplant were placed in a comparator group, matched 2:1 via incidence density sampling on age epoch.
There were 16 LTX recipients with pre-TXP RYGB matched to 32 controls. Median time from RYGB to transplant was 11.7 years. Mean weight loss was 66 ± 19 kg. There were significantly more women with pre-TXP RYGB than in the matched control (RYGB:68.8% vs control:25%, P = .009). Demographics were otherwise similar between groups. Pre-TXP RYGB did not significantly increase hospital or ICU length of stay (P = .5, P = .3) but was associated with a significantly increased rate of fungal infection at 1 year (RYGB:33.4% vs control:9.7%, P = .01), and a numerical trend to increased bacterial infection (RYGB:56.2% vs control:32.2%, P = .09).
Despite the substantial weight loss attributed to BS, patients with pre-TXP RYGB demonstrated increased rates of fungal infection after transplant and trended toward increased bacterial infection. While the anatomical complexity associated with LTX surgery after RYGB did not appear to significantly affect ICU or hospital length of stay, it may have contributed to overall infectious risk, and possibly to impaired survival. Additionally, bypass of the host natural barrier defenses of the stomach could also have contributed to infectious risk. Our findings highlight the complexity of this patient population. Future prospective studies are needed to investigate risk of infection after LTX in the setting of pre-Txp BS. Potential modification in fungal prophylaxis protocols to include pre-TXP RYGB may be warranted.
移植前（TxP）减重手术（BS）对肝移植（LTX）后结局的影响尚未完全阐明。Roux-en Y 胃旁路术（RYGB）是最常见的 BS 手术之一。本研究的主要目的是确定 LTX 受者 TxP RYGB 后的感染风险。
对 2001 年 1 月 1 日至 2018 年 9 月 30 日期间在本中心接受 LTX 的成年患者进行 TxP RYGB 筛查；排除胃切除术经袖状或带的患者。无 BS 术前或术后史的患者被纳入对照组，通过年龄时段的发生率密度抽样进行 2:1 匹配。
16 例 LTX 受者 TxP RYGB 与 32 例对照匹配。从 RYGB 到移植的中位时间为 11.7 年。平均体重减轻 66±19kg。TxP RYGB 组的女性明显多于对照组（RYGB：68.8% vs 对照组：25%，P=0.009）。两组之间的其他人口统计学特征相似。TxP RYGB 并未显著延长住院或 ICU 住院时间（P=0.5，P=0.3），但 1 年时真菌感染率显著升高（RYGB：33.4% vs 对照组：9.7%，P=0.01），且细菌感染呈数值增加趋势（RYGB：56.2% vs 对照组：32.2%，P=0.09）。
尽管 BS 导致体重明显减轻，但 TxP RYGB 患者移植后真菌感染率增加，细菌感染率呈增加趋势。尽管 RYGB 后 LTX 手术的解剖复杂性似乎并未显著影响 ICU 或住院时间，但它可能会增加整体感染风险，并可能影响存活率。此外，绕过宿主胃的天然屏障防御也可能增加感染风险。我们的研究结果突出了这一患者群体的复杂性。未来需要前瞻性研究来调查 TxP BS 背景下 LTX 后的感染风险。可能需要修改真菌预防方案，将 TxP RYGB 包括在内。
