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Weight Loss Interventions for Morbidly Obese Patients with Compensated Cirrhosis: A Markov Decision Analysis Model

  • 2013 SSAT Poster Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Many transplant centers require that patients maintain a BMI below 40 kg/m2 in order to be eligible for listing, rendering many morbidly obese patients with end-stage liver disease unable to access liver transplantation as a method of treatment. In order to determine the safest and most efficacious weight loss regimen in this challenging population, Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and diet and exercise were modeled to assess their impact on life expectancy in morbidly obese patients with cirrhosis. A Markov state transition model was developed to assess the survival benefit of undergoing RYGB, AGB, or 1 year of diet and exercise in morbidly obese patients with compensated cirrhosis. A base case analysis of no weight loss intervention in a 45-year-old patient with compensated cirrhosis and a BMI of 45 kg/m2 revealed an average survival of 7.93 years. The average survival for the weight loss simulations was 9.14, 8.84, and 8.16 years for RYGB, AGB, and diet and exercise, respectively. In morbidly obese patients with compensated cirrhosis, RYGB allows patients to lose more weight more rapidly than is probable with either AGB or diet and exercise, thus having the greatest impact on survival.

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References

  1. Nair S, Verma S, Thuluvath PJ. Obesity and its effect on survival in patients undergoing orthotopic liver transplantation in the United States. Hepatology 2002;35:105–109.

    Article  PubMed  Google Scholar 

  2. Thuluvath PJ, Guidinger MK, Fung JJ, Johnson LB, Rayhill SC, Pelletier SJ. Liver transplantation in the United States, 1999–2008. American Journal of Transplantation 2010;10:1003–1019.

    Article  CAS  PubMed  Google Scholar 

  3. Angulo P. Nonalcoholic fatty liver disease and liver transplantation. Liver Transplantation 2006;12:523–534.

    Article  PubMed  Google Scholar 

  4. Koehler E, Watt K, Charlton M. Fatty liver and liver transplantation. Clinics in Liver Disease 2009;13:621–630.

    Article  PubMed  Google Scholar 

  5. Afzali A, Berry K, Ioannou GN. Excellent post-transplant survival for patients with nonalcoholic steatohepatitis in the United States. Liver Transplantation 2012;18:29–37.

    Article  PubMed  Google Scholar 

  6. Pelletier SJ, Schaubel DE, Wei G, Englesbe MJ, Punch JD, Wolfe RA, Port FK, Merion RM. Effect of body mass index on the survival benefit of liver transplantation. Liver Transplantation 2007;13:1678–1683.

    Article  PubMed  Google Scholar 

  7. Rustgi VK, Marino G, Rustgi S, Halpern MT, Johnson LB, Tolleris C, Taddei TH. Impact of body mass index on graft failure and overall survival following liver transplant. Clinical Transplantation 2004;18:634–637.

    Article  PubMed  Google Scholar 

  8. Leonard J, Heimbach JK, Malinchoc M, Watt K, Charlton M. The impact of obesity on long-term outcomes in liver transplant recipients—results of the NIDDK liver transplant database. American Journal of Transplantation 2008;8:667–672.

    Article  CAS  PubMed  Google Scholar 

  9. Thuluvath PJ. Morbid obesity with one or more other serious comorbidities should be a contraindication for liver transplantation. Liver Transplantation 2007;13:1627–1629.

    Article  PubMed  Google Scholar 

  10. Berzigotti A, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Morillas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Groszmann RJ; Portal Hypertension Collaborative Group. Obesity is an independent risk factor for clinical decompensation in patients with cirrhosis. Hepatology 2011;54:555–561.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Curioni CC, Lourenço PM. Long-term weight loss after diet and exercise: a systematic review. International Journal of Obesity 2005;29:1168–1174.

    Article  CAS  PubMed  Google Scholar 

  12. Promrat K, Kleiner DE, Niemeier HM, Jackvony E, Kearns M, Wands JR, Fava JL, Wing RR. Randomized controlled trial testing the effects of weight loss on nonalcoholic steatohepatitis. Hepatology 2010;51:121–129.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  13. Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Agren G, Carlsson LM, and Swedish Obese Subjects Study. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. New England Journal of Medicine 2007; 347:741–752.

    Article  Google Scholar 

  14. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. American Journal of Medicine 2009;122:248–256.

    Article  PubMed  Google Scholar 

  15. Mosko JD, Nguyen GC. Increased perioperative mortality following bariatric surgery among patients with cirrhosis. Clinical Gastroenterology and Hepatology 2011;9:897–901.

    Article  PubMed  Google Scholar 

  16. Dallal RM, Mattar SG, Lord JL, Watson AR, Cottam DR, Eid GM, Hamad G, Rabinovitz M, Schauer PR. Results of laparoscopic gastric bypass in patients with cirrhosis. Obesity Surgery 2004;14:47–53.

    Article  PubMed  Google Scholar 

  17. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. Journal of Hepatology 2006;44:217–231.

    Article  PubMed  Google Scholar 

  18. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA 2004:292:1724–1737.

    Article  CAS  PubMed  Google Scholar 

  19. Segev DL, Thompson RE, Locke JE, Simpkins CE, Thuluvath PJ, Montgomery RA, Maley WR. Prolonged waiting times for liver transplantation in obese patients. Annals of Surgery 2008;248:863–870.

    Article  PubMed  Google Scholar 

  20. O’Leary JG, Landaverde C, Jennings L, Goldstein RM, Davis GL. Patients with NASH and cryptogenic cirrhosis are less likely than those with hepatitis C to receive liver transplants. Clinical Gastroenterology and Hepatology 2011;9:700–704.

    Article  PubMed  Google Scholar 

  21. Park CW, Tsai NT, Wong LL. Implications of worse renal dysfunction and medical comorbidities in patients with NASH undergoing liver transplant evaluation: impact on MELD and more. Clinical Transplantation 2011;25:606–611.

    Article  Google Scholar 

  22. Bessler M, Daud A, DiGiorgi MF, Schrope BA, Inabnet WB, Davis DG. Frequency distribution of weight loss percentage after gastric bypass and adjustable gastric banding. Surgery for Obesity and Related Diseases 2008;4:486–491.

    Article  PubMed  Google Scholar 

  23. Bryce CL, Chang CC, Angus DC, Arnold RM, Farrell M, Roberts MS. The Effect of Race, Sex, and Insurance Status on Time-to-Listing Decisions for Liver Transplantation. Journal of Transplantation 2010; 2010:467976.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D’Amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464–470.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Bianca Bromberger, Paige Porrett, Rashikh Choudhury & Kristoffel Dumon

  2. Abington Memorial Hospital, Temple University School of Medicine, 1245 Highland Avenue, Price Bldg., Suite 604, Abington, PA, 19001, USA

    Kenric M. Murayama

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  1. Bianca Bromberger
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  2. Paige Porrett
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  3. Rashikh Choudhury
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  4. Kristoffel Dumon
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  5. Kenric M. Murayama
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Correspondence to Kenric M. Murayama.

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Bromberger, B., Porrett, P., Choudhury, R. et al. Weight Loss Interventions for Morbidly Obese Patients with Compensated Cirrhosis: A Markov Decision Analysis Model. J Gastrointest Surg 18, 321–327 (2014). https://doi.org/10.1007/s11605-013-2298-y

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  • DOI: https://doi.org/10.1007/s11605-013-2298-y

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