Bariatric surgery in liver cirrhosis

Abstract

Introduction: Obesity 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 methods: Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed.

Results: Twenty-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.

Conclusion: BS 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.

Keywords: NAFLD; Roux-en-Y-gastric bypass; bariatric surgery; liver cirrhosis; liver failure; obese patients; obesity; sleeve gastrectomy.

Figure 1

Development of weight of patients undergoing bariatric surgery suffering from liver cirrhosis (n = 27). Weight (kg) at time of surgery (0), 1 year (1y), 2 years (2y), and 3 years (3y) after surgery (A). Excess weight loss [EWL (%)] after 1, 2, and 3 years (B).

Figure 2

Development of weight and excess weight loss (EWL) of patients undergoing bariatric surgery suffering from liver cirrhosis, stratified by bariatric procedure. Weight (kg) at time of surgery (0), 1 year (1y), 2 years (2y), and 3 years (3y) after surgery (A). Excess weight loss [EWL (%)] after 1, 2, and 3 years (B). One patient was excluded due to another procedure type (Omega-Loop), impossible to fit into the comparison. SG, sleeve gastrectomy; RYGB, Roux-en-Y-gastric bypass.