Laparoscopic Adjustable Gastric Banding In Patients with Unexpected Cirrhosis: Safety and Outcomes. Obes Surg. 2015;25:1858-1862. [PMID: 25708241 DOI: 10.1007/s11695-015-1623-9]

Liver Transplantation 2023: Status Report, Current and Future Challenges

Liver transplantation offers live-saving therapy for patients with complications of cirrhosis and stage T2 hepatocellular carcinoma. The demand for organs far outstrips the supply, and innovations aimed at increasing the number of usable deceased donors as well as alternative donor sources are a major focus. The etiologies of cirrhosis are shifting over time, with more need for transplantation among patients with alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease and less for viral hepatitis, although hepatitis B remains an important indication for transplant in countries with high endemicity. The rise in transplantation for alcohol-associated liver disease and nonalcoholic/metabolic fatty liver disease has brought attention to how patients are selected for transplantation and the strategies needed to prevent recurrent disease. In this review, we present a status report on the most pressing topics in liver transplantation and future challenges.

Non-alcoholic fatty liver disease (NAFLD): a review of pathophysiology, clinical management and effects of weight loss

Given the increasing prevalence of diabetes and obesity worldwide, the deleterious effects of non-alcoholic fatty liver disease (NAFLD) are becoming a growing challenge for public health. NAFLD is the most common chronic liver disease in the Western world. NAFLD is closely associated with metabolic disorders, including central obesity, dyslipidaemia, hypertension, hyperglycaemia and persistent abnormalities of liver function tests.In general NAFLD is a common denominer for a broad spectrum of damage to the liver, which can be due to hepatocyte injury, inflammatory processes and fibrosis. This is normally seen on liver biopsy and can range from milder forms (steatosis) to the more severe forms (non-alcoholic steatohepatitis (NASH), advanced fibrosis, cirrhosis and liver failure). In these patients, advanced fibrosis is the major predictor of morbidity and liver-related mortality, and an accurate diagnosis of NASH and NAFLD is mandatory. Histologic evaluation with liver biopsy remains the gold standard to diagnose NAFLD. Diagnosis of NAFLD is defined as presence of hepatic steatosis, ballooning and lobular inflammation with or without fibrosis. Weight loss, dietary modification, and the treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established. Dietary recommendations and lifestyle interventions, weight loss, and the treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established with promising results but are difficult to maintain. Pioglitazone and vitamin E are recommended by guidelines in selected patients. This review gives an overview of NAFLD and its treatment options.

Bariatric Surgery is Effective and Safe for Obese Patients with Compensated Cirrhosis: A Systematic Review and Meta-Analysis

BACKGROUND

With the global pandemic of obesity and nonalcoholic fatty liver disease (NAFLD), the incidence of cirrhosis associated with nonalcoholic steatohepatitis (NASH) has greatly increased. This study aimed to evaluate the efficacy and safety of bariatric surgery in obese cirrhotic patients.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched for relevant studies. Effectiveness outcomes were weight loss, remission of comorbidities, and improvement in liver function. Safety outcomes were procedural complications and mortality.

RESULTS

A total of 15 studies were included in this meta-analysis. Patients with compensated cirrhosis lost weight significantly after surgery, and the percentage of excess weight loss was 60.44 (95% CI, 44.34 to 76.55). Bariatric surgery resulted in remission of NAFLD in 57.9% (95% CI, 27.5% to 88.3%), T2DM in 58.4% (95% CI, 48.4% to 68.4%), hypertension in 53.1% (95% CI, 43% to 63.3%), dyslipidemia in 59.8% (95% CI, 41.1% to 78.5%) of patients with cirrhosis. Bariatric surgery reduced the levels of alanine aminotransferase and aspartate aminotransferase. The incidence of surgical complications in patients with cirrhosis was about 19.2% (95% CI, 11.7% to 26.6%), which was higher than that in patients without cirrhosis (OR 2.67 [95% CI, 1.26 to 5.67]). Patients with cirrhosis had an overall mortality rate of 1.3%, and the mortality rates for compensated cirrhosis and decompensated cirrhosis were 0.9% and 18.2%, respectively.

CONCLUSIONS

Bariatric surgery is effective for weight loss, remission of comorbidities, and reversal of liver damage. Although cirrhotic patients have a higher risk of complications and death, bariatric surgery is relatively safe for well-compensated cirrhosis.

Bariatric Surgery in NAFLD

Currently, there are no approved medications to treat patients with nonalcoholic steatohepatitis (NASH) with fibrosis or cirrhosis. Although the management goal in these patients is weight reduction by 7-10% with lifestyle modifications, only less than 10% of patients achieve this target at 1-year, and fewer maintain the weight loss at 5 years. Bariatric surgery is an option that may be considered in those who fail to lose weight by lifestyle changes. Bariatric surgery has been shown to improve liver histology including fibrosis secondary to NASH, in addition to other benefits including an improvement or resolution of type 2 diabetes mellitus, dyslipidemia, and hypertension, and a reduction of cardiovascular morbidity or mortality. There are no guidelines of bariatric surgery indications for the management of NASH. The purpose of this review is to critically appraise the current knowledge of the role of bariatric surgery and the potential mechanisms for its perceived benefits in the management of patients with NASH-related liver disease.

Outcomes of Bariatric Surgery in Patients with Liver Cirrhosis: a Systematic Review

Obesity is commonly associated with non-alcoholic fatty liver disease and is a significant cause of chronic liver disease and cirrhosis. Some patients undergoing bariatric surgery suffer from cirrhosis of the liver. Currently, there is a lack of consensus on the management of these patients and the safety and efficacy of bariatric surgery in this group. This review aims to update our previously published systematic review on the same topic. A total of 21 studies reporting experience on patients with cirrhosis undergoing bariatric surgery were included. Sleeve gastrectomy was the most common surgery performed, followed by Roux-en-Y gastric bypass. The results show that bariatric surgery may be feasible in carefully selected patients with obesity and cirrhosis although they have slightly higher morbidity and mortality rates.

Safety of metabolic and bariatric surgery in obese patients with liver cirrhosis: a systematic review and meta-analysis

BACKGROUND

With the pandemic of obesity and the growing experience in metabolic and bariatric surgery (MBS), the number of patients with obesity and liver cirrhosis undergoing MBS is increasing.

OBJECTIVE

To analyze the morbidity and mortality following MBS in patients with obesity and liver cirrhosis.

SETTING

Systematic review and meta-analysis.

METHODS

The published literature was systematically reviewed, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, for studies reporting outcomes of MBS among patients with liver cirrhosis. The predetermined endpoints were the overall complication after MBS, intraoperative complications, liver-related complications after MBS, all-cause 90-day mortality after MBS, and liver-related mortality post-MBS. The pooled weighted proportions for each of the endpoints was calculated using random effect meta-analysis.

RESULTS

A total of 18 studies, including 471 patients with obesity and liver cirrhosis undergoing MBS, qualified for the final quantitative analysis. The mean age and mean body mass index (BMI) of the pooled patient cohort were 50.2 years and 47.2 kg/m². The pooled weighted proportions of the overall post-MBS complications, intraoperative complications, liver-related complications, overall 90-day mortality, and liver failure related mortality post MBS were 22.14% (CI_95%: 15.43%-29.55%), .08% (CI_95%: 0%-1.02%), 4.62% (CI_95%: 1.27%-9.30%), 0% (CI_95%: 0%-.44%), .08% (CI_95%: 0%-1.03%), respectively. Significantly lower postoperative complications were noted with sleeve gastrectomy (10.08% [95%CI: 5.14%-16%]) compared with Roux-en-Y gastric bypass (31.53% [95%CI: 18.62%-45.68%]; (P = .02).

CONCLUSION

We found an overall low postoperative surgical and liver-related mortality post MBS among patients with obesity and liver cirrhosis. The overall postoperative complications and liver-related complications were higher among patients with liver cirrhosis than in noncirrhotic patients. Sleeve gastrectomy showed lower postoperative complications compared with Roux-en-Y gastric bypass.

Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions

BACKGROUND AND AIMS

Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures.

METHODS

We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review.

RESULTS

Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate.

CONCLUSIONS

Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.

Bariatric Surgery in Cirrhotic Patients: a Matched Case-Control Study

INTRODUCTION

Laparoscopic bariatric surgery (LBS) in liver end-stage organ disease has been proven to improve organ function and patients' symptoms. A series of LBS in patients with cirrhosis have shown good results in weight loss, but increased risk of complications. Current literature is based on clinical series. This paper aims to compare LBS (69% gastric bypass) between patients with cirrhosis and without cirrhosis.

METHODS

We conducted a retrospective 1:3 matched case-control study including bariatric patients with cirrhosis and without cirrhosis. Demographics, operative variables, postoperative complications, long-term weight loss, and comorbidity resolution were compared between groups.

RESULTS

Sixteen Child A patients were included in the patients with cirrhosis (PC) group and 48 in patients without cirrhosis (control) group. Mean age was 50 years; preoperative BMI was 39 ± 6.8 kg/m². Laparoscopic gastric bypass and laparoscopic sleeve gastrectomy were performed in 69% and 31%, respectively. Follow-up was 81% at 2 years for both groups. PC group had a higher rate of overall (31% vs. 6%; p < 0.05) and severe (Clavien-Dindo ≥ III; 13% vs. 0%; p = 0.013) complications than that of the control group. Mean %EWL of PC at 2 years of follow-up was 84.9%, without differences compared with that of the control group (83.1%). Comorbidity remission in PC was 14%, 50%, and 85% for hypertension, type 2 diabetes, and dyslipidemia, respectively. Patients without cirrhosis had a higher resolution rate of hypertension (65% vs. 14%, p = 0.03).

CONCLUSION

LBS is effective for weight loss and comorbidity resolution in patients with obesity and Child A liver cirrhosis. However, these results are accompanied by significantly increased risk of complications.

Bariatric Surgery in Cirrhotic Patients: Is It Safe?

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/m2 vs 52 kg/m2) 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.

Obesity in the Liver Transplant Setting

The obesity epidemic has resulted in an increased prevalence of obesity in liver transplant (LT) candidates and in non-alcoholic fatty liver disease (NAFLD) becoming the fastest growing indication for LT. LT teams will be dealing with obesity in the coming years, and it is necessary for them to recognize some key aspects surrounding the LT in obese patients. Obesity by itself should not be considered a contraindication for LT, but it should make LT teams pay special attention to cardiovascular risk assessment, in order to properly select candidates for LT. Obese patients may be at increased risk of perioperative respiratory and infectious complications, and it is necessary to establish preventive strategies. Data on patient and graft survival after LT are controversial and scarce, especially for long-term outcomes, but morbid obesity may adversely affect these outcomes, particularly in NAFLD. The backbone of obesity treatment should be diet and exercise, whilst being careful not to precipitate or worsen frailty and sarcopenia. Bariatric surgery is an alternative for treatment of obesity, and the ideal timing regarding LT is still unknown. Sleeve gastrectomy is probably the procedure that has the best evidence in LT because it offers a good balance between safety and efficacy.

Cost-effectiveness Analysis of Bariatric Surgery for Patients With Nonalcoholic Steatohepatitis Cirrhosis

IMPORTANCE

Obesity is the most common risk factor for nonalcoholic steatohepatitis (NASH), the progressive form of nonalcoholic fatty liver disease that can lead to cirrhosis and hepatocellular carcinoma. Weight loss can be an effective treatment for obesity and may slow the progression of advanced liver disease.

OBJECTIVE

To assess the cost-effectiveness of bariatric surgery in patients with NASH and compensated cirrhosis.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation study used a Markov-based state-transition model to simulate the benefits and risks of laparoscopic sleeve gastrectomy (SG), laparoscopic Roux-en-Y gastric bypass (GB), and intensive lifestyle intervention (ILI) compared with usual care in patients with NASH and compensated cirrhosis and varying baseline weight (overweight, mild obesity, moderate obesity, and severe obesity). Patients faced varied risks of perioperative mortality and complications depending on the type of surgery they underwent. Data were collected on March 22, 2017.

MAIN OUTCOMES AND MEASURES

Life-years, quality-adjusted life-years (QALYs), costs (in 2017 $US), and incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

Demographic characteristics of the patient population were based on a previously published prospective study (n = 161). Patients in the model were 41.0% female, and the base case age was 54 years. Compared with usual care, SG was associated with an increase in QALYs of 0.263 to 1.180 (bounds of ranges represent overweight to severe obesity); GB, 0.263 to 1.207; and ILI, 0.004 to 0.216. Sleeve gastrectomy was also associated with an increase in life-years of 0.693 to 1.930; GB, 0.694 to 1.947; and ILI, 0.012 to 0.114. With usual care, expected life-years in overweight, mild obesity, moderate obesity, and severe obesity were 12.939, 11.949, 10.976, and 10.095, respectively. With usual care, QALY in overweight was 6.418; mild obesity, 5.790; moderate obesity, 5.186; and severe obesity, 4.577. Sleeve gastrectomy was the most cost-effective option for patients across all weight classes assessed: ICER for SG in patients with overweight was $66 119 per QALY; mild obesity, $18 716 per QALY; moderate obesity, $10 274 per QALY; and severe obesity, $6563 per QALY. A threshold analysis on the procedure cost of GB found that for GB to be cost-effective, the cost of the surgery must be decreased from its baseline value of $28 734 by $4889 for mild obesity, by $3189 for moderate obesity, and by $2289 for severe obesity. In overweight patients, GB involved fewer QALYs than SG, and thus decreasing the cost of surgery would not result in cost-effectiveness.

CONCLUSIONS AND RELEVANCE

Bariatric surgery could be highly cost-effective in patients with NASH compensated cirrhosis and obesity or overweight. The findings from this analysis suggest that it can inform clinical trials evaluating the effect of bariatric procedures in patients with NASH cirrhosis, including those with a lower body mass index.

Considerations for bariatric surgery in patients with cirrhosis

With the ever increasing global obesity pandemic, clinical burden from obesity related complications are anticipated in parallel. Bariatric surgery, a treatment approved for weight loss in morbidly obese patients, has reported to be associated with good outcomes, such as reversal of type two diabetes mellitus and reducing all-cause mortality on a long term basis. However, complications from bariatric surgery have similarly been reported. In particular, with the onslaught of non-alcoholic fatty liver disease (NAFLD) epidemic, in associated with obesity and metabolic syndrome, there is increasing prevalence of NAFLD related liver cirrhosis, which potentially connotes more risk of specific complications for surgery. Bariatric surgeons may encounter, either expectedly or unexpectedly, patients with non-alcoholic steatohepatitis (NASH) and NASH related cirrhosis more frequently. As such, the issues and considerations surrounding their medical care/surgery warrant careful deliberation to ensure the best outcomes. These considerations include severity of cirrhosis, liver synthetic function, portal hypertension and the impact of surgical factors. This review explores these considerations comprehensively and emphasizes the best approach to managing cirrhotic patients in the context of bariatric surgery.

First right lobe living-donor hepatectomy after sleeve gastrectomy

Background

Obesity presents one of the leading causes of many chronic liver disorders and injuries. Nowadays, non-alcoholic steatohepatitis (NASH) demonstrates a challenging issue for the global health system. NASH can progress to life-threatening conditions such as cirrhosis and hepatocellular or cholangio carcinoma. Currently, NASH cirrhosis is a major indication for liver transplant (LT).

Case presentation

We present the case of a 37 year-old male who has lost 74 kg after undergoing successful laparoscopic sleeve gastrectomy (SG) four years ago. Recently, he underwent right hepatectomy in the course of living-donor liver transplantation for his sick father in our clinic. Before the SG was conducted four years ago, his weight was at 157 kg and his Body Mass Index (BMI) at 49 kg/m². At that time, Ultrasound examination showed severe fatty liver changes and intraoperative inspection of the liver was consistent with that observation. At the time of surgery, he weighed 83 kg and his BMI was at 27 kg/m². An effective weight reduction after bariatric surgery might protect NASH patients from further deterioration of their medical condition.

Conclusion

To our knowledge, we report the first successful case of a right lobe living-donor hepatectomy in a patient who previously underwent successful laparoscopic sleeve gastrectomy (LSG).

Bariatric surgery in individuals with liver cirrhosis: A narrative review

Introduction:

Bariatric surgery has become the gold standard treatment for morbid obesity, but there is no consensus regarding its safety and efficacy among individuals with chronic liver diseases.

Objective:

To critically evaluate the existing evidence on literature about bariatric surgery in individuals with liver cirrhosis.

Method:

Narrative review performed by means of an online search in the MEDLINE and LILACS databases.

Results:

Bariatric surgery is safe and effective in individuals with chronic liver disease without clinical decompensation or significant portal hypertension. Individuals with severe liver function impairment present significantly higher surgical morbidity and mortality. Among candidates to liver transplantation, surgery may be performed before, after and even during transplantation, and there is a predominant trend to perform it after. Vertical sleeve gastrectomy seems to be the most adequate technique in this group of subjects.

Conclusion:

Bariatric surgery is safe and effective in individuals with compensated cirrhosis without significant portal hypertension, but presents higher morbidity. Among candidates to liver transplantation and/or individuals with severe portal hypertension, morbidity and mortality are significantly higher.

A Systematic Review of Bariatric Surgery in Patients with Liver Cirrhosis

Nonalcoholic steatohepatitis is becoming a common cause of liver cirrhosis and a significant number of patients undergoing bariatric surgery suffer with it. There is currently lack of consensus among surgeons regarding safety of bariatric surgery in patients with liver cirrhosis and the best bariatric procedure in these patients. This review investigates published English language scientific literature systematically in an attempt to answer these questions. Eleven studies that reported experience of bariatric surgery in cirrhotic obese patients were included in this review. This review shows an acceptably higher overall risk of complications and perioperative mortality with bariatric surgery in cirrhotic patients. Surgeons must discuss the possibility of an unexpected intraoperative diagnosis of cirrhosis preoperatively with all bariatric surgery patients and agree on a course of action.

Treating morbid obesity in cirrhosis: A quest of holy grail

The problem of obesity is increasing worldwide in epidemic proportions; the situation is similarly becoming more common in patients with cirrhosis which negatively affect the prognosis of disease and also makes liver transplantation difficult especially in the living donor liver transplantation setting where low graft to recipient weight ratio negatively affects survival. Treatment of obesity is difficult in cirrhosis due to difficulty in implementation of lifestyle measures, limited data on safety of anti-obesity drugs and high risk of surgery. Currently approved anti-obesity drugs have limited data in patients with cirrhosis. Bariatric surgery remains an option in selected compensated cirrhotic patients. Endoscopic interventions for obesity are emerging and are quite promising in patients with cirrhosis as these are minimally invasive. In present review, we briefly discuss various modalities of weight reduction in obese patients and their applicability in patients with cirrhosis.