Bariatric surgery in liver cirrhosis

Abstract

IntroductionObesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial.Material and MethodsObese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed.ResultsTwenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child–Pugh score, while three could be removed from the waiting list for a liver transplantation.ConclusionBS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

How best to combine liver transplantation and bariatric surgery?—Results from a global, web‐based survey

“…In most patients in this series, cirrhosis was however incidentally diagnosed during protocol biopsy during MBS. In a small number, MBS was performed during preparation for LT. A few patients with TIPS were included 59 . Based on the overall literature, MBS in patients with compensated cirrhosis seems to be safe, however a careful patient selection is key and optimizing patients' secondary comorbidities needs to be done before surgery.…”

“…Patients with decompensated cirrhosis had much higher mortality rates compared to those with more stable liver disease ( 59 Based on the overall literature, MBS in patients with compensated cirrhosis seems to be safe, however a careful patient selection is key and optimizing patients' secondary comorbidities needs to be done before surgery.…”

Treatment of liver fibrosis: Past, current, and future

“…BS has been shown to induce NASH disappearance in nearly 85% (95%CI: 75.8%-92.2%) of patients and to decrease fibrosis in 33.8% of patients (95%CI: 23.6%-45.2%) with NASH at 1 year after surgery[ 135 ]. Another clinical study showed that excessive weight loss shown in patients with cirrhosis with 73% (33%–167%), 85% (33%–190%), and 73% (29%–107%) after 1, 2, and 3 years of BS[ 136 ], respectively. Among 27 patients with cirrhosis, 3 patients had significant improvement in liver function and did not need liver transplantation, whereas 2 out of 27 patients had deleterious liver function post-BS treatment[ 136 ].…”

“…Another clinical study showed that excessive weight loss shown in patients with cirrhosis with 73% (33%–167%), 85% (33%–190%), and 73% (29%–107%) after 1, 2, and 3 years of BS[ 136 ], respectively. Among 27 patients with cirrhosis, 3 patients had significant improvement in liver function and did not need liver transplantation, whereas 2 out of 27 patients had deleterious liver function post-BS treatment[ 136 ].…”