Bariatric Surgery in the Transplant Patient

| July 18, 2012

by Kunoor Jain-Spangler, MD, and Dana Portenier, MD

Drs. Jain-Spangler and Portenier are from Duke University Medical Center, Durham, North Carolina.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

ABSTRACT
Obesity in the transplant patient is neither new nor easy to manage. In this article, we identify the benefits of bariatric surgery in the different transplant populations as well as the three major operations being performed to ameliorate this problem: laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass, and laparoscopic sleeve gastrectomy. Each procedure has various advantages as well as disadvantages, and these are discussed in detail. We believe obesity in pre- and post transplant patients can be managed with bariatric surgery although the patient population with organ failure versus insufficiency is higher risk and requires further research. Bariatric Times. 2012;9(7):16–17

Introduction
The idea of transplanting organs is not new, nor is the disease of obesity. Transplantation can be found as far back as the myths of the ancient Greeks while the first successful renal transplant in twins was performed in 1954.[1] Most scientific work in the transplant population focuses on acute and chronic rejection despite obesity being a devastating problem. Human obesity is clearly depicted in Stone Age artifacts as well as in ancient Greece and Rome. The first scientific discussion can be seen in Vesalius’ 1543 treatise, De humani corporis fabrica.[2] Since then, no optimal medical therapies have been described for patients with morbid obesity, especially in transplant patients.

There are three main patient scenarios in discussing bariatrics and transplantation. The first is that of the patient with morbid obesity with organ insufficiency (e.g., renal insufficiency, heart failure, hepatic insufficiency). The second scenario is the patient with morbid obesity with organ failure (e.g., on bridging therapies such as dialysis or with a left ventricular assist device [LVAD]). The final scenario is the post-transplant patient who has become morbidly obese. The first and third scenarios appear to be the ideal time for obesity intervention. This article will discuss these patients more comprehensively. Organ insufficiency can often be cured by transplantation but patients with morbid obesity are less likely to receive a transplant. In one study,[3] it was shown that those with a body mass index (BMI) of 40kg/m2 or greater are 44 percent less likely to receive a transplant.

The rationale behind this is not motivated by malice or bias, but rather the results of several studies that have shown patients with morbid obesity have two times the number of cardiac events as well as a higher incidence of delayed graft rejection and reduced life expectancy.[4–10] From an operative standpoint, patients with morbid obesity have more wound infections and require more operative time.[6,11,12] Due to the findings of these and several other studies, the United Network for Organ Sharing (UNOS) has developed criteria for each type of transplantation that patients must meet preoperatively in order to undergo transplant surgery. Criteria for transplantation are rather strict and include BMI, often set at 30 to 35kg/m2.

Fortunately, obesity is a condition that can and should be altered in order to hasten a patient’s ability to qualify for transplant surgery. There are several surgical options, and over the last few years the procedure of choice in the pre-transplant patient has been debated.
Laparoscopic adjustable gastric banding. The laparoscopic adjustable gastric band (LAGB) prior to transplant surgery is a consideration as it has lower perioperative risk compared to other weight loss surgeries.[13] There is also no permanent alteration of the gastrointestinal (GI) anatomy and no malabsorption, which may affect a patient’s ability to absorb medications required after an organ transplant operation. Some disadvantages of the LAGB procedure include slower weight loss overall when compared to other bariatric procedures. LAGB requires the implantation of a foreign body, which may complicate the immune system in patients with future immunosuppression requirements due to transplant surgery and LAGB also has a high surgical revision rate (up to 60%).[14]
One recent study[15] advocates LAGB as the procedure of choice in pancreas transplant due to the previously mentioned advantages.

Laparoscopic Roux-en-Y gastric bypass. Laparoscopic Roux-en-Y gastric bypass (RYGB) is another surgical option for the patient seeking weight loss in order to qualify for an organ transplant. While the data on this subject are scarce, the conclusions from these few published studies are that RYGB is the best method for pre-transplant weight loss.16 It is associated with moderate perioperative risk and good weight loss. There is no foreign body long term; however, there is the added risk of bowel anastomoses as well as malabsorption.

A study Takata et al[17] looked at seven patients with end-stage renal disease (ESRD) who underwent RYGB in order to meet the BMI criterion for renal transplantation. There were no perioperative complications, and the patients experienced mean excess weight loss (EWL) of 61 percent at 9+ months. More importantly, all ESRD patients reached a BMI that qualified them transplant surgery.

Another long-term study[18] of patients with chronic kidney failure (CKF) also concluded that gastric bypass surgery is a safe and effective means for achieving significant long-term weight loss and relief of comorbid conditions in patients with renal failure on dialysis and in preparation for transplantation.

Laparoscopic sleeve gastrectomy. The third bariatric procedure now being performed for pre-transplant weight loss is laparoscopic sleeve gastrectomy (SG), which involves a longitudinal resection of the stomach on the greater curvature. This procedure is relatively new in the transplant population and there are little data. SG is associated with reasonable perioperative risk, somewhere between the

LAGB and RYGB. Thus far, there appears to be good, sustainable weight loss, and again there is no implantation of a foreign body. In SG, there is irreversible gastric resection with some decrease in hydrochloric acid production; however, the important point is that there is minimal malabsorption, which is importnat from a medication standpoint as the pylorus remains intact. Of the sparse data published, one study[19] reported the outcomes of nine patients with chronic kidney disease (CKD) who underwent SG. Five patients were on hemodialysis preoperatively and of these patients four made it to the transplant list. The results of this study suggest that LSG is an effective treatment for obesity in patients with CKD.

Choosing the Best Operation
So, which procedure is right for which patient? We feel this decision should be individually based on the patient, taking into account several factors, including the following:
•    End organ being transplanted
•    Amount of weight loss necessary to get to transplant weight
•    Urgency of transplantation (i.e., patient with very limited dialysis access may not have time to wait for LAGB to work)
•    Past surgeries that may provide an obstacle to performing a specific type of bariatric or transplant procedure or may interfere with medication absorption
•    Comorbidities.

Ultimately, the decision should be made following intense discussion between the patient, bariatric surgeon, and transplant surgeon. This must be a multidisciplinary team approach from the beginning that will continue for the life of the patient.

Considerations
The patient who gains weight following transplant surgery is not uncommon; in fact, 20 percent of lean patients develop obesity within two years of transplantation.[20] This may in part be explained by corticosteroid effect as well as the actions of leptin.[21] Leptin is a hormone produced in adipose tissue and stimulated by steroids that plays a key role in regulating energy intake and energy expenditure, including appetite and metabolism.[19] It may also be a potential salt-regulating factor and may function pathophysiologically as a common link to obesity and hypertension.[22] Hyperleptinemia has been found in patients with ESRD and drops after renal transplant while Epogen also decreases leptin levels.21 Patients with ESRD on chronic steroids find themselves in a hyperleptinemic state that prevents progression to morbid obesity. Unfortunately, once these patients undergo transplant surgery their leptin levels fall, often giving rise to obesity.[21,23] Transplant patients with obesity suffer from far more early death than their cohorts, and this early death is in most cases not due to increased rejection, but due to complications of obesity.[24] Currently there are several case reports and series that bariatric surgery following transplantation is safe, feasible, and effective.[25,26]

Conclusion
When combined, organ failure and obesity present a problem that should not be left unaddressed. We feel that patients with obesity with organ insufficiency can be appropriately screened and prepared for bariatric surgery, allowing them the opportunity to make it to transplantation. In addition, we feel that patients who gain weight following transplant surgery should in no way be excluded from receiving a bariatric procedure. On the contrary, these patients should undergo active workup and preparation for bariatric surgery to prevent recurrence of comorbidities or failure of the transplanted organ. Patients with obesity who have already suffered organ failure and are in need of bariatric and transplant surgery are a poorly studied and poorly understood population. There are case reports in which these patients have been successfully bridged through bariatric surgery by medical implements like dialysis or an LVAD and made it to transplantation.[25,26] These case reports are sparse, however, and this patient population will benefit from continued research.

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