Simultaneous Vertical Sleeve Gastrectomy And Deceased Donor Liver Transplant In A Pediatric Patient With Cirrhosis And Class 3 Obesity

Background: Liver transplantation is a life saving procedure for children with end-stage liver disease with the goal of returning to a normal healthy life. Obesity and weight gain can lead to post-transplant steatosis and contribute to patient morbidity and mortality. In patients with obesity, simultaneous bariatric surgery can lead to reduced body mass index (BMI) and decrease allograft steatosis and patient metabolic syndrome.Methods: After obtaining patient and family assent/consent, patient records were reviewed and analyzed.Results: The patient was initially evaluated at 8 years of age for right upper quadrant pain. Imaging consistent with cirrhosis and portal hypertension prompted additional workup, revealing positive hepatitis C. Despite treatment and clearance of the hepatitis C virus, he was evaluated for liver transplantation at age 10 due to suspected hepatopulmonary syndrome. The transplant team determined that a simultaneous vertical sleeve gastrectomy would be required due to class 3 severe obesity (early onset severe obesity with rapid weight gain not responsive to lifestyle interventions; started on liraglutide 1.8 mg daily two months prior to surgery and stopped at the time of surgery) and complications (including elevated fasting glucose, hypertriglyceridemia, and obstructive sleep apnea on CPAP). Thromboelastography appeared compensated, so the patient received a vertical sleeve gastrectomy immediately followed by a deceased donor orthotopic liver transplant. His post-operative course was complicated by increased oxygen requirements that resolved within 2 weeks. No staple line or gastric bleeding issues were noted. Two months after transplant, he has good graft function with normal liver enzyme tests on tacrolimus with mycophenolate mofetil. He has had a 9.4% reduction from his peak BMI of 42.97 kg/m2 to 38.92 kg/m2 with weight stabilization post-operatively despite pulse steroids followed by an oral steroid taper for induction immunosuppression.Conclusion: Our experience demonstrates that liver transplant and vertical sleeve gastrectomy can be done concomitantly and safely in the pediatric population. Assessing the long-term outcomes of this and other similar patients will assist in determination of optimal patient selection, target and actual BMI reduction, and metabolic goals in the pediatric liver transplant population.