Background: Obesity presents one of the leading causes of many chronic liver disorders and injuries. Nowadays, non-alcoholic steatohepatitis (NASH) demonstrates a challenging issue for the global health system. NASH can progress to life-threatening conditions such as cirrhosis and hepatocellular or cholangio carcinoma. Currently, NASH cirrhosis is a major indication for liver transplant (LT). Case presentation: We present the case of a 37 year-old male who has lost 74 kg after undergoing successful laparoscopic sleeve gastrectomy (SG) four years ago. Recently, he underwent right hepatectomy in the course of living-donor liver transplantation for his sick father in our clinic. Before the SG was conducted four years ago, his weight was at 157 kg and his Body Mass Index (BMI) at 49 kg/m . At that time, Ultrasound examination showed severe fatty liver changes and intraoperative inspection of the liver was consistent with that observation. At the time of surgery, he weighed 83 kg and his BMI was at 27 kg/m . An effective weight reduction after bariatric surgery might protect NASH patients from further deterioration of their medical condition. Conclusion: To our knowledge, we report the first successful case of a right lobe living-donor hepatectomy in a patient who previously underwent successful laparoscopic sleeve gastrectomy (LSG). Keywords: First donor, NASH, Liver transplant, Living liver donation, Sleeve gastrectomy Background Herein we report the first right lobe living-donor Obesity is associated with many chronic diseases in- hepatectomy four years after successful laparoscopic cluding non-alcoholic fatty liver disease (NAFLD) and sleeve gastrectomy in a 37 year-old man. non-alcoholic steatohepatitis (NASH). Untreated NASH can progress to fibrosis and cirrhosis. Furthermore, NASH Case presentation can increase the risk of developing cholangio carcinoma A 37 year-old male who underwent successful laparo- and hepatocellular carcinoma. NASH cirrhosis is becoming scopic sleeve gastrectomy four years ago and who has a major indication for liver transplant (LT) [1–3]. consequently lost 74 kg was presented to our clinic with Weight reduction by bariatric surgery has shown to be other family members willing to provide their sick father an effective way of preventing the progression of NAFLD with a right lobe for the liver transplantation. Before the to chronic liver disease and cirrhosis [4–6]. Additionally, SG was done four years ago his weight was at 157 kg bariatric surgery was found to be feasible and safe in and his Body Mass Index (BMI) at 49 kg/m . At that selected cirrhotic patients, liver transplanted patients and time Ultrasound examination showed severe fatty liver in the setting of combined procedures such as liver changes with diffuse increased hepatic parenchymal transplantation [7–10]. echogenicity and also intraoperative inspection of the liver Significant weight loss after SG might prevent NASH was consistent with that observation. Unfortunately, liver patients from further deterioration of their liver function. biopsy was not taken. We did not quantify steatosis with other imaging modalities, such as MRI or CT, since the liver donation was not an issue at that time. At the time of surgery, he weighed 83 kg and his BMI * Correspondence: email@example.com 3 was at 27 kg/m . His lowest weight after SG was at Hepatobiliary and Transplant Surgery, Jordan Hospital, Amman, Jordan Full list of author information is available at the end of the article 80 kg. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Obed et al. BMC Surgery (2018) 18:31 Page 2 of 4 Full donor work up including liver biopsy was com- donation, the most commonly performed procedure in pleted. The liver biopsy showed steatosis in less than our center, since it provides a sufficient liver remnant 5%, no inflammation, no hepatocyte ballooning and no volume. Additionally, in this particular case the left lobe fibrosis. had two small arteries in comparison with the right lobe He was chosen as an appropriate donor with a total that only had a single big right hepatic artery. Also, there liver volume of 1800 cm and a future remnant liver were no veins from the right lobe merging into the mid- volume of 900 cm . The graft-to-recipient weight ratio dle hepatic vein. (GRWR) was at 0.9%. On the recipient side, left and right hepatic arteries Donor work up was completed including extended lab were divided and a large anastomosis with branch-patch analysis, anesthesia, and cardiac, assessment, psychiatric reconstruction was established. The right hepatic vein team and ethical committee evaluation for organ trans- and the right portal vein appeared without any abnor- plantation and was approved for liver donation. malities (Fig. 2). The donor operation time was 3 h and The Liver Transplant Board confirmed the indication 20 min. The donor didn’t receive any blood products for liver transplant and approved the living donor liver and was admitted to our intensive care unit for one day. transplantation (LDLT). After completing the evaluation, The donor had an uneventful recovery. On the first LDLT was performed. postoperative day, patient ambulation and clear fluid His father suffered from end-stage liver disease second- oral intake took place and he was discharged after seven ary to NASH cirrhosis, accompanied by type 2 diabetes days with normal liver function (Table 1). mellitus. Evaluations revealed a Child-Pugh stage B, a Currently, eight months after the right lobe donation model for end-stage liver disease (MELD) calculated score procedure, his liver function appears to be normal and of 17 and a body weight at 100 kg. his body weight remains stable in comparison to his During the right lobe hepatectomy, only minimal ad- weight prior to surgery (BMI = 27 kg/m ). hesions were found. The liver appeared grossly normal Graft reperfusion in the recipient was normal and liver with a sharp left lateral lobe. The left liver lobe was sup- biopsy was not required. plied by a branch of the left gastric artery and a smaller Similarly, the recipient had an uneventful postopera- branch of the main hepatic artery. The donor common tive course. Ambulation and reintroduction of oral feeding hepatic artery, after the bifurcation of the left HA were started on postoperative day two and he was dis- branch, was recovered with a segment of the gastroduo- charged with normal liver function three weeks after denal artery (Fig. 1). We chose to perform a right lobe LDLT. His diabetes disappeared after three months. Discussion and conclusions Obesity has reached an epidemic level. In many countries the incidence of obesity, defined by a BMI ≥ 35 kg/m , ranges between 7 and 24% and has even higher preva- lences in Europe . It is one of the main contributors to the global burden of the chronic clinical spectrum, includ- ing NAFLD. NAFLD includes a variety of liver injuries that range from simple steatosis to non-alcoholic steato- hepatitis (NASH) . Weight reduction by bariatric surgery has proved to be an effective way of preventing the progression of NAFLD to chronic liver disease and cirrhosis [4–6]. NASH cirrhosis presents the end stage of the spectrum of NAFLD and is becoming a main indication for LT in the United States. Presently, it is the third most common indication for LT and it is estimated to become the most common indication for LT within the next 1–2 decades. Bariatric surgery was found to be convincing and safe in selected cirrhotic patients, liver transplanted patients and in the setting of combined procedures such as liver Fig. 1 Preoperative liver triple phase CT- scan showed right hepatic artery arising from celiac trunk with relevant left hepatic artery transplantation. arising from left gastric artery; short red lines mark the split lines of A good percentage of obese patients are disqualified at common hepatic artery and gastroduodenal artery coming out with the time of presentation for LT due to the high risk of the right liver lobe combined diseases. Obed et al. BMC Surgery (2018) 18:31 Page 3 of 4 Fig. 2 Preoperative liver triple phase CT-scan showed normal appearance of right hepatic vein (a) and right portal vein (b) Obesity is certainly associated with diabetes mellitus, In general, all treatments that lead to the increase of coronary disease and tumors, and might imply signifi- the donor pool are welcomed. In absence of the gastric cant morbidity and mortality post-LT. There are several sleeve procedure, our patient would not have been eli- surgical strategies to improve the outcome in this group gible for donation. of patients, including bariatric surgery before LT, bariat- The lack of donor biopsy at the time of sleeve gastrec- ric surgery after LT and bariatric surgery [13–19] at the tomy demonstrates a study limitation in our case. time of LT as initially described by Heimbach et al., who To our knowledge, we report the first successful case reported their expertise of combined LT and gastric of a right lobe living-donor hepatectomy in a patient sleeve resection (SG) in seven patients with a BMI who previously underwent successful laparoscopic sleeve greater than 35 kg/m . gastrectomy (LSG). The advantages of combined LT with SG are certainly In conclusion, donor hepatectomy and LDLT appear the reduction to one operative implementation for the to be safe and feasible operations from donors who patient and the consecutive prevention of a second oper- underwent SG for obesity. Larger studies are needed to ation with potentially severe adhesions. Recent studies confirm this strategy, especially in the light of donor have demonstrated a significant improvement of NAFLD shortage in the field of liver transplantation. Activity Score and fibrosis after SG . Abbreviations Significant weight loss after bariatric surgery could BMI: Body Mass Index; GRWR: Graft-to-recipient weight ratio; LDLT: Living help NASH patients to avoid the progression that might donor liver transplant; LSG: Laparoscopic sleeve gastrectomy; LT: Liver require liver transplant. transplant; NAFLD: Non-alcoholic fatty liver disease; NASH: Non-alcoholic steatohepatitis; SG: Sleeve gastrectomy Even in the absence of published solid data, liver dona- tion after major surgery seems to be feasible. Patients Availability of data and materials who are willing to donate their liver after successful bar- The data supporting our thesis is completely available in this article. Articles iatric surgery should be evaluated. If the donor evalu- referred to can be found in the reference list. ation reveals no medical contraindication, LDLT could Authors’ contributions be performed; probably with the same risks that donors AO, AB and AJ analyzed the existing data regarding the treatment of the without SG in their history would have. patient considered, wrote the manuscript, prepared the Figures and analyzed the existing literature on the issue. AO, AB and AJ critically revised the manuscript. All authors read and approved the final version of the manuscript. Table 1 Shows postoperative liver function test for seven days Post-operative AST (IU/L) ALT (IU/L) Total Bilirubin Ethics approval and consent to participate day (mg/dL) Not applicable. 0 159 194 1.4 Consent for publication 1 211 178 2.6 Written informed consent was obtained from the patient for publication of this case report and any accompanying images. 2 170 134 1.9 3 100 98 1.7 Competing interests 4 79 88 1.7 The authors declare that they have no competing interests. 5 52 46 1.5 6 43 34 1.3 Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in 7 33 29 1.1 published maps and institutional affiliations. Obed et al. BMC Surgery (2018) 18:31 Page 4 of 4 Author details Hepatology, Gastroenterology and Hepatobiliary/Transplant Unit, Jordan Hospital, Amman, Jordan. General and Transplant Surgery, Jordan Hospital, Amman, Jordan. Hepatobiliary and Transplant Surgery, Jordan Hospital, Amman, Jordan. 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Published: May 29, 2018