LAUSR

Cirrhosis due to nonalcoholic steatohepatitis (NASH) is an increasingly frequent indication for liver transplantation (LT) in the United States and elsewhere. Bariatric surgery (BS) is the only intervention that leads to a significant weight loss and improvement of obesity-related comorbidities and quality of life maintained in the long term. LT programs now increasingly evaluate candidates who are obese and may also have had prior BS. Some candidates are denied LT because they are morbidly obese while many recipients become increasingly obese after LT. In this issue, Safwan et al. report a retrospective series of 11 patients with a history of BS (9 Roux-en-Y gastric bypasses [RYGP], 1 sleeve gastrectomy [SG], 1 jejunoileal bypass) who underwent LT between 2006 and 2016, representing 1.1% of recipients. Histologic features of NASH were present in all but 1 patient who presented with acute liver failure of unknown etiology. A total of 5 recipients also had a history of significant alcohol consumption. This experience confirms the feasibility of LT after BS. However, there are some important nuances. For instance, if a RYGP has been performed, biliary reconstruction may be difficult if a hepatojejunostomy is required because a second Roux-en-Y loop needs be fashioned. However, all biliary challenges were successfully managed either endoscopically, by interventional radiology, or surgically with a hepatojejunostomy performed in 2 recipients. For the latter, the authors used an access loop to facilitate percutaneous biliary access after LT. The presence of an intestinal bypass did not complicate immunosuppressive management as also reported by others. Recipients’ mean body mass index remained stable. Liver biopsy, performed in 8 (72.7%) recipients, revealed significant macrovesicular steatosis in only 2 (18.2%) patients without NASH recurrence. Although these are short-term results that require confirmation with longer follow-up in larger cohorts of patients, they suggest a protective effect of the RYGP against weight gain and NASH recurrence, which have both become main issues in LT patients. Although BS has induced histologic remission of NASH, longer-term data are needed. While liver fibrosis has been identified as the strongest predictor of poor longterm outcomes in patients with NASH, it remains to be confirmed that BS can prevent progression of liver fibrosis or induce its regression in the long term. In this report, most recipients had a Roux-en-Y gastric bypass. While SG avoids intestinal bypass with all the inherent advantages, more data are needed to define the role of SG in this setting. Indeed, confirmation of the equivalent efficacy of SG to RYGP is still limited. Furthermore, the division of the greater curvature vessels may be complex and challenging in the presence of portal hypertension. Transjugular intrahepatic portosystemic shunt may be an option in morbidly obese patients with compensated cirrhosis who are candidates for BS. However, SG has been associated with an increased risk of portal vein thrombosis. In contrast, although RYGP is considered technically more challenging because of the 2 digestive anastomoses, it requires only the division of small vessels to create the window on the lesser curvature of the stomach with a reduced risk of bleeding and is compatible with LT as shown by Safwan et al. and others. Despite the great enthusiasm for BS, additional work is needed to establish whether the latter may effectively prevent the progression of NASH and liver fibrosis reducing the need for LT. The use of BS in the presence of cirrhosis should be carefully evaluated by a multidisciplinary team including both the liver transplant and the bariatric surgeon.