The rising tide of obesity and its related liver complications, particularly non-alcoholic steatohepatitis (NASH), presents a complex challenge that requires the collaborative expertise of multiple surgical specialties. This blog post will delve into the distinct yet interconnected roles of hepatobiliary, general, and transplant surgeons in addressing these issues, focusing on how their combined efforts lead to better patient outcomes.

The Growing Need for Specialized Surgical Care

The increasing prevalence of obesity has led to a surge in non-alcoholic fatty liver disease (NAFLD), with a significant portion progressing to NASH, cirrhosis, and eventually, liver failure [1, 2]. This has not only increased the demand for liver transplantation (LT), but has also made bariatric surgery (BS) a crucial intervention. The management of these conditions requires a multidisciplinary surgical approach, with hepatobiliary, general, and transplant surgeons playing vital roles.

Hepatobiliary Surgeons: The Liver Experts

Hepatobiliary surgeons specialize in diseases of the liver, gallbladder, bile ducts, and pancreas. Their crucial contributions include:

Pre-Transplant Evaluation: Assessing patients with advanced liver disease to determine their suitability for transplantation, carefully evaluating the severity of liver damage and associated conditions [3].
Complex Surgical Procedures: Performing liver transplant procedures, managing vascular issues, bile duct problems, and other complications during and after the surgery [3].
Management of Complications: Addressing issues that arise during or after liver transplantation and bariatric surgery [3].
Multidisciplinary Collaboration: Working with other specialists to provide holistic care for patients requiring liver and/or bariatric procedures, and determining best courses of action for each patient [3].

General Surgeons: The Foundation of Bariatric Intervention

General surgeons are at the forefront of performing bariatric surgeries to address obesity and its related conditions. Their contributions include:

Bariatric Expertise: Performing various bariatric procedures such as sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYBP), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD) [4].
Patient Assessment: Evaluating patients for bariatric surgery, considering their overall health, obesity-related conditions (including NAFLD), and surgical history [4].
Surgical Skill: Performing bariatric procedures meticulously, managing potential complications and ensuring patient safety [4].
Post-Operative Care: Monitoring patients post-operatively, and addressing any issues related to the surgery [4].
Procedure Selection: Deciding the best bariatric procedure based on the patient’s unique profile, with procedures like SG often preferred for patients with liver disease, as it is considered a relatively safer procedure than RYBP [5, 6].

Transplant Surgeons: The Guardians of Liver Replacement

Transplant surgeons are experts in performing liver transplantation, especially in complex cases involving obese patients and those with related conditions like NASH. Their roles include:

Pre-Transplant Assessment: Determining patient suitability for transplantation by assessing the severity of liver disease and associated complications such as obesity and metabolic disorders, while utilizing the MELD score [7].
Intricate Surgical Procedures: Performing the complex surgery of removing a diseased liver and replacing it with a healthy one [7].
Post-Transplant Care: Managing post-operative care, immunosuppression, and monitoring patients for graft rejection and other complications [7].
Managing Complex Cases: Transplant surgeons address the challenges in performing liver transplantation for obese patients, including increased surgical complications, morbidity, and the risk of NASH recurrence [7, 8].
Consideration for Bariatric Surgery: Collaborating with general and hepatobiliary surgeons, they decide on the need for bariatric surgery before or simultaneously with liver transplantation [7].

The Interplay of Bariatric Surgery and Liver Transplantation

The timing of bariatric surgery relative to liver transplantation is a critical consideration:

BS before LT: This approach helps to reduce weight, improve comorbidities, and potentially reduce post-transplant complications [9].
Simultaneous BS and LT: While this approach is more streamlined, requiring only one anesthetic and hospitalization, it demands careful patient selection and may not always be feasible [9].
BS after LT: Although challenging, this may be considered in specific cases, requiring a high level of expertise [9].

The Synergy of Surgical Specialties

The collaborative approach of these three surgical specialties ensures the best possible outcomes for patients facing the combined challenges of obesity and liver disease. They work in tandem to:

Provide Comprehensive Care: Combining expertise to address all aspects of the disease process, from initial assessment to long-term management.
Optimize Treatment Plans: Creating tailored treatment plans based on individual patient needs and conditions.
Ensure Patient Safety: Minimizing risks and complications through meticulous surgical practices and thorough post-operative care.

Conclusion

The management of obesity and liver disease requires a harmonious collaboration between hepatobiliary, general, and transplant surgeons. Their individual expertise, combined with a shared commitment to patient care, provides a comprehensive and effective approach to these complex challenges.

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References

[1] Hales, C. M., Carroll, M. D., Fryar, C. D., & al (2020). Prevalence of obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief, 360(Feb), 1-8.

[2] Abdelaal, M., le Roux, C. W., & Docherty, N. G. (2017). Morbidity and mortality associated with obesity. Annals of Translational Medicine, 5(7), 161.

[3] Martin, P., DiMartini, A., Feng, S., & al (2014). Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology, 59(3), 1144.

[4] Colquitt, J. L., Pickett, K., Loveman, E., & al (2014). Surgery for weight loss in adults. Cochrane Database of Systematic Reviews, 8(8).

[5] Billeter, A. T., Senft, J., Gotthardt, D., & al (2016). Combined non-alcoholic fatty liver disease and type 2 diabetes mellitus: sleeve gastrectomy or gastric bypass?-A controlled matched pair study of 34 patients. Obesity Surgery, 26(8), 1867.

[6] Suraweera, D., Dutson, E., & Saab, S. (2017). Liver transplantation and bariatric surgery: best approach. Clinical Liver Disease, 21(2), 215.

[7] Safwan, M., Collins, K. M., Abouljoud, M. S., & al (2017). Outcome of liver transplantation in patients with prior bariatric surgery. Liver Transplantation, 23(11), 1415.

[8] Mandell, M. S., Zimmerman, M., Campsen, J., & al (2008). Bariatric surgery in liver transplant patients: weighing the evidence. Obesity Surgery, 18(12), 1515.

[9] Zamora-Valdes, D., Watt, K. D., Kellogg, T. A., & al (2018). Long-term outcomes of patients undergoing simultaneous liver transplantation and sleeve gastrectomy. Hepatology, 68(2), 485.