Single-Lobe Living Donor Liver Transplant in a Morbidly Obese Cirrhotic Patient Preceded by Laparoscopic Sleeve Gastrectomy

Nonalcoholic steatohepatitis (NASH) is a stage of nonalcoholic fatty liver disease (NAFLD), and, in most patients, it is associated with obesity and metabolic syndrome with progression to end-stage liver disease in about 20% of patients (McCullough (2004); Matteoni et al. (1999); Liou and Kowdley (2006)). It has been estimated that between 20 and 30% of patients with end-stage cirrhosis referred for liver transplantation (LT) evaluation and 30 to 70% of LT recipients exhibit some degree of obesity (Mu？oz and ElGenaidi (2005)). Management of obesity in chronic liver disease patients is not only difficult but also preludes them from undergoing major bariatric surgery due to associated high morbidity and mortality. Here, we present a case report of a morbidly obese patient who underwent laparoscopic sleeve gastrectomy followed by single-lobe living donor liver transplantation (LDLT) with a successful outcome. We believe that this is the first report of successful LDLT following planned weight loss to facilitate LDLT. 1. Case Report A 29-year-old young male law graduate, morbidly obese since adolescence, has been symptomatic since the last 7 years with fatigue, generalized weakness, and fluctuating jaundice. He was 160？kg at the time of presentation with a BMI of 55.36？kg/m2. He was diagnosed to have cirrhosis with persistently high bilirubin which fluctuated between 2 and 5？mg/dL. His Child’s score at presentation was B9 with a MELD score of 14. Extensive evaluation for the etiology of liver disease including viral markers and autoimmune markers and iron and copper studies were all negative. There was no history of alcohol intake; hence, in view of morbid obesity and dyslipidemia, the diagnosis of nonalcoholic steatohepatitis for cirrhosis was considered. His gastroduodenoscopy showed small varices with portal hypertensive gastropathy, and a triple-phase CT scan of the abdomen showed a shrunken liver with splenomegaly, multiple portosystemic collaterals, and no ascites. He was listed for deceased donor liver transplantation and advised weight reduction with dietary and behavioral measures. However, he did not show any significant improvement over the next three months. Since he was morbidly obese and had failed medical therapy for weight reduction, he was planned for bariatric surgery after counseling for worsening of liver disease in the postoperative period and a possible requirement for immediate liver transplantation in that eventuality. A prospective living donor was identified in the family and completely worked up in case the patient showed signs of