Innovative approach using an intragastric balloon for weight loss in a morbidly obese patient undergoing liver transplantation

Authors


  • This report has approval of the respective institute's ethical committee.

Address reprint requests to Narendra S. Choudhary, M.D., Institute of Liver Transplantation and Regenerative Medicine, Medanta–The Medicity, Sector 38, Gurgaon, India 122001. E-mail: docnarendra@gmail.com

TO THE EDITORS:

Morbid obesity is associated with poor outcomes after liver transplantation.[1, 2] Bariatric surgery or weight loss by lifestyle modification is often not possible because of the presence of decompensated cirrhosis. A 61-year-old male presented with decompensated alcoholic cirrhosis (jaundice, low albumin level, high international normalized ratio, and mild ascites). His comorbidities included diabetes mellitus and morbid obesity (body mass index = 48.3 kg/m2). He had residual esophageal varices (after endoscopic variceal ligation) but no fundal varices. He was listed for deceased donor liver transplantation, and a BioEnterics intragastric balloon was placed endoscopically to promote weight loss. He lost 24 kg over 6 months (body mass index at transplantation = 39.2 kg/m2), and his diabetic control improved significantly (with his hemoglobin A1c level decreasing from 9.2 to 5.4 g/dl). He underwent deceased donor liver transplantation 3 months later; the balloon was removed endoscopically just before surgery in order to facilitate a better operative field. His postoperative recovery was uneventful, and he was doing well 3 months after deceased donor liver transplantation without any rebound weight gain. Patients with decompensated cirrhosis have a significant risk of perioperative mortality after bariatric surgery in comparison with patients with compensated cirrhosis (16.3% versus 0.9%).[3] Intragastric balloon placement is a nonsurgical approach, and it has been shown to improve parameters of insulin resistance,[4] obesity-related complications, and quality of life for obese patients.[5] A meta-analysis including 3608 patients has shown that an intragastric balloon is more effective than a placebo for weight loss, with nausea and vomiting being the most common side effects (8.6%).[6] We could not find any reports regarding the use of intragastric balloons to promote liver transplantation in morbidly obese patients. Although long-term weight loss has not been described with the use of balloons,[6] improved diabetic control and a lower body mass index decrease the perioperative complications of liver transplantation. In conclusion, in a decompensated patient with cirrhosis who is morbidly obese and does not have significant gastroesophageal varices, the placement of an intragastric balloon is a useful and innovative modality for promoting short-term weight loss and thereby making the patient fit for surgery and reducing perioperative morbidity and mortality.

  • Narendra S. Choudhary, D.M.1

  • Sanjiv Saigal, D.M.1

  • Neeraj Saraf, D.N.B.1

  • Rajesh Puri, D.M.2

  • Arvinder Soin, M.S.1,2

  • Institutes of 1Liver Transplantation and Regenerative Medicine and 2Digestive and Hepatobiliary Sciences Medanta-The Medicity, Gurgaon, India

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