The Multicenter Belgian Survey on Liver Transplantation for Hepatocellular Failure after Bariatric Surgery

doi:10.1016/j.transproceed.2010.07.010

Transplantation Proceedings

Volume 42, Issue 10, December 2010, Pages 4395-4398

https://doi.org/10.1016/j.transproceed.2010.07.010 Get rights and content

Abstract

The prevalence of obesity has grown dramatically over the last decades, with nonalcoholic steatohepatitis increasingly observed. Therapeutic options for morbid obesity include bariatric surgery. Fatal liver failure (LF) has been recorded after jejunoileal bypass (JIB) but is controversial after biliopancreatic diversion (BPD, Scopinaro operation). We performed a survey on the frequency of liver transplantation (LT) after bariatric surgery in Belgium. An enquiry was sent to all Belgian liver transplant centers to investigate the occurrence of subacute and chronic LF after bariatric surgery. After weight-reduction surgery, 10 patients in 3 Belgian transplant centers were listed for LT due to severe hepatocellular failure. Nine of them had undergone a Scopinaro operation and 1 a jejunoileal bypass. The median time to develop LF was 5 years. The patient with JIB developed chronic LF after 25 years. Seven patients were transplanted; two died awaiting a graft and one is still on the waiting list. After LT, 1 patient developed rapid reappearance of LF at 10 months, requiring retransplantation. Two recipients died after LT because of multiorgan failure shortly after transplantation. In another case, a de novo cancer was fatal at 6 years' follow-up. The remaining recipients were doing well. According to this survey, the BPD operation carries a potential risk of LF. However, because there were only 10 cases, we remain unaware of the actual incidence of Scopinaro operation–induced LF. We advise strict follow-up of liver function and timely dismantling of BPD.

Section snippets

Methods

An enquiry was sent to all transplant centers in Belgium to report the number of LTs performed for liver failure after bariatric surgery. A prospective database was set up to record various demographic, clinical, and surgical parameters, focusing on the degree of hepatocellular failure, the timing of its occurrence, and the outcome after LT. The 10 patients were reported by 3 out of 6 Belgian transplant centers: Ghent (n = 5), Leuven (n = 3), and Antwerp (n = 2).

Results

One patient developed chronic liver failure after JIB. The bariatric procedure was performed in 1977. She had a body mass index (BMI) of 45 kg/m² at the time of surgery and a postoperative decline to 26 kg/m². The diagnosis of chronic liver failure was established in 2002, ie, 25 years after the JIB. Occurrence of signs of decompensated liver failure indicated the need for transplantation. The LT was uneventful; the JIB was dismantled at the time of transplantation to prevent a relapse of liver

Discussion

This Belgian survey has reported 10 patients who developed liver failure after bariatric surgery: 1 after JIB and 9 after BPD. Since 1970, JIB became a popular treatment for morbid obesity. Unfortunately, this operation resulted in manifold postoperative complications, including increased steatosis, lobular lymphocytic inflammation, and pericellular fibrosis leading to cirrhosis.⁶ Acute liver failure after JIB has been recorded in 1.2%–11% of subjects in several reports. Some patients who

References (20)

J.G. Kral et al.
Effects of surgical treatment of the metabolic syndrome on liver fibrosis and cirrhosis
Surgery
(2004)
K.A. Elder et al.
Bariatric surgery: a review of procedure and outcomes
Gastroenterology
(2007)
J.H. Payne et al.
Surgical treatment of obesity
Am J Surg
(1969)
J.A. Lowell et al.
Liver transplantation after jejunoileal bypass for morbid obesity
J Am Coll Surg
(1997)
S.L. Heimburger et al.
Reversal of severe fatty hepatic infiltration after intestinal bypass for morbid obesity by calorie-free amino-acid infusion
Am J Surg
(1975)
N. Scopinaro et al.
Biliopancreatic diversion for obesity at eighteen years
Surgery
(1996)
E.J. Drenick et al.
Hepatic steatosis after intestinal bypass-prevention and reversal by metronidazole, irrespective of protein-calorie malnutrition
Gastroenterology
(1982)
E. Fabbrini et al.
Obesity and nonalcoholic fatty liver disease: biochemical, metabolic and clinical implications
Hepatology
(2010)
H. Buchwald et al.
Bariatric surgery: a systematic review and meta-analysis
JAMA
(2004)
R. De Ridder et al.
Review article: non-alcoholic fatty liver disease in morbidly obese patients and the effect of bariatric surgery
Aliment Pharmacol Ther
(2007)

There are more references available in the full text version of this article.

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Liver transplantationThe Multicenter Belgian Survey on Liver Transplantation for Hepatocellular Failure after Bariatric Surgery

Abstract

Section snippets

Methods

Results

Discussion

Surgery

Gastroenterology

Am J Surg

J Am Coll Surg

Am J Surg

Surgery

Gastroenterology

Obesity and nonalcoholic fatty liver disease: biochemical, metabolic and clinical implications

Hepatology

Bariatric surgery: a systematic review and meta-analysis

JAMA

Review article: non-alcoholic fatty liver disease in morbidly obese patients and the effect of bariatric surgery

Aliment Pharmacol Ther

Liver transplantation
The Multicenter Belgian Survey on Liver Transplantation for Hepatocellular Failure after Bariatric Surgery