Bariatric Surgery in Cirrhotic Patients: Is It Safe?

Abstract

Introduction Ten percent of cirrhotic patients are known to have a high risk of postoperative complications. Ninety percent of bariatric patients suffer from non-alcoholic fatty liver disease (NAFLD), and 50% of them may develop non-alcoholic steatohepatitis (NASH) which can progress to cirrhosis. The aim of this study was to assess whether the presence of cirrhosis at the time of bariatric surgery is associated with an increased rate and severity of short-and long-term cirrhotic complications. Methods A cohort of 110 bariatric patients, between May 2003 and February 2018, who had undergone liver biopsy at the time of bariatric surgery were reassessed for histological outcome and divided into two groups based on the presence (C, n = 26) or absence (NC, n = 84) of cirrhosis. The NC group consisted of NASH (n = 49), NAFLD (n = 24) and non-NAFLD (n = 11) liver histology. Medical notes were retrospectively assessed for patient characteristics, development of 30-day postoperative complications, severity of complications (Clavien-Dindo (CD) classification) and length of stay. The C group was further assessed for long-term cirrhosis-related outcomes. Results The C group was older (52 years vs 43 years) and had lower BMI (46 kg/m 2 vs 52 kg/m 2 ) and weight (126 kg vs 145 kg) compared to the NC group (p < 0.05). The C group had significantly higher overall complication rate (10/26 vs 14/84, p < 0.05) and severity of complications (CD class ≥ III, 12% vs 7%, p < 0.05) when compared to the NC group. The length of stay was similar between the two groups (5 days vs 4 days). The C group had significant improvement in model end-stage liver disease scores (7 vs 6, p < 0.01) with median follow-up of 4.5 years (range 2-11 years). There were no long-term cirrhosis-related complications or mortality in our studied cohort (0/26). Conclusion Bariatric surgery in cirrhotic patients has a higher risk of immediate postoperative complications. Long-term cirrhosis-related complications or mortality was not increased in this small cohort. Preoperative identification of liver cirrhosis may be useful for risk stratification, optimisation and informed consent. Bariatric surgery in well-compensated cirrhotic patients may be used as an aid to improve long-term outcome.

Epidemiology of non-alcoholic fatty liver disease and hepatocellular carcinoma

“…(109) Nevertheless, for patients with cirrhosis careful consideration must be given in weighing the risks and benefits of bariatric surgery especially as studies have demonstrated that those with cirrhosis may experience significant complications post-surgery. (110,111) Other preventive HCC treatments should include counseling for the cessation of smoking and reducing alcohol consumption, when appropriate, as well as management of hypercholesteremia and type 2 diabetes and obesity, if present. (112,113) In fact, some treatment of risk factors for NASH may provide potential benefit for HCC.…”

“… 108 Nevertheless, for patients with cirrhosis, careful consideration must be given to weighing the risks and benefits of bariatric surgery, especially as studies have demonstrated that those with cirrhosis may experience significant complications post-surgery. 109 , 110 …”

Bariatric surgery and the liver—Mechanisms, benefits, and risks

“…73,74 Case-control studies have reported a significantly higher postoperative major complication rate (approximately 12%) in patients with cirrhosis, albeit with an acceptably low mortality rate. 73,75 Laparoscopic procedures in the cirrhotic patient warrant precautions such as well-thought-out trocar placement, careful pneumoperitoneum pressurization, patient positioning taking into account oversized liver lobes, and the avoidance of postoperative abdominal drains. 76 Notably, the complication rate following SG was lower than after RYGB (31.3% vs. 14.6% for any complication).…”

Adipositas-Chirurgie – eine sichere Option bei Risiko-Patienten mit irreversibler Organ-Dysfunktion

“…Dies entspricht den Daten aus dem amerikanischen Register (American College of Surgeons National Surgical Quality Improvement Program), welche die Adipositas-Chirurgie bei dialysepflichtigen Patienten als sicher und effektiv beschreiben [15]. Da Adipositas als Risikofaktor für NASH und in der Folge auch für Leberzirrhose gut bekannt ist [16], wurde -wie zu erwartenbei der Mehrheit unserer Patienten intraoperativ eine Leberzirrhose festgestellt. Bei den Patienten mit Leberzirrhose werden beide Verfahren, LSG und LRYGB, in der Literatur als sichere Eingriffe beschrieben [6,17,18]; auch bei uns wurden beide Verfahren angewendet.…”