Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1116_Библиотеки_им_академика_М_И_Перельмана.pdf
Sleeve Gastrectomy in Non-alcoholic Steatohepatitis …
42. Palmeri ML, Wang MH, Rouze NC, Abdelmalek MF, Guy CD, Moser B, et al. Noninvasive
evaluation of hepatic fibrosis using acoustic radiation force-based shear stiffness in patients
with nonalcoholic fatty liver disease. J Hepatol. 2011;55(3):666–72.
43. Friedrich-Rust M, Nierhoff J, Lupsor M, Sporea I, Fierbinteanu-Braticevici C, Strobel D,
et al. Performance of acoustic radiation force impulse imaging for the staging of liver fibrosis: a pooled meta-analysis. J Viral Hepat. 2012;19(2):e212–9.
44. Szczepaniak LS, Nurenberg P, Leonard D, Browning JD, Reingold JS, Grundy S,
et al. Magnetic resonance spectroscopy to measure hepatic triglyceride content: prevalence of hepatic steatosis in the general population. Am J Physiol Endocrinol Metab.
2005;288(2):E462–8.
45. Bedogni G, Bellentani S, Miglioli L, Masutti F, Passalacqua M, Castiglione A, et al. The
fatty liver index: a simple and accurate predictor of hepatic steatosis in the general population. BMC Gastroenterol. 2006;6:33.
46. Kotronen A, Peltonen M, Hakkarainen A, Sevastianova K, Bergholm R, Johansson LM, et al.
Prediction of non-alcoholic fatty liver disease and liver fat using metabolic and genetic factors. Gastroenterology. 2009;137(3):865–72.
47. Sterling RK, Lissen E, Clumeck N, Sola R, Correa MC, Montaner J, et al. Development of
a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology. 2006;43(6):1317–25.
48. Angulo P, Hui JM, Marchesini G, Bugianesi E, George J, Farrell GC, et al. The NAFLD
fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD.
Hepatology. 2007;45(4):846–54.
49. Feldstein AE, Wieckowska A, Lopez AR, Liu YC, Zein NN, McCullough AJ. Cytokeratin-18
fragment levels as noninvasive biomarkers for nonalcoholic steatohepatitis: a multicenter validation study. Hepatology. 2009;50(4):1072–8.
50. Kleiner DE, Makhlouf HR. Histology of nonalcoholic fatty liver disease and nonalcoholic
steatohepatitis in adults and children. Clin Liver Dis. 2016;20(2):293–312.
51. Brunt EM, Janney CG, Di Bisceglie AM, Neuschwander-Tetri BA, Bacon BR. Nonalcoholic
steatohepatitis: a proposal for grading and staging the histological lesions. Am J
Gastroenterol. 1999;94(9):2467–74.
52. Singh S, Allen AM, Wang Z, Prokop LJ, Murad MH, Loomba R. Fibrosis progression in
nonalcoholic fatty liver vs nonalcoholic steatohepatitis: a systematic review and meta-analysis of paired-biopsy studies. Clin Gastroenterol Hepatol. 2015;13(4):643–54.e1–9; quiz
e39–40.
53. Dulai PS, Singh S, Patel J, Soni M, Prokop LJ, Younossi Z, et al. Increased risk of mortal-
ity by fibrosis stage in nonalcoholic fatty liver disease: systematic review and meta-analysis.
Hepatology. 2017;65(5):1557–65.
54. Ratziu V, Charlotte F, Heurtier A, Gombert S, Giral P, Bruckert E, et al. Sampling variability
of liver biopsy in nonalcoholic fatty liver disease. Gastroenterology. 2005;128(7):1898–906.
55. Ratziu V, Bellentani S, Cortez-Pinto H, Day C, Marchesini G. A position statement on
NAFLD/NASH based on the EASL 2009 special conference. J Hepatol. 2010;53(2):372–84.
56. Bazick J, Donithan M, Neuschwander-Tetri BA, Kleiner D, Brunt EM, Wilson L, et al.
Clinical model for NASH and advanced fibrosis in adult patients with diabetes and NAFLD:
guidelines for referral in NAFLD. Diabetes Care. 2015;38(7):1347–55.
57. Simeone JC, Bae JP, Hoogwerf BJ, Li Q, Haupt A, Ali AK, et al. Clinical course of non-
alcoholic fatty liver disease: an assessment of severity, progression, and outcomes. Clin
Epidemiol. 2017;9:679–88.
58. Kleiner DE, Brunt EM, Van Natta M, Behling C, Contos MJ, Cummings OW, et al.
Design and validation of a histological scoring system for nonalcoholic fatty liver disease.
Hepatology. 2005;41(6):1313–21.
59. Bedossa P, Poitou C, Veyrie N, Bouillot JL, Basdevant A, Paradis V, et al. Histopathological
algorithm and scoring system for evaluation of liver lesions in morbidly obese patients.
Hepatology. 2012;56(5):1751–9.
135
136
60. Infante-Rivard C, Esnaola S, Villeneuve JP. Clinical and statistical validity of conven-
tional prognostic factors in predicting short-term survival among cirrhotics. Hepatology.
1987;7(4):660–4.
61. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to pre-
dict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.
Hepatology. 2000;31(4):864–71.
62. Peng Y, Qi X, Guo X. Child-Pugh versus MELD score for the assessment of prognosis in
liver cirrhosis: a systematic review and meta-analysis of observational studies. Medicine
(Baltimore). 2016;95(8):e2877.
63. Souto KP, Meinhardt NG, Ramos MJ, Ulbrich-Kulkzynski JM, Stein AT, Damin DC.
Nonalcoholic fatty liver disease in patients with different baseline glucose status undergoing
bariatric surgery: analysis of intraoperative liver biopsies and literature review. Surg Obes
Relat Dis. 2018;14(1):66–73.
64. Mathurin P, Hollebecque A, Arnalsteen L, Buob D, Leteurtre E, Caiazzo R, et al. Prospective
study of the long-term effects of bariatric surgery on liver injury in patients without advanced
disease. Gastroenterology. 2009;137(2):532–40.
65. Liu X, Lazenby AJ, Clements RH, Jhala N, Abrams GA. Resolution of nonalcoholic steato-
hepatits after gastric bypass surgery. Obes Surg. 2007;17(4):486–92.
66. Mattar SG, Velcu LM, Rabinovitz M, Demetris AJ, Krasinskas AM, Barinas-Mitchell E,
et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease
and the metabolic syndrome. Ann Surg. 2005;242(4):610–7; discussion 8–20.
67. Shimizu H, Phuong V, Maia M, Kroh M, Chand B, Schauer PR, et al. Bariatric surgery in
patients with liver cirrhosis. Surg Obes Relat Dis. 2013;9(1):1–6.
68. Kral JG, Thung SN, Biron S, Hould FS, Lebel S, Marceau S, et al. Effects of surgical treat-
ment of the metabolic syndrome on liver fibrosis and cirrhosis. Surgery. 2004;135(1):48–58.
69. Brolin RE, Bradley LJ, Taliwal RV. Unsuspected cirrhosis discovered during elective obesity
operations. Arch Surg. 1998;133(1):84–8.
70. Mosko JD, Nguyen GC. Increased perioperative mortality following bariatric surgery among
patients with cirrhosis. Clin Gastroenterol Hepatol. 2011;9(10):897–901.
71. Wolter S, Duprée A, Coelius C, El Gammal A, Kluwe J, Sauer N, et al. Influence of liver
disease on perioperative outcome after bariatric surgery in a Northern German cohort. Obes
Surg. 2017;27(1):90–5.
72. Miñambres I, Rubio MA, de Hollanda A, Breton I, Vilarrasa N, Pellitero S, et al. Outcomes
of bariatric surgery in patients with cirrhosis. Obes Surg. 2019;29(2):585–92.
73. Rebibo L, Gerin O, Verhaeghe P, Dhahri A, Cosse C, Regimbeau JM. Laparoscopic sleeve
gastrectomy in patients with NASH-related cirrhosis: a case-matched study. Surg Obes Relat
Dis. 2014;10(3):405–10; quiz 565.
74. Perez-Protto SE, Quintini C, Reynolds LF, You J, Cywinski JB, Sessler DI, et al. Comparable
graft and patient survival in lean and obese liver transplant recipients. Liver Transplant.
2013;19(8):907–15.
75. Conzen KD, Vachharajani N, Collins KM, Anderson CD, Lin Y, Wellen JR, et al. Morbid
obesity in liver transplant recipients adversely affects longterm graft and patient survival in a
single-institution analysis. HPB (Oxford). 2015;17(3):251–7.
76. Chang SH, Liu X, Carlsson NP, Park Y, Colditz GA, Garonzik-Wang JM, et al. Reexamining
the association of body mass index with overall survival outcomes after liver transplantation.
Transplant Direct. 2017;3(7):e172.
77. 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(1):105–9.
78. Rustgi VK, Marino G, Rustgi S, Halpern MT, Johnson LB, Tolleris C, et al. Impact of body
mass index on graft failure and overall survival following liver transplant. Clin Transplant.
2004;18(6):634–7.
79. Saab S, Lalezari D, Pruthi P, Alper T, Tong MJ. The impact of obesity on patient survival in
liver transplant recipients: a meta-analysis. Liver Int. 2015;35(1):164–70.
M. H. Jamal and R. El-Abd
Sleeve Gastrectomy in Non-alcoholic Steatohepatitis …
137
80. Triguero J, García A, Molina A, San Miguel C, Notario P, Villegas T, et al. Complications
associated with liver transplantation in recipients with body mass index >35 kg/m
2
: would it
be a poor prognosis predictive factor? Transplant Proc. 2015;47(9):2650–2.
81. Aguilar M, Liu B, Holt EW, Bhuket T, Wong RJ. Impact of obesity and diabetes on wait-
list survival, probability of liver transplantation and post-transplant survival among chronic
hepatitis C virus patients. Liver Int. 2016;36(8):1167–75.
82. Sharpton SR, Terrault NA, Posselt AM. Outcomes of sleeve gastrectomy in obese liver trans-
plant candidates. Liver Transplant. 2019;25(4):538–44.
83. Heimbach JK, Watt KD, Poterucha JJ, Ziller NF, Cecco SD, Charlton MR, 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(2):363–8.
84. Morris MC, Jung AD, Kim Y, Lee TC, Kaiser TE, Thompson JR, et al. Delayed sleeve
gastrectomy following liver transplantation: a 5-year experience. Liver Transplant.
2019;25(11):1673–81.
85. Tsamalaidze L, Stauffer JA, Arasi LC, Villacreses DE, Franco JSS, Bowers S, et al.
Laparoscopic sleeve gastrectomy for morbid obesity in patients after orthotopic liver transplant: a matched case-control study. Obes Surg. 2018;28(2):444–50.
86. Osseis M, Lazzati A, Salloum C, Gavara CG, Compagnon P, Feray C, et al. Sleeve gastrec-
tomy after liver transplantation: feasibility and outcomes. Obes Surg. 2018;28(1):242–8.
Sleeve Gastrectomy in Immunocompromised Patients
Amin Andalib
1 Introduction
Over the course of the past decade and a half, sleeve gastrectomy (SG) has
become the most frequently performed primary bariatric surgery worldwide [1, 2].
During this time period, the popularity of SG has mainly been driven by the inferior results after adjustable gastric banding coupled with SG procedure being technically easier to perform compared to bypass-type procedures [3, 4] as well as its
safety profile and the satisfactory long-term outcomes [5–7]. Consequently, SG
has turned into the procedure of choice in patients with complex medical histories
including those suffering from advanced chronic kidney disease [8], renal transplant candidates [9] or patients suffering from inflammatory bowel disease (IBD)
[10] and other conditions requiring chronic immunosuppressant therapy [11].
2 Safety and Postoperative Morbidity
In the general population and irrespective of comorbid conditions, laparoscopic
SG is considered to be very safe with a thirty-day mortality and composite morbidity of 0.05% and 2.4%, respectively [12]. Two of the most troubling postoperative complications are postoperative staple-line leaks (0.6–1%) and hemorrhage
(0.7–1.4%) [12–14].
In the current era of bariatric surgery, with the improved operative safety profiles and the established role for minimally invasive techniques, patients who
A. Andalib (*)
Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, QC,
Canada
e-mail: amin.andalib@mcgill.ca
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_16
139
A. Andalib140
undergo bariatric/metabolic procedures more frequently suffer from severe baseline chronic conditions including IBD, rheumatoid/autoimmune disorders, and
solid organ transplantation. These conditions are routinely treated with immunosuppressive agents and other novel disease-modifying anti-rheumatic drugs
(DMARDs). Consequently, the immunocompromised patients are considered a
high-risk population for perioperative adverse events by the nature of their chronic
use of immunosuppressants and other DMARDs that impact their wound healing
and prone them to infectious postoperative complications [15, 16].
2.1 Postoperative Morbidity After SG
in Immunocompromised Patients
For the immunocompromised patient population, SG is widely accepted as the
bariatric/metabolic procedure of choice [17] and this is primarily due to its acceptable safety profile and low incidence of major postoperative complications.
In a large multicenter study using 2005–2013 data from the American College
of Surgeons National Surgical Quality Improvement Program (ACS NSQIP),
Andalib et al. evaluated the 30-day postoperative outcomes of primary SG and
roux-en y gastric bypass (RYGB) in patients on chronic immunosuppressant
medications within at least 30 days prior to surgery [11]. While 30-day postoperative mortality and major morbidity were significantly higher among the patients
dependent of chronic immunosuppression compared to those who were not (0.5%
vs. 0.1% and 5.0% vs. 2.5%, respectively), the prevalence of such major complications were acceptable. Furthermore, both SG and RYGB procedures were found to
be equally safe in this patient population [11]. In another large study by Mazzei
et al. using 2015–2016 Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP) data, after a propensity-matched analysis,
chronic preoperative use of corticosteroids was not found to be an independent
predictor for worse outcomes except for a two-fold higher risk for leak (0.6% vs.
0.3%) along with slightly higher risk of readmission and reintervention after both
SG and RYGB compared to patients who did not take steroids [18]. Despite the elevated risk, the overall incidence of such postoperative adverse events remains low.
In addition, there is also data demonstrating the safety of continuing certain immunomodulators and biologic agents in the immediate perioperative period leading up
to surgery such as cardiac, orthopedic and colorectal procedures [18–20].
2.2 Perioperative Timing of Immunosuppressive Therapy
Given that the use of immunosuppressant/modulators is often critical for maintenance and management of patients’ chronic rheumatoid and autoimmune disorders, the consequences of withholding perioperative dosing should be carefully
considered by bariatric surgeons and in consultation with the respective treating
specialists. Moreover, due to the lack of high-quality studies on the perioperative
Sleeve Gastrectomy in Immunocompromised Patients
141
use and management of these agents in patients undergoing bariatric surgery, there
is great variability in clinical practice regarding holding or timing of perioperative
dosing of immunosuppressive agents [21].
In a recent systematic review, Kassel et al. attempted to evaluate the impact
and management of perioperative use of immunosuppressive agents in patients
undergoing bariatric surgery [21]. However, given the limited literature available
on the use of immunosuppressive therapies in patients undergoing bariatric surgery, data from non-bariatric procedures, specifically abdominal or other gastrointestinal operations were used to examine the risks associated with perioperative
use of immunosuppressive agents and DMARDs. Also due to the small and heterogeneous nature of the available studies, the data could not be pooled to provide a meta-analysis [21]. Although immunosuppressants discussed in this review
article were associated with an increased risk for infections, the limited data
available suggest corticosteroids, methotrexate, and tumor necrosis factor-alpha
(TNF-α) inhibitors may be safe to restart postoperatively provided there are no
signs of infections [21]. Furthermore, if medically possible prior to elective bariatric surgery, one should aim to hold immunosuppressants 2–12 weeks preoperatively and until 2–4 weeks after surgery [22, 23]. For biologic immunomodulators
and other DMARDs like TNF-α inhibitors, the timing of the surgery should ideally be planned according to the last dose since most agents are administered
every 2–8 weeks (Table 1) and if needed only one dose may be skipped after
surgery [24].
Therefore, management of each immunosuppressant agent must be handled individually and based on their respective routine interval dosing due to the
Table 1 Summary of preoperative dosing recommendations for selected TNF-α inhibitors.
(Adapted from Ref. [21])
Generic name
(Brand)
Adalimumab
(Humira)
Certolizumab
(Cimzia)
Etanercept (Enbrel) SC 1–2 weeks 3 days 2–3 weeks
Golimumab
(Simponi)
Infliximab
(Remicade)
TNF-α = Tumor necrosis factor-alpha; SC = Subcutaneous; IV = Intravenous
a
Dosing interval may vary based on the indication for the medication and the severity of the
disease
b
Administration of the last dose may vary depending on the dosing interval
Route of
administration
SC 1–2 weeks 14 days 2–3 weeks
SC 2–4 weeks 14 days 3–5 weeks
SC 4 weeks 14 days 5 weeks
IV 8 weeks – 9 weeks
SC 4–8 weeks 9 days 5–9 weeks
Dosing intervalaHalf-life
Recommended
administration of
last dose (before
surgery date)
b
A. Andalib142
varying disease-specific desired effects and the potential for undesired perioperative adverse events. Ideally, the decision and the timing to withhold the immunosuppressant medications should be weighed against the benefits of their use for
each case individually and in a multi-disciplinary fashion. Additional research is
needed to determine, with more granularity, the timing recommendations to hold
and restart these medications with respect to bariatric surgery.
3 Outcomes of SG in Immunocomromised Patients
3.1 Weight Loss and Improvements in Obesity-Related
Conditions
As previously mentioned, the literature on the use of bariatric surgery especially
SG in immunocompromised patients is scant. Therefore, the data on the beneficial
outcomes of SG in this patient population is also mainly driven from case series
[10, 25–27]. Furthermore, given the small sample size in reported studies, and an
even smaller sample size for those who underwent SG, reported weight loss and
comorbidity outcomes are pooled together and reported for all types of bariatric
surgery included [10, 25–27].
In a systematic review, Shoar et al. discuss 7 studies that have reported outcomes of bariatric surgery in a total of 43 IBD patients of whom 58% suffered
from Crohn’s disease [27]. Crohn’s patients more often underwent SG (72%),
while those with ulcerative colitis underwent SG or RYGB in similar frequency
(44%). Overall between 8 and 77 months after bariatric surgery, IBD patients had
an average 71% excess weight loss (EWL) and a 14.3 kg/m2 drop in body mass
index (BMI) [27].
In a recent prospective cohort study, Xu et al. report on the 1-year outcomes of
obese patients suffering from rheumatoid arthritis who underwent bariatric surgery
(n = 32) and compared them to an obese non-surgical group (n = 33) [28]. In the
surgical arm, 41% of patients underwent SG procedure and the rest had RYGB. At
one-year, bariatric surgery yielded an average 33 kg weight loss equivalent to 11.3
2
drop in BMI [28].
kg/m
In terms of long-term weight loss after SG procedure in the general population,
a 40–60% EWL or a mean BMI reduction of 8–10 kg/m2 are realistic estimates
to consider [29–31]. Moreover, long-term improvements in obesity-related conditions especially metabolic syndrome including type 2 diabetes mellitus after SG
are impressive and occur in >60% of patient population [6, 30, 31]. When comparing long-term outcomes of SG to RYGB, a recent meta-analysis of 4 randomized
control trials with reported 5-year outcomes of SG and RYGB procedures revealed
that weight loss up to 5 years after surgery has been either comparable or favoring
RYGB with only a modest difference in BMI (1–2 kg/m2) and weight loss up to
5 kg [7]. Moreover, five years after surgery, the remission rate of type 2 diabetes
mellitus was similar between SG and RYGB (55% vs. 60%, respectively; p = 0.42)
[7]. Hence, SG procedure is highly effective for weight loss and improving
Sleeve Gastrectomy in Immunocompromised Patients
143
obesity-related conditions. Finally, as demonstrated above the weight loss and
related comorbidity outcomes after SG procedure appear to be similar among the
immunocompromised patients and the general population.
3.2 Changes to Rheumatoid and Autoimmune Conditions
Obesity is common among patients with rheumatoid and autoimmune disorders
such as rheumatoid arthritis and IBD [32, 33]. Moreover, obese patients with
these conditions often have worse response to therapy after all types of DMARDs
[34–36]. This association is not very surprising as obesity is linked to an increase
in a pro-inflammatory state mediated by known cytokines such as interleukin-6,
TNF-α, as well as adipokines such as leptin, adiponectin, and resistin, or neuropeptides such as substance P, which are all molecules either produced within
adipocytes or within macrophages and lymphocytes that infiltrate the mesenteric
fat [37, 38]. Consequently, since both obesity and autoimmune disorders share a
chronic inflammatory state, the advantage of bariatric/metabolic surgery in alleviating severity of such conditions is not surprising.
Various studies have demonstrated the improvement in many autoimmune disorders after bariatric surgery. In a study using 2004–2014 United States National
Inpatient Sample database, Sharma et al. identified 15,319 morbidly obese patients
who had a combined discharge diagnosis of IBD, of whom 3.2% (n = 493) had
prior bariatric surgeries (47% underwent SG; n = 233) [39]. They found that a
prior bariatric surgery was associated with lower incidence rate ratios for renal
failure, malnutrition, and fistulae formation compared to obese non-surgical group
[39]. The systematic review by Shoar et al. mentioned earlier evaluating outcomes of bariatric surgery in 43 IBD patients, of whom 58% had Crohn’s disease
mainly involving the small bowel, reported disease remission in 20 patients (48%),
improvement in another two individuals (5%), but disease exacerbation was noted
in 17% [27]. Interestingly, intestinal bacterial overgrowth that can develop due
to bypass-type bariatric procedures like RYGB, may be associated with acute
flare-ups of Crohn’s disease [40, 41]. Also, there is a potential risk of flare-up crises in patients with small bowel Crohn’s disease, involving the operated segments
of the small bowel after RYGB. Thus, one might argue that for obese patients
with Crohn’s disease especially those with small bowel involvement and previous
bowel resections, SG should be the bariatric procedure of choice.
Similar association and improvements were shown after bariatric surgery for
patients with other rheumatoid disorders including gout, psoriasis, systemic lupus
erythematosus, multiple sclerosis, and rheumatoid arthritis [42–46]. As mentioned
above, in a prospective cohort study, Xu et al. reported on 1-year outcomes of
obese patients suffering from rheumatoid arthritis who underwent bariatric surgery
(41% had SG surgery) compared to an obese non-surgical group [28]. At 1-year
follow-up and compared to obese controls, patients who underwent bariatric surgery, showed significantly better American College of Rheumatology 20/50/70
A. Andalib144
(ACR 20/50/70) criteria and the weight loss after surgery was associated with
lower disease activity [28].
Finally, although bariatric procedures are shown to improve outcomes of obese
patients with rheumatoid disorders, bariatric surgery could also lead to some deleterious effects especially with respect to bone metabolism and is associated with
an elevated risk of fractures [46]. SG is shown to have a less negative impact on
bone metabolism compared to bypass-type procedures like RYGB or duodenal
switch [47–49]. Thus, in the absence of any contraindication like severe gastroesophageal reflux disease, SG may once again be a better procedure choice in the
immunocompromised patients due to rheumatoid disorders.
4 Summary
In summary, while studies on the perioperative use of immunosuppressive agents
in patients undergoing bariatric surgery are lacking, the use of these medications
in this population are not. The timing and the risk of withholding immunosuppressant medications should be weighed against the benefits of their use in each case
and in a multi-disciplinary fashion. If medically possible prior to elective bariatric surgery, one should aim to hold immunosuppressants 2–12 weeks preoperatively and until 2–4 weeks after surgery. When applicable, for some DMARDs like
TNF-α inhibitors, the timing of the surgery should be planned according to the last
dose since most agents are administered every 2–8 weeks and if needed only one
dose can be skipped after surgery. The beneficial outcomes of SG including weight
loss and improvements in obesity-related conditions in the immunocompromised
patients are comparable to those in immunocompetent individuals. Furthermore,
given that both obesity and rheumatoid/autoimmune disorders share a chronic
inflammatory state, it is not surprising that a reduction in obesity-induced inflammation after SG can lead to improvements in these conditions requiring immunosuppressive therapy.
References
1. Khorgami Z, Shoar S, Andalib A, Aminian A, Brethauer SA, Schauer PR. Trends in utiliza-
tion of bariatric surgery, 2010–2014: sleeve gastrectomy dominates. Surg Obes Relat Dis.
2017;13:774–8.
2. Angrisani L, Santonicola A, Iovino P, Vitiello A, Zundel N, Buchwald H, Scopinaro N.
Bariatric surgery and endoluminal procedures: IFSO worldwide survey 2014. Obes Surg.
2017;27:2279–89.
3. Aminian A, Chaudhry RM, Khorgami Z, Andalib A, Augustin T, Rodriguez J, Kroh M,
Schauer PR, Brethauer SA. A challenge between trainee education and patient safety: does
fellow participation impact postoperative outcomes following bariatric surgery? Obes Surg.
2016;26:1999–2005.
4. Bouchard P, Demyttenaere S, Court O, Franco EL, Andalib A. Surgeon and hospi-
tal volume outcomes in bariatric surgery: a population-level study. Surg Obes Relat Dis.
2020;16:674–81.
Sleeve Gastrectomy in Immunocompromised Patients
5. Aminian A, Brethauer SA, Andalib A, Punchai S, Mackey J, Rodriguez J, Rogula T, Kroh M,
Schauer PR. Can sleeve gastrectomy “cure” diabetes? Long-term metabolic effects of sleeve
gastrectomy in patients with type 2 diabetes. Ann Surg. 2016;264:674–81.
6. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, Navaneethan SD,
Singh RP, Pothier CE, Nissen SE, Kashyap SR. Bariatric surgery versus intensive medical
therapy for diabetes—5-year outcomes. N Engl J Med. 2017;376:641–51.
7. Aminian A. Bariatric procedure selection in patients with type 2 diabetes: choice between
Roux-en-Y gastric bypass or sleeve gastrectomy. Surg Obes Relat Dis. 2020;16:332–9.
8. Andalib A, Aminian A, Khorgami Z, Navaneethan SD, Schauer PR, Brethauer SA.
Safety analysis of primary bariatric surgery in patients on chronic dialysis. Surg Endosc.
2016;30:2583–91.
9. Bouchard P, Tchervenkov J, Demyttenaere S, Court O, Andalib A. Safety and efficacy
of the sleeve gastrectomy as a strategy towards kidney transplantation. Surg Endosc.
2020;34:2657–64.
10. Aminian A, Andalib A, Ver MR, Corcelles R, Schauer PR, Brethauer SA. Outcomes of bari-
atric surgery in patients with inflammatory bowel disease. Obes Surg. 2016;26:1186–90.
11. Andalib A, Aminian A, Khorgami Z, Jamal MH, Augustin T, Schauer PR, Brethauer SA.
Early postoperative outcomes of primary bariatric surgery in patients on chronic steroid or
immunosuppressive therapy. Obes Surg. 2016;26:1479–86.
12. Aminian A, Brethauer SA, Sharafkhah M, Schauer PR. Development of a sleeve gastrectomy
risk calculator. Surg Obes Relat Dis. 2015;11:758–64.
13. Birkmeyer NJ, Dimick JB, Share D, Hawasli A, English WJ, Genaw J, Finks JF, Carlin AM,
Birkmeyer JD, Michigan Bariatric Surgery C. Hospital complication rates with bariatric surgery in Michigan. JAMA. 2010;304:435–42.
14. Berger ER, Clements RH, Morton JM, Huffman KM, Wolfe BM, Nguyen NT, Ko CY, Hutter
MM. The Impact of different surgical techniques on outcomes in laparoscopic sleeve gastrectomies: the first report from the Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP). Ann Surg. 2016;264:464–73.
15. Ahmed Ali U, Martin ST, Rao AD, Kiran RP. Impact of preoperative immunosuppressive
agents on postoperative outcomes in Crohn’s disease. Dis Colon Rectum. 2014;57:663–74.
16. Abou Khalil M, Abou-Khalil J, Motter J, Vasilevsky CA, Morin N, Ghitulescu G, Boutros M.
Immunosuppressed patients with Crohn’s disease are at increased risk of postoperative complications: results from the ACS-NSQIP database. J Gastrointest Surg. 2019;23:1188–97.
17. Gagner M, Hutchinson C, Rosenthal R. Fifth international consensus conference: current sta-
tus of sleeve gastrectomy. Surg Obes Relat Dis. 2016;12:750–6.
18. Mazzei M, Zhao H, Edwards MA. Perioperative outcomes of bariatric surgery in the set-
ting of chronic steroid use: an MBSAQIP database analysis. Surg Obes Relat Dis.
2019;15:926–34.
19. Uchino M, Ikeuchi H, Bando T, Chohno T, Sasaki H, Horio Y, Kuwahara R, Minagawa T,
Goto Y, Ichiki K, Nakajima K, Takahashi Y, Ueda T, Takesue Y. Associations between multiple immunosuppressive treatments before surgery and surgical morbidity in patients with
ulcerative colitis during the era of biologics. Int J Colorectal Dis. 2019;34:699–710.
20. George MD, Baker JF, Winthrop KL, Goldstein SD, Alemao E, Chen L, Wu Q, Xie F, Curtis
JR. Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery. Ann Rheum Dis.
2020;79:573–80.
21. Kassel L, Hutton A, Zumach G, Rand J. Systematic review of perioperative use of immu-
nosuppressive agents in patients undergoing bariatric surgery. Surg Obes Relat Dis.
2020;16:144–57.
22. Fleshner P. Expert commentary on perioperative management of biologic and immunosup-
pressive medications in Crohn’s disease. Dis Colon Rectum. 2018;61:431–2.
23. Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, Gewurz-Singer O, Giles
JT, Johnson B, Lee S, Mandl LA, Mont MA, Sculco P, Sporer S, Stryker L, Turgunbaev
145