Tariq Nabil, Saharia Ashish, Nwokedi Ugoeze, Hobeika Mark J, Mobley Constance M, Hsu David, Potter Lucy M, Moore Linda W, Elaileh Ahmed, Sherman Vadim, Ghobrial R Mark
Department of Surgery , Houston Methodist Hospital , Houston , Texas , USA.
Liver Transpl. 2023 Apr 1;29(4):422-430. doi: 10.1002/lt.26560. Epub 2022 Sep 9.
Pretransplantation bariatric surgery in patients with high Model for End-Stage Liver Disease (MELD) score is fraught with risks. Bariatric surgery after liver transplantation (LT) may be complicated by surgical adhesions but could have advantages if performed at the time of transplantation. We investigated a method of brief-interval staging combining LT and sleeve gastrectomy (SG). LT recipients with a body mass index (BMI) > 40 kg/m 2 received an SG during the same hospitalization as the LT (LT/SG), at the same time as a planned brief-interval return to the operating room for biliary anastomosis. Differences in intraoperative attributes of the LT (Stage 1) versus SG (Stage 2) procedures were analyzed using Wilcoxon signed-rank test with significance p < 0.05 and compared with patients with obesity having a two-stage LT without SG. A total of 14 cases {median MELD score 33 (interquartile range [IQR], 18-40)} were compared with 28 controls; 60% were critically ill prior to surgery with mechanical ventilation, vasopressors, or continuous renal replacement therapy. Median interval between procedures was 16.1 (IQR, 12.5-22.7) hours for cases and 12.2 (IQR, 11.1-16.6) hours for controls, p = 0.27. Median BMI at LT/SG was 47.0 (IQR, 41.7-51.3) kg/m 2 versus 38.1 (IQR, 35.7-39.8) kg/m 2 for controls, p < 0.001. At 1 year, median excess body weight loss was 74.0% (IQR, 46.2%-78.7%) in cases and 15.8% (IQR, -5.4% to 62.6%) in controls, p = 0.13; total weight loss was 38.1% (IQR, 23.9-42.9) in cases versus 7.7% (IQR, -2.4% to 27.6%) for controls, p = 0.03. Graft survival at 1 year was 92.9% for cases and 89.3% for controls with similar early postoperative outcomes. This proof-of-concept study revealed that a brief-interval SG during LT is feasible in patients with high MELD and resulted in sustained weight loss at 1 year with similar graft survival. Further studies are needed to determine an optimal strategy.
终末期肝病模型（MELD）评分高的患者在肝移植前进行减肥手术充满风险。肝移植（LT）后进行减肥手术可能会因手术粘连而出现并发症，但如果在移植时进行则可能具有优势。我们研究了一种将肝移植和袖状胃切除术（SG）相结合的短间隔分期方法。体重指数（BMI）>40 kg/m²的肝移植受者在与肝移植相同的住院期间接受袖状胃切除术（LT/SG），同时计划在短间隔后返回手术室进行胆道吻合术。使用Wilcoxon符号秩检验分析肝移植（第1阶段）与袖状胃切除术（第2阶段）手术的术中特征差异，显著性p<0.05，并与接受两阶段肝移植且未行袖状胃切除术的肥胖患者进行比较。共14例患者{中位MELD评分为33（四分位间距[IQR]，18 - 40）}与28例对照进行比较；60%的患者在手术前病情危急，需要机械通气、血管加压药或持续肾脏替代治疗。病例组手术之间的中位间隔时间为16.1（IQR，12.5 - 22.7）小时，对照组为12.2（IQR，11.1 - 16.6）小时，p = 0.27。LT/SG组的中位BMI为47.0（IQR，41.7 - 51.3）kg/m²，对照组为38.1（IQR，35.7 - 39.8）kg/m²，p<0.001。1年后，病例组的中位超重体重减轻率为74.0%（IQR，46.2% - 78.7%），对照组为15.8%（IQR， - 5.4%至62.6%），p = 0.13；病例组的总体重减轻率为38.1%（IQR，23.9 - 42.9），对照组为7.7%（IQR， - 2.4%至27.6%），p = 0.03。病例组1年时的移植物存活率为92.9%，对照组为89.3%，术后早期结果相似。这项概念验证研究表明，在MELD评分高的患者中，肝移植期间进行短间隔袖状胃切除术是可行的，并且在1年时能实现持续体重减轻，移植物存活率相似。需要进一步研究以确定最佳策略。
