Liver transplantation and sleeve gastrectomy in the medically complicated obese: New challenges on the horizon.

In the last 30 years, operative, technical and medical advances have made liver transplantation (LT) a life-saving therapy that is used worldwide today. Global industrialization has been a contributor to morbid obesity and this has brought about the metabolic syndrome along with many downstream complications of such. Non-alcoholic steatohepatitis (NASH) has become a recognized hepatic manifestation of the metabolic syndrome and NASH cirrhosis is predicted to be the primary indication for LT in the United States by 2025. Several case series and database reviews have begun analyzing the efficacy of weight reduction surgery in the LT recipient. These data have reasonably demonstrated that weight reduction surgery in the LT recipient is a feasible endeavor. However, several questions have been raised regarding the type of weight reduction surgery, timing of surgery in relation to LT, patient and allograft survival and post-LT maintenance of weight loss to name a few. We look forward to a time when weight reduction surgery will work to improve the technical conduct of LT, improve perioperative benchmarks such as blood transfusions, intensive care unit length of stay and help to prevent recurrence of NASH cirrhosis in the medically complicated obese patient. In the meantime, well-designed prospective clinical trials that focus on the issues highlighted will help guide us in the care of these complicated patients who will soon account for the majority of the patients in our clinics.