Would you choose a liver transplant or a sleeve to survive?

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The audience of this publication is meta­bolic surgeons and those who believe in the effectiveness of metabolic surgery in the treatment of obesity and it’s comorbidities. However there are still a lot of non believers out there amongst our colleagues whom we should continue to engage with in scientific discussions to highlight the rule of meta­bolic surgery in alleviating lethal medical conditions associated with obesity.

Last month we performed the first suc­cessful liver transplant surgery in Kuwait for a patient who had liver failure caused by non alcoholic steatohepatitis. Whilst in his Surgery the thought occurred to me that if this gentleman had a sleeve surgery few years ago, he would have not needed the transplant. About 90% of patients with a BMI above 35 would have NAFLD, which is es­sentially a benign condition caused by the deposition of fat in the liver. About 30% of those will progress to hepatitis (NASH) and 5-10% of those would progress to cirrho­sis. In 2013 I read an article about a court case in Australia where a patient with NASH leading to Cirrhosis and death from hepato­cellular carcinoma took his primary physi­cian to court because when he presented to him in 2006, the primary physician did not refer him to a metabolic surgeon. The patient won the case as he convinced the jury that metabolic surgery is the most ef­fective treatment for NASH and that if he had that surgery in 2006 he would not have progressed to cirrhosis and would not have developed hepatocellular carcinoma.

Evidence is mounting supporting the use of metabolic surgery for the treatment of NASH. A metanalysis by Rajasekhara Et al published in the journal of clinical gas­troenterology and Hepatology included 15 studies with 766 paired liver biopsies be­fore and after metabolic surgery showed an improvement or resolution in steatosis in 91.6% of patients (95% confidence in­terval [CI], 82.4%–97.6%), the resolution of steatohepatitis in 81.3% of patients (95% CI, 61.9%–94.9%), and a resolution of even fibrosis in 65.5% of patients (95% CI, 38.2%– 88.1%). This is a powerful finding that even early stages of fibrosis are reversed with metabolic surgery.

NASH is estimated to become the leading cause for liver failure in the United States by the year 2025, especially after the discov­ery in recent years for the cure for hepatitis C virus. We are seeing many cases of liver failure due to NASH nowadays in the Gulf countries.

Metabolic surgery should be supported by health policies and insurance companies and this is one way of regulating this branch of Surgery thus giving it a respectable rec­ognition leading to centers of excellence instead of the current situation where this Surgery is practiced without much political support. How many patients where saved from liver transplants by metabolic surgery and how many where let down by their pri­mary health care physicians and hepatolo­gists by not referring them for a metabolic surgeon

 

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