Liver failure and transplantation after duodenal switch

Liver Injury and Acute Liver Failure After Bariatric Surgery: An Overview of Potential Injury Mechanisms

The obesity epidemic has caused a surge in the use of bariatric surgery. Although surgery-induced weight loss is an effective treatment of nonalcoholic fatty liver disease, it may precipitate severe hepatic complications under certain circumstances. Acute liver injury (ALI) and acute liver failure (ALF) following bariatric surgery have been reported in several case series. Although rare, ALI and ALF tend to emerge several months after bariatric surgery. If so, it can result in prolonged hospitalization, may necessitate liver transplantation, and in some cases prove fatal. However, little is known about the risk factors for developing ALI or ALF after bariatric surgery and the mechanisms of liver damage in this context are poorly defined. This review provides an account of the available data on ALI and ALF caused by bariatric surgery, with emphasis on potential injury mechanisms and the outcomes of liver transplantation for ALF after bariatric surgery.

Jejunal-Ileal Bypass and its Complications: Case Report and Review of the Literature

Herein, we describe an interesting case of a patient who underwent a jejunal-ileal bypass (JIB). She presented to the hospital with gastrointestinal bleeding after which her hospital course was complicated by electrolyte abnormalities. She was a 76-year-old Caucasian female with a past medical history of hypertension, type II diabetes, atrial fibrillation on warfarin, chronic obstructive pulmonary disease (COPD) treated with 3 liters of oxygen at home, obstructive sleep apnea, and morbid obesity, with history of an unknown type of bariatric procedure done in the 1970s. Her upper endoscopy showed a normal esophagus, stomach, and duodenum despite her history of bariatric surgery. Her colonoscopy revealed stenotic terminal ileum and an incidental colonic anastomosis at 35 cm from the anal verge with spot tattoo ink of unknown significance. Also noted were moderate internal hemorrhoids and large external hemorrhoids which were likely the source of her bleeding. Post endoscopy she had marked derangement in electrolytes, specifically hypocalcemia, hypomagnesemia, and hypo-phosphatemia. 

JIB was first popularized in the 1960s for the treatment of obesity. There are two variations of the procedure, colloquially known as the Scott bypass and the Payne bypass. Our patient underwent the Scott JIB. The relatively longer intestinal tract combined with her ileal stenosis may explain her 50 years of relatively stable adaptation. It is imperative that treating physicians have a keen understanding of anatomy and physiology to adequately care for the long-term needs of these patients. 

Single-anastomosis duodenoileal bypass as a revisional or second-step operation after sleeve gastrectomy

BACKGROUND

One-loop duodenal switch leads to weight loss and improvement or resolution of co-morbidities similar to standard duodenal switch, and it is technically less demanding.

OBJECTIVES

To analyze the weight loss and metabolic improvement after conversion of sleeve gastrectomy to single-anastomosis duodenoileal bypass.

SETTING

University Hospital, Madrid, Spain.

METHODS

This was a retrospective cohort study. Patients submitted to sleeve gastrectomy with insufficient weight loss or programmed for a 2-step surgical approach were included. Single-anastomosis duodenoileostomy was completed if there was no stricture in the stomach and no severe symptoms of gastroesophageal reflux.

RESULTS

Fifty-one patients with a mean initial body mass index of 52 kg/m2 were included. Maximum excess weight loss after the sleeve procedure was 63%. Mean time to the second operation was 36 months. The common channel was 250 cm in 41 patients and 300 cm in 10 patients. The follow-up rate was 77% at 5 years. Excess weight loss and total weight loss were 79% and 39%, respectively, at 1 year from the second surgery and 79% and 41%, respectively, at 5 years. Furthermore, 47% of the patients with diabetes achieved complete remission after sleeve gastrectomy, and 94% achieved remission after conversion to single-anastomosis duodenoileal bypass. Final weight loss was significantly higher in those patients who achieved better weight loss after the sleeve gastrectomy than those who did not.

CONCLUSIONS

Single-anastomosis duodenoileal bypass is a beneficial procedure after sleeve gastrectomy for those who fail to lose weight or those with co-morbidities or as a planned second step.

Liver transplantation for bariatric surgery-related liver failure: a systematic review of a rare condition

BACKGROUND

Protein malnutrition and bacterial overgrowth occurring after bariatric surgery (BS) might cause severe liver failure (LF) needing liver transplantation (LT).

OBJECTIVES

To evaluate indications and outcomes of LT for BS-related LF.

SETTING

University hospital in France.

METHODS

The EMBASE, MEDLINE, and COCHRANE central databases were systematically searched according to the PRISMA criteria from inception up through December 2017 for articles describing LT for LF after BS.

RESULTS

Fourteen studies reporting 36 patients listed for LT, of which 32 underwent the procedure, were retained. The types of previously performed BS included jejunoileal bypass (n = 16), bilio-pancreatic diversion according to Scopinaro (n = 14) or with duodenal switch (n = 3), bilio-intestinal bypass (n = 1), long-limb Roux-en-Y gastric bypass (n = 1), and single anastomosis omega gastric bypass (n = 1). Liver failure developed a median of 20 months after BS (mean ± SD: 105 ± 121 mo; range, 5-300 mo). This interval of time was significantly shorter after biliopancreatic diversion than jejunoileal bypass (mean ± SD: 22 ± 21 mo versus 269 ± 27 mo; P = .0001). Four patients (11.1%) died while on the waiting list for LT, and 4 more (12.5%) died after LT. Morbidity and liver retransplantation were reported in 8 (25%) and 2 (6.2%) patients, respectively. Twenty-one patients (65.6%) had their BS procedure reversed (1 patient before, 15 patients during, and 5 patients after LT, respectively). Biopsy-proven steatosis recurrence after LT was reported in 6 patients (18.7%), 4 of whom did not have BS reversal.

CONCLUSIONS

Severe LF occurring after BS, although rare, might require LT. When indicated, LT is effective at restoring liver function, even when BS reversal is performed synchronously.

Cirrhosis following single anastomosis duodeno-ileal switch: A case report

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We report a rare case of a liver cirrhosis in a patient who underwent single anastomosis duodenal switch procedure.

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We describe the possible presentation of the patient with a liver cirrhosis.

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Management of single anastomosis duodenal switch patients should include close monitoring of liver function.

Introduction

Single anastomosis duodeno-ileal switch (SADI-S) involves a single, loop duodeno-ileal anastomosis with omission of the traditional Roux-en-Y distal ileo-ileal anastomosis. Not much has been published on the complications of SADI-S.

Presentation of case

The patient is a 40 year-old male who underwent robot-assisted SADI-S three years prior. At the time of surgery, his body mass index (BMI) was 69 kg/m². His BMI was 31 kg/m² at the time of presentation. Computed tomography of the abdomen and pelvis showed a liver with a nodular appearance and moderate ascites throughout the abdomen and above the liver. Liver function showed AST 73 U/L, ALT 63 U/L, alkaline phosphatase 128 U/L, bilirubin 1.0 mg/dL, and albumin 2.8 g/dL. He underwent diagnostic and therapeutic paracentesis with removal of 6L of fluid that was negative for infection or malignant cells. Esophagogastroduodenoscopy showed grade I esophageal varices and diffuse mild gastritis.

Discussion

Mild hepatic dysfunction is common after biliopancreatic diversion and usually manifests as a temporary rise in liver enzymes that peak several months after surgery and normalize by one year. Cirrhosis and liver failure are rare sequelae that may develop at any time after surgery. Potential mechanisms include the absorption of hepatotoxic compounds from the bypassed small intestine in the context of bacterial overgrowth, protein malnutrition, and excessive free fatty acid mobilization causing steatosis and oxidative damage to hepatocytes.

Conclusion

Close laboratory monitoring is important after SADI-S in order to detect worsening hepatic dysfunction, which may occur many years after the surgery in the absence of other etiologies for liver failure.

Liver failure following biliopancreatic diversions: a narrative review

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.