Laparoscopic Sleeve Gastrectomy for Obesity After Combined Liver-intestinal Transplantation: A Case Report

After intestinal transplantation (ITx), up to 24% of patients with premorbid obesity will have persistence or relapse of obesity.¹ This is important because obesity is an independent risk factor for graft loss, delayed graft function, and reduced patient survival.² Bariatric surgery is the most effective and durable treatment for morbid obesity. Beneficial effects of bariatric surgery are in part due to altered gastrointestinal physiology and gut–brain–endocrine signaling pathways, which regulate hunger, satiety, and nutrient metabolism.³ In regard to the transplanted intestine, it is unclear whether these pathways can still be therapeutically used because there is intestinal lymphatic disruption and enteric denervation.⁴ When one of our young intestinal graft recipients suffered from morbid obesity and inquired about bariatric surgery, we decided to consider this possibility. We want to share our experience because, to our knowledge, bariatric surgery has not been performed on recipients of an intestinal graft. The institutional review board and patient consented for this case report (S65120).

A 46-y-old female patient underwent combined liver-ITx for short bowel syndrome and intestinal failure–associated liver disease following mesenteric ischemia. She was previously overweight with a body mass index (BMI) of 29 kg/m². At the time of ITx, she weighed 58 kg (BMI: 19 kg/m²). Within 1-y post combined liver-ITx, she regained her premorbid weight. She developed a metabolic syndrome: arterial hypertension treated with amlodipine and hypercholesterolemia treated with statins. Lifestyle changes, diet and exercise, did not result in significant weight loss. There were no signs of nonalcoholic fatty liver disease; a liver biopsy was not performed. There was no diabetes. Nine years after combined liver-ITx, at a weight of 106 kg and BMI of 35 kg/m², laparoscopic sleeve gastrectomy was performed after careful multidisciplinary consideration (Figure 1). Despite extensive intra-abdominal adhesions, the procedure was uneventful. To better assess anatomy, surgery was performed with endoscopy assistance. At 1.5-y follow-up, her weight decreased to 78 kg (BMI: 26 kg/m², 29% total weight loss). The procedure had no effect on liver or intestinal graft function, nor on absorption of immunosuppressive drugs. There was a temporary decline in renal function due to reduced oral intake, which fully recovered. Within 6 mo after sleeve gastrectomy, arterial hypertension and hypercholesterolemia resolved, and medication was stopped.

FIGURE 1.: Timeline of the patient´s weight, total daily tacrolimus and everolimus dosage, tacrolimus and everolimus trough levels, and kidney function (serum creatinine).

Sleeve gastrectomy was the preferred procedure for our patient. Not having to alter the gastrointestinal tractus, as opposed to bypass procedures, had important benefits. Firstly, adhesiolysis of the transplanted small bowel could be avoided. Secondly, the uptake of medication is more reliable after sleeve gastrectomy. This is especially true for immunosuppressive drugs, which are primarily taken up by the duodenum.⁵

To conclude, laparoscopic sleeve gastrectomy was safely performed, with expected outcome in terms of weight reduction. The effect of transplanting the gastrointestinal tract on its function and neurohormonal physiology requires further investigations. In future cases, we plan to test for gut hormones, such as glucagon-like peptide-1, before and after bariatric surgery. These insights could additionally aid in unraveling the complex pathophysiology of obesity and metabolic syndrome. Bariatric surgery should be considered to treat motivated patients with morbid obesity after ITx.