Liver failure following biliopancreatic diversions: a narrative review

Abstract

CONTEXT AND OBJECTIVE: Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. DESIGN AND SETTING: Narrative review; bariatric surgery service of a public university hospital. METHODS: A review of the literature was conducted through an online search of medical databases. RESULTS: Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. CONCLUSIONS: Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD. RESUMO CONTEXTO E OBJETIVO:A ocorrência de falência hepática após a derivação jejunoileal foi extensivamente descrita no passado e foi um dos principais fatores que levaram ao abandono do procedimento. Os procedimentos predominantemente malabsortivos mais modernos, chamados de derivações biliopancreáticas, também já foram implicados em diversos casos de falência hepática aguda e subaguda. O objetivo foi revisar a atual evidência disponível sobre a ocorrência de insuficiência hepática após derivações biliopancreáticas. TIPO DE ESTUDO E LOCAL: Revisão narrativa; Serviço de Cirurgia Bariátrica de hospital universitário. MÉTODOS: Revisão da literatura conduzida por meio de pesquisa online de bancos de dados médicos. RESULTADOS: A associação entre derivações biliopancreáticas e falência hepática na literatura é infrequente. Entretanto, ela aparenta ser mais do que meramente anedótica. Os mecanismos fisiopatológicos continuam pouco compreendidos, mas parecem estar relacionados à rápida perda de peso, desnutrição proteica e déficit de fatores hepatotróficos, altos níveis circulantes de ácidos graxos livres e supercrescimento bacteriano em segmentos intestinais excluídos do trânsito. A reversão da cirurgia pode melhorar o comprometimento hepático. CONCLUSÕES: Embora infrequente, a falência hepática continua sendo preocupante após as derivações biliopancreáticas. Seguimento cuidadoso é mandatório em indivíduos submetidos a essas cirurgias.

Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes

“…(7,9) Over the last decade, several case series have described liver failure after BS. (10)(11)(12)(13) In most of the reports, liver failure occurred early postoperatively, presented with quick deterioration of liver function, and may have been associated with rapid weight loss and malnutrition. (12,14) However, the effect of BS on liver function and the nutrition consequences in patients with cirrhosis, regardless of etiology, years after BS are not completely clear.…”

“…The demographics and clinical characteristics of all the patients are shown in Table 1. By design, median (IQR) age (54 [46-61] years versus 54 [47-62] years) and MELD score (12 [8-20] versus 13 [9][10][11][12][13][14][15][16][17][18]) at evaluation were similar between the BS and concurrent cohorts. Patients in the BS cohort tended to be female (83.3% versus 44.2%; P < 0.01).…”

“…The 1-and 3-year survival rates for BS versus the concurrent cohort was 85% (95% CI, 71%-100%) and 84% (95% CI, 74%-96%) versus 85% (95% CI, 71%-100%) and 82% (95% CI, 72%-94%; P = 0.57), respectively. The length of stay for the initial hospitalization was similar in the BS group (median [IQR]; 14 [8][9][10][11][12][13][14][15][16][17][18][19][20][21] days versus 9 [6-17] days; P = 0.13). The number of patients with at least 1 readmission (52% versus 52%) was similar (P = 1.0).…”

“…The short‐term and longterm surgical complications of BS are well documented, including infection and nutrient deficiencies . Over the last decade, several case series have described liver failure after BS . In most of the reports, liver failure occurred early postoperatively, presented with quick deterioration of liver function, and may have been associated with rapid weight loss and malnutrition .…”

Hepatic Failure After Bariatric Surgery: A Systematic Review

“…However, sometimes, we encounter reports in the literature regarding individuals experiencing bariatric surgeries presenting with hepatic impairment such as serious complications that can lead to liver transplantation or even death. Although hepatic impairment following biliopancreatic diversion with duodenal switch (BPD/DS), and Roux-en-Y gastric bypass (RYGB) was recently reviewed (9,10), the evidence regarding this event is distracting, and our information about the underlying mechanisms, possible risk factors, and best managements is restricted to each author's discussion.…”