Bariatric surgery and transplantation: A bridge not so far
Bibliographic record
Abstract
To the Editor: We read the recent article “Obesity, Transplantation, and Bariatric Surgery: An Evolving Solution for Growing Epidemic”1Diwan TS Lee TC Nagai S et al.Obesity, transplantation, and bariatric surgery: an evolving solution for a growing epidemic.Am J Transplant. 2020; 00: 1-13Google Scholar with great interest. The authors have provided excellent evidence in favor of bariatric surgery in the transplant population. We agree in principle that bariatric surgery improves posttransplant outcomes based on the available evidence. We would like to emphasize further the role of bariatric surgery in the liver transplant population. In the pretransplant population, there is conflicting evidence whether bariatric surgery improves survival outcomes. Mosko et al2Mosko JD Nguyen GC. Increased perioperative mortality following bariatric surgery among patients with cirrhosis.Clin Gastroenterol Hepatol. 2011; 9: 897-901Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar reported increased perioperative mortality following bariatric surgery among patients with cirrhosis (compensated cirrhotic patients n = 3888, decompensated cirrhotic patients n = 62). This experience was further echoed by Asrani et al3Asrani S Khan F Saracino G et al.Bariatric surgery and increased risk of death after listing for liver transplantation.Am J Transplant. 2016; 16Google Scholar in their report on bariatric surgery and increased risk of death after listing for liver transplant. This is in comparison to smaller case series in which noninferior outcomes to access and transplant have been reported.4Lin MYC Mehdi Tavakol M Sarin A et al.Laparoscopic sleeve gastrectomy is safe and efficacious for pretransplant candidates.Surg Obes Relat Dis. 2013; 9: 653-658Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 5Safwan M Collins KM Abouljoud MS Salgia R. Outcome of liver transplantation in patients with prior bariatric surgery.Liver Transpl. 2017; 23: 1415-1421Crossref PubMed Scopus (35) Google Scholar, 6Takata MC Campos GM Ciovica R et al.Laparoscopic bariatric surgery improves candidacy in morbidly obese patients awaiting transplantation.Surg Obes Relat Dis. 2008; 4 (;discussion 164–155.): 159-164Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar Hiembeck et al7Heimbach JK Watt KDS Poterucha JJ et al.Combined liver transplantation and gastric sleeve resection for patients with medically complicated obesity and end-stage liver disease.Am J Transplant. 2013; 13: 363-368Crossref PubMed Scopus (170) Google Scholar have been pioneers in regard to simultaneous sleeve gastrectomy with liver transplant (S-LT), but despite their experience being in the clinical domain since 2013, it is yet to be mirrored by other institutions. We firmly opine that the donor and recipient characteristics would have to be the benchmark for S-LT, and thus only a selected group of patients shall qualify for the procedure. It is interesting that most S-LT reports have emphasized recipient characteristics and have not given due credit to the quality of allografts; future studies need to highlight the allograft details in the outcome data. Delayed sleeve gastrectomy with liver transplant (D-LT) experience is still maturing, and despite a few reports of post perioperative and postoperative complications,8Elli EF Gonzalez-Heredia R Sanchez-Johnsen L Patel N Garcia-Roca R Oberholzer J. Sleeve gastrectomy surgery in obese patients post-organ transplantation.Surg Obes Relat Dis. 2016; 12: 528-534Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,9Al-Nowaylati A-R Al-Haddad BJS Dorman RB et al.Gastric bypass after liver transplantation.Liver Transpl. 2013; 19: 1324-1329Crossref PubMed Scopus (67) Google Scholar the evidence is still in favor. We believe that there is a paucity of bariatric surgeons who would be willing to operate on the pretransplant cirrhotic patient population. The struggle in the future would be to provide training to transplant surgeons in bariatric surgery or vice versa, and there is no cross-training provision in ASTS training curriculum. The present era of liver transplant is already limping to find good-quality donors; the quest to find good donors for suitable S-LT recipients may be an uphill task. It may also be difficult to set guidelines for bariatric surgery in liver transplant patients due to limited clinical evidence.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.006 | 0.032 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.002 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.002 | 0.004 |
| Scholarly communication | 0.005 | 0.010 |
| Open science | 0.003 | 0.002 |
| Research integrity | 0.014 | 0.031 |
| Insufficient payload (model declined to judge) | 0.008 | 0.005 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".