Bariatric Surgery in Patients with Liver Cirrhosis and Portal Hypertension

by Juan Camilo Barreto, MD; Michael G. Sarr, MD; and James M. Swain, MD

All from the Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota.

The Problem
Cirrhosis is an unexpected finding at the time of bariatric surgery in about 1 to 2 percent of the patients undergoing elective bariatric surgery. The surgeon is then suddenly faced with several questions that may be difficult to address at the moment of a planned bariatric operation, with the patient already under general anesthesia. Would it be appropriate to continue with the planned elective bariatric procedure? Is it necessary to consider a different alternative, and if so, which one? Is portal hypertension present and, if so, is it an absolute contraindication to proceed?

A different situation occurs when a patient with known hepatic cirrhosis presents for consideration for bariatric surgery. What type of workup is required? At what point would a bariatric procedure be contraindicated? What about the patient with morbid obesity who is being evaluated for a liver transplant?

Most patients with medically complicated (Class III) obesity have some degree of fatty liver disease, so-called non-alcoholic fatty liver disease (NAFLD). NAFLD covers the spectrum of simple steatosis, non-alcoholic steatohepatitis (NASH), which involves some necroinflammatory changes and early fibrosis, and established non-alcoholic cirrhosis with bridging fibrosis, which accounts for 20 percent of all patients with hepatic cirrhosis.[1] Therefore, there is a substantial group within this population of patients who would benefit from weight loss. Unfortunately, the data in the literature regarding the management of extremely obese patients with cirrhosis is scarce, and there is no strong evidence that supports a specific approach for them.

Safety of Bariatric Surgery in Cirrhosis
There is evidence that bariatric surgery can be performed safely in selected patients with cirrhosis.

Brolin et al[2] reported their experience with 125 patients with unexpected cirrhosis discovered at the time of elective bariatric operations in their own institution and through a questionnaire answered by 126 surgeons worldwide. The planned procedure was performed in 73 percent of the patients, not attempted in 14 percent, and aborted at some point in another six percent. A liver biopsy was performed in 87 percent of the procedures. There were no intraoperative deaths, but there were four perioperative deaths within the first 30 days (3.2%), including two caused by hepatic failure. There were no major complications in the patients in whom the planned procedure was aborted. However, neither the stage of liver disease nor the presence of portal hypertension was mentioned in the article. Although the type of bariatric procedure performed by the surgeons who answered the survey is not mentioned in the survey results, the opinion in 59 percent was that a restrictive procedure (banded gastroplasty) was the most appropriate and safest option. These investigators concluded that despite the greater risk in these patients, it appears that bariatric procedures can be performed safely in patients with cirrhosis, but a restrictive procedure might be best.

Dallal et al[3] also published their experience, identifying 30 patients with cirrhosis in a group of 2,119 (1.4%) bariatric patients. In 90 percent of cases, the diagnosis was made intraoperatively. The types of procedure were Roux-en-Y gastric bypass (RYGB) in 27 patients, sleeve gastrectomy (SG) in two patients, and a staged RYGB in one patient. There were no perioperative deaths, conversions to laparotomy, or liver-related complications. All patients had normal synthetic function and were Child-Pugh class A. Mean duration of hospital stay was four days, and complications occurred in nine patients, including one anastomotic leak. They found a greater incidence of transient renal dysfunction (four cases of acute tubular necrosis) and an increased potential for blood loss (average of 290mL compared to 115mL in their previous published cohort). The average excess weight loss (EWL) at followup was 63 percent ± 15 percent. Of note, liver function tests (LFTs) were neither sensitive nor specific, and ultrasonography and physical examination were unreliable to diagnose the presence of cirrhosis in these fully compensated patients preoperatively.

Effects of bariatric surgery on steatosis, steatohepatitis, and cirrhosis
The benefits on NAFLD derived from weight loss and from the metabolic changes induced by bariatric surgery have been widely documented. Weight loss reverses, in part, the metabolic syndrome, restoring much of the insulin sensitivity and abrogating the dyslipidemia.[4-6] Moreover, the weight loss leads to improvement in, and often reversal of, the steatosis and steatohepatitis. In a report of 36 patients who underwent laparoscopic placement of an adjustable gastric band, NASH was present in 18 patients at the time of operation and persisted only in four patients after the weight loss induced by the gastric banding. All patients had major improvements in lobular steatosis, necroinflammatory changes, and fibrosis. Prior to banding, 18 patients had a fibrosis score of two or more, compared with only three patients to a similar amount of fibrosis at repeat liver biopsy at followup.[7] These results are even more evident after a gastric bypass, which can decrease the prevalence of steatosis from around 90 percent before operation to as low as three percent after a successful gastric bypass.[8]

Some reports have even shown that bariatric surgery can reverse cirrhosis. Kral et al[9] described their findings in 104 patients who underwent repeat liver biopsy for a variety of reasons after a prior duodenal switch/biliopancreatic diversion (DS/BPD). Severe fibrosis had decreased in 28 patients, and 11 patients with confirmed cirrhosis at the time of the DS/BPD showed decreased fibrosis and even disappearance of regenerative nodules and bridging fibrosis. The patients who had persistent or worsening fibrosis after bariatric surgery had other known causes of liver damage, such as alcohol intake, hemosiderosis, or obstructive biliary disease.

Other reports have questioned the role of malabsorptive procedures in inducing liver disease. In the report by Baltasar et al,[10] 10 out of 470 patients who had a DS/BPD developed clinically significant hepatic impairment, including one death from liver failure. These patients had no known liver disease preoperatively other than NAFLD. They were treated with enteral or parenteral supplementation, and all except one patient eventually had a favorable outcome. Possible explanations include protein malnutrition, deficiency of hepatotrophic factors, bacterial overgrowth causing excessive endotoxins, and accumulation of free fatty acids. There have been other isolated case reports of hepatic impairment after BPD.[11,12] Groups with extensive experience in these malabsorptive procedures have not reported this complication,[13] or have found only transient increases of the liver enzymes that normalize subsequently.[14]

In summary, the available data seem to confirm that bariatric surgery can be performed safely in patients with well-compensated cirrhosis; the slight increase in the risk of hepatic complications should be balanced by the potential benefits of weight loss and improvement in fatty liver disease. There is a potential, although rare, risk of hepatic impairment with malabsorptive procedures.

Deciding the Type of Bariatric Procedure when Cirrhosis is Found Intraoperatively
There are no data in the literature that support with objective findings any specific bariatric procedure for patients with cirrhosis. Therefore, the following recommendations are based exclusively on experts’ opinions.

Currently, four bariatric procedures are performed most commonly worldwide: RYGB, laparoscopic adjustable gastric banding (LAGB), DS/BPD, and the more recently described sleeve gastrectomy (SG), either as the first part of a staged procedure or as a stand alone procedure.[15, 16] All of these are routinely carried out laparoscopically in most centers.

RYGB is the most widely accepted bariatric procedure in the US. Its safety and effectiveness have been analyzed for many years in multiple reports.[4, 5, 17, 18] In experienced hands, RYGB can be carried out quickly (<2 hours), and causes a minimal degree of malabsorption. One of the main concerns that can preclude its use in patients with cirrhosis is that the bypassed stomach will be inaccessible should variceal bleeding develop.

DS/BPD is a highly effective procedure regarding weight loss, resolution of metabolic syndrome, and reversal of NAFLD and its complications.[19, 20] However, at the same time, it has the greatest risk of complications, not only during the perioperative period, but also during followup. The induced malabsorption can cause metabolic complications and, as mentioned previously, there are a few reports about hepatic dysfunction after BPD.[10-12] There is no solid data, however, addressing the outcomes of malabsorptive bariatric surgery in patients with cirrhosis.

Restrictive operations—LAGB and SG—are also a consideration. In general, both are quick procedures, less invasive than a RYGB or DS/BPD, have shown a good success rate regarding weight loss, and have the advantage that both can be converted subsequently to a RYGB or a DS/BPD should the patient’s risk factors improve. This scenario is of particular importance when patients with decompensated cirrhosis are candidates for liver transplantation, but morbid obesity and its complications are making them ineligible.[21] Of note, makers of both adjustable band devices approved by the Food and Drug Administration (FDA) list cirrhosis, portal hypertension, and other conditions predisposing to upper gastrointestinal bleeding, such as gastric varices, among the contraindications for the placement of these gastric bands because of the lack of data regarding its safety.[22] It should be noted that there are no data in the literature addressing the use of LAGB in patients with cirrhosis or portal hypertension.

The intraoperative decisionmaking for unexpected cirrhosis may involve changing the planned procedure to a different one—for example, a RYGB or DS/BPD to a SG. This possibility should be discussed preoperatively with the patient if there is any suspicion of underlying liver disease so they can give informed consent to the alternative procedure. Another important issue that can impact decisionmaking is insurance coverage, because sometimes the alternative procedure may not be covered by the insurance company. This should be discussed with the patient in advance whenever possible.

Many times, when unexpected cirrhosis is found intraoperatively and there are any questions regarding the extent of cirrhosis or portal hypertension, or if the patient has not consented to have an alternative procedure, the best approach will be to perform a liver biopsy and defer the operation until these issues have been addressed.

Cirrhosis Known Preoperatively
Patients with known cirrhosis and medically complicated obesity will be referred sometimes for consideration of bariatric surgery. The cause of cirrhosis should be elucidated (i.e. NASH, hepatitis, alpha 1-antitrypsin deficiency). The major questions to be answered by the surgeon are the following: 1) What is the extent of their portal hypertension?; and 2) how compensated is their hepatic function? We previously discussed that the available data, although scarce, suggests that bariatric surgery can be performed with acceptable morbidity and mortality in patients with a Child-Pugh class A, and can even improve liver disease when it is secondary to NAFLD. The recommendation with these patients is to proceed with the regular preoperative workup of all bariatric patients, which includes assessments of the cardiopulmonary and endocrine systems, and evaluate for the presence of portal hypertension, as will be discussed later in this article. The procedure of choice for those good-risk patients with cirrhosis, with the available data, would be more likely a restrictive procedure, such as SG. If liver disease is secondary to steatohepatitis, and there is no portal hypertension, a RYGB should be considered as well because of the added benefits to the metabolic syndrome.

Patients who have decompensated liver function should be managed in partnership with the liver transplant service. The model for end-stage liver disease (MELD) can be a useful tool to measure the risk of mortality from any major abdominal surgery.[23] Decompensated patients will have a high perioperative risk regardless of the approach, and they should be managed in tertiary care centers with ample experience, both in bariatric surgery and liver transplantation. Every patient should be considered on an individual basis, and the question is whether a bariatric procedure should be done first versus a liver transplant. Some patients can benefit from weight loss and reversal of complications associated with obesity before proceeding to liver transplantation.[21] In these patients, the procedure should be a nonmalabsorptive bariatric operation. Patients with more severe hepatic decompensation will more likely require proceeding to transplantation first.

Portal Hypertension Found Intraoperatively
The presence of portal hypertension adds substantial potential morbidity and mortality to any surgical procedure. Bariatric surgery is a major abdominal operation and is no exception. Patients who have signs of severe portal hypertension, such as ascites, varices, and large, dilated perigastric veins, are best served by aborting the bariatric procedure, because the risk of severe hemorrhage with any gastric-based bariatric operation, even placement of an adjustable gastric band, is unacceptably high. The presence of esophageal and/or gastric varices at the esophagogastric junction, as well as the increased venous pressure within the gastric wall, make the partitioning of the proximal stomach for a RYGB and the SG for both the LSG and the DS/BPD too high a risk to proceed.

In contrast, patients who do not have ascites or varices, but just have dilated perigastric veins, may still be candidates for a bariatric procedure. Often, the safest approach would be to perform a liver biopsy and defer the procedure until further evaluation of the extent of the portal hypertension is completed and the surgeon has had the chance to discuss with the patient the alternatives and added risks. The degree of portal hypertension can guide subsequent management.

Evaluation of Portal Hypertension
After an initial history and physical exam, searching for evident clinical data (history of gastrointestinal bleeding, ascites, caput medusae), and assessing liver function, patients with cirrhosis should undergo an upper endoscopy, looking for varices and/or portal gastropathy. Unfortunately, physical exam will not be accurate in an extremely obese patient. A computed tomography (CT) can detect intraabdominal varices not seen endoscopically and can reveal the presence of clinically indeterminable ascites and splenomegaly. Ultrasonography may be less reliable in extremely obese patients.[24]

If there are any concerns about the presence of portal hypertension, measuring portal pressure can be of particular value. Portal pressure can be achieved by measuring the hepatic vein wedge pressure. Then, the corrected portal pressure can be obtained by subtracting the central venous pressure (CVP) from the measured portal pressure. The extent of portal hypertension can be classified as the following:

•    Mild: <8mmHg (low risk)
•    Moderate: 8–10mmHg (moderate risk)
•    Severe: >12mmHg (high risk)

Patients with mild portal hypertension can be offered a restrictive bariatric procedure based on the same criteria mentioned previously. A RYGB can be cautiously considered as well if the metabolic benefits are worth the risk of having a nonaccessible stomach, should hepatic disease progress and gastric variceal bleeding develop.

In patients with moderate portal hypertension, there is a possibility of offering SG if it appears safe to do so at the time of laparoscopy. Most surgeons would not consider a RYGB in these circumstances because of the advanced state of cirrhosis and the possibility of variceal bleeding.

We know of no viable bariatric surgical options for patients with severe portal hypertension. In those patients with an otherwise preserved liver function, some consideration can be given to placement of transjugular, intrahepatic, porto-systemic shunts (TIPSS) to decrease the portal pressure and then proceed to a safer, technically possible surgical procedure.[25] These patients must be selected carefully and should be managed in conjunction with the liver transplant and hepatology teams.

Conclusions
Unrecognized or recognized cirrhosis is not necessarily an absolute contraindication to bariatric surgery, provided there is good hepatic function and no evidence of severe portal hypertension (corrected portal pressure <12mmHg). NASH-related cirrhosis has been shown to improve with all forms of bariatric surgery. The best option in many of these patients appears to be a restrictive procedure. The liver transplant team should be involved in the care of these patients and to assist in decisions regarding eligibility for future liver transplant, whether this should take place before bariatric surgery, or after bariatric surgery and weight loss. Highly selected patients with severe portal hypertension may still be potential candidates provided their hepatic function is compensated; however, a TIPSS can be used to decrease the portal pressure to allow a safe bariatric procedure, possibly as a bridge to liver transplantation.

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Category: Past Articles, Review