RAMB - Fevereiro 2017

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2017; 63(2):190-194

factors that generate potential biases and limit the find-

ings. Another systematic review, conducted by Jan et al.,

showed favorable results comparable to those of the gen-

eral obese population in relation to weight loss and the

resolution of comorbidities. On the other hand, the au-

thors underscore that the risks are significantly higher,

with 21.3% surgical morbidity, 1.6% perioperative mortal-

ity and 2.4% late-onset mortality. The risk of decompen-

sation of liver function was also high (6.5%) and should

be taken into consideration. The main results of the stud-

ies evaluated are presented in Table 1.

Among severe cirrhotic patients that are candidate to

liver transplant, the choice of technique to be employed

is fundamental due to two key issues: potential damage

to the absorption of immunosuppressive medication and

the possibility of endoscopic access to the biliary tree.

There are no studies examining the pharmacokinetics of

immunosuppressants in liver transplant patients under-

going bariatric surgery. In kidney transplant patients

undergoing gastric bypass, however, there are reports of

a need for larger doses of tacrolimus, sirolimus, myco-

phenolate sodium and cyclosporine.

With regard to

access to the biliary tree, stenoses are common after de-

ceased donor transplants, occurring in up to 17% of cases.

Due to these factors, vertical sleeve gastrectomy appears

to be the most appropriate technique in this group of

patients, as it does not cause significant malabsorption

and enables endoscopic access to the biliary tree.

The ideal time for bariatric surgery in liver transplant

candidates is another controversial issue. There is a pos-

sibility of performing the procedure before, after and even

during transplantation. A relevant concern in this regard

is the impact of obesity on the outcome of the transplant.

Recent studies have reported that operative mortality,

two-year survival and graft viability are similar in obese

and non-obese individuals. Perioperative morbidity is

slightly higher.

2,3

Performing bariatric surgery in non-

-compensated transplant candidates leads to higher mor-

bidity and mortality, including the occurrence of anasto-

motic fistulas, which often reaches 12.5%.

21,22

Recently, there has been growing interest in the pos-

sibility of endoluminal treatments for obesity in indi-

viduals with high surgical risk. An endoscopic intragastric

balloon implant in this group of patients, which is an

attractive alternative, has presented satisfactory results

in studies conducted by Choudhary et al.

A case report by Campsen et al.

showed the realiza-

tion of adjustable gastric band implantation during a

liver transplant had satisfactory results after 6 months.

Heimbach et al.

reported the combined realization of

liver transplantation and vertical sleeve gastrectomy in

seven patients with one case of a fistula on the staple line

and zero mortality. The combined option is interesting

because it reduces the number of surgical approaches in

high-risk patients. On the other hand, this approach re-

quires complex logistics (especially the concomitant avail-

ability of transplant and bariatric teams) and can combine

serious complications that are not related to either pro-

cedure.

21,22,26,27

Therefore, in patients with non-compen-

sated cirrhosis or with moderate to severe portal hyper-

TABLE 1

Main results of bariatric surgery in individuals with liver diseases.

Study

N Type of study

Surgical technique

Morbidity Perioperative

mortality

Late mortality

Takata et al.

15 Retrospective cohort

Vertical sleeve gastrectomy

and gastric bypass

13.3%

Lin et al.

26 Retrospective cohort

Vertical sleeve gastrectomy 23.1%

Mosko et al.

(Compensated cirrhosis)

3,888 Retrospective cohort

Several

0.9%

Mosko et al.

(Decompensated cirrhosis)

62 Retrospective cohort

Several

16.3%

Dallal et al.

30 Retrospective cohort

Gastric bypass

30%

3.3%

Woodford et al.

14 Prospectively collected

database analysis

Adjustable gastric band 14.3%

Shimizu et al.

23 Prospective database

analysis

Vertical sleeve gastrectomy

and gastric bypass

34.8%

4.3%

Lazzati et al.

56 Meta-analysis

Several

23.2%

5.3%

Jan et al.

122 Meta-analysis

Several

21.3%

1.6%

N: number of patients; NR: not reported.