Abstract
Severe obesity is associated with increased perioperative risk after major hepatectomy and may adversely affect long-term outcomes. Whilst bariatric surgery is an effective treatment for obesity, simultaneous liver resection and bariatric procedures are rarely performed outside the transplant setting. We report a case of a 29-year-old woman (body mass index 39.3 kg/m2) with hepatocellular adenoma who underwent a one-stage right hepatectomy followed by gastric plication. Operative time was 199 min with blood loss of 500 ml and no transfusion required. The postoperative course was uneventful, with no complications ≥ Clavien–Dindo grade II. The patient was discharged on postoperative day 9. Histology confirmed R0 resection. At 3 months, the patient achieved a 15-kg weight loss with improved metabolic parameters. This case demonstrates that simultaneous major hepatectomy combined with restrictive bariatric surgery is feasible and safe in carefully selected patients.
Introduction
Obesity is associated with an increased incidence of liver tumours and presents a significant challenge in hepatic surgery [1, 2]. In patients requiring major hepatectomy, severe obesity increases technical complexity and perioperative risk [3].
Simultaneous liver resection and bariatric surgery is rarely reported outside transplant settings [4, 5]. A combined approach may reduce cumulative surgical burden; however, evidence regarding its safety and feasibility remains limited.
Case report
A 29-year-old woman [body mass index (BMI) 39.3 kg/m2] with hepatic steatosis, hypertension, and hypothyroidism was referred for evaluation of a liver lesion. Imaging revealed two lesions in segments V–VII consistent with hepatocellular adenoma, although malignancy could not be excluded (Fig. 1).
Preoperative magnetic resonance imaging demonstrating two lesions in segments V–VII of the right hepatic lobe. Imaging findings were consistent with hepatocellular adenomas.
Following multidisciplinary evaluation, a combined procedure was indicated. The patient was considered a suitable candidate for a combined procedure because she fulfilled indications for both major liver resection and bariatric surgery. Preoperative assessment demonstrated preserved liver function, absence of significant fibrosis or portal hypertension, and an adequate future liver remnant. Her young age and obesity-related comorbidities further supported the decision to perform a simultaneous metabolic intervention.
A right hepatectomy with cholecystectomy (Fig. 2) was performed via a right subcostal incision using the clamp-crush technique and intermittent Pringle manoeuvre. The right hepatic vein was divided and ligated. Gastric plication was subsequently performed with two rows of sutures over a 36F bougie following mobilization of the greater curvature. Liver resection was intentionally completed before the bariatric procedure to ensure adherence to oncological principles and to avoid potential technical difficulties related to manipulation of a previously plicated stomach.
Intraoperative view after completion of right hepatectomy showing the liver transection plane and preserved left liver remnant.
Total operative time was 199 min with blood loss of 500 ml. No transfusion was required.
The postoperative course was uneventful. No complications ≥ Clavien–Dindo grade II occurred. Oral intake was initiated on postoperative day 1, and the patient was discharged on day 9.
Histology confirmed R0 resection of two hepatocellular adenomas without β-catenin activation (Fig. 3). At 3 months, the patient had lost 15 kg with improvement in metabolic parameters. At 6 months, the patient had lost 18 kg, reaching BMI 34 kg/m2.
Histopathological examination confirming hepatocellular adenoma, including hepatocyte nuclear factor 1 alpha (HNF1A)-inactivated subtype (H-HCA) and inflammatory subtype (I-HCA) (haematoxylin and eosin staining). No aberrant nuclear β-catenin expression was detected.
Discussion
Simultaneous liver resection and bariatric surgery have been primarily described in transplant settings [4]. Outside this context, available data are limited to isolated case reports, which demonstrate technical feasibility and acceptable short-term outcomes [4, 5].
A combined approach may reduce the need for staged procedures, repeated anaesthesia, and delayed metabolic intervention. However, it increases operative complexity and requires careful patient selection [2].
In this case, gastric plication was chosen as a restrictive and potentially reversible procedure. It was preferred over sleeve gastrectomy to avoid gastric resection and potential staple-line-related complications in the setting of major hepatic surgery. Furthermore, gastric plication reduced operative complexity whilst still providing an early metabolic effect and clinically meaningful weight loss. Given the absence of diabetes and the patient's relatively young age, a purely restrictive approach was considered appropriate. The patient met established criteria for bariatric surgery [6], and oncological principles were maintained by performing liver resection first.
A potential concern is the impact of early postoperative catabolism on liver regeneration [3, 4]. This risk appears limited in patients with preserved liver function and adequate future liver remnant, as demonstrated in this case.
To our knowledge, reports of simultaneous major hepatectomy and restrictive bariatric procedures outside transplant settings remain very limited. This case supports the short-term feasibility and safety of such an approach in carefully selected patients; however, longer follow-up is required to evaluate durability of weight loss, metabolic outcomes, and long-term surgical safety.
Careful patient selection and management in experienced hepatobiliary centres remain essential. This case highlights the potential role for combined surgical strategies in selected patients with concurrent oncological and metabolic indications.
Conclusion
Simultaneous right hepatectomy and gastric plication appears feasible and safe in carefully selected patients with preserved liver function when performed in experienced centres. Further studies are required to confirm long-term safety and metabolic outcomes.
Conflicts of interest
None declared.
Funding
None declared.
Consent
Written informed consent was obtained from the patient.
