Non-alcoholic fatty liver disease (NAFLD) has been reported in approximately 70-90% of patients with morbid obesity undergoing metabolic and bariatric surgery (MBS). Non-alcoholic fatty liver disease has now become the commonest cause of cirrhosis. Cirrhosis, which is the end stage of NAFLD, frequently coexists in patients seeking MBS, with 1–4% of patients found to have incidental liver cirrhosis during surgery. Additionally, there is a substantial number of patients who have advanced fibrosis (F3). There is a concern among the surgeons and gastroenterologists about the safety of MBS in such patients. A recent study on this subject has shown positive outcomes including weight loss and impact on liver fibrosis.
Researchers of this study, ‘Safety and Efficacy of Bariatric Surgery in Advanced Liver Fibrosis’, published in Obesity Surgery (Kaul A, Singla V, Baksi A, Aggarwal S, Bhambri A, Shalimar D, Yadav R. Safety and Efficacy of Bariatric Surgery in Advanced Liver Fibrosis. Obes Surg. 2020 Nov;30(11):4359-4365. doi: 10.1007/s11695-020-04827-3. Epub 2020 Jul 3. PMID: 33900587), retrospectively examined data of patients with evidence of cirrhosis or advanced liver fibrosis at All India Institute of Medical Sciences (AIIMS), New Delhi, India. Patients underwent preoperative transient elastography (TE)/ Fibroscan to measure (LSM) and Controlled Attenuation Parameter (CAP) and an intraoperative liver biopsy. Follow up Fibroscan and percutaneous liver biopsy was performed at six to 12 months. Etiology of cirrhosis was NASH in most of the patients. Two patients were reformed alcoholics, and one was on treatment for Hepatitis B.
The salient findings of the study were:
A total of 38 patients (22 had cirrhosis; 16 had stage 3 fibrosis) were included. All patients except one were CTP class A. 76%, 15.8% and 7.9% patients underwent LSG, RYGB and OAGB respectively.
The median preoperative LSM and CAP values were 15.5 kPa and 352.5 dB/m. They were 10.9 kPa and 303 dB/m at 12 months. In the cirrhotic cohort, the median LSM decreased from 19.2 to 15.2 and the median CAP decreased from 344 to 321.5.
Twelve patients underwent liver biopsy at 12 months. Nine (75%) of them had an improvement in fibrosis with total resolution in 3 patients.
There was no leak or 30-day mortality. There was one mortality in the cirrhotic cohort due to progressive liver failure. One patient developed flank ecchymosis in the post-operative period, which was managed conservatively. The incidence of early and late hepatic decompensation was 2.6% and 5.3% respectively, in this series.
“The results of this study reinforce the safety of bariatric surgery incirrhosis and advanced liver fibrosis besides demonstrating the advantages of Fibroscan for follow-up of such patients,” said Dr Sandeep Aggarwal (MBBS, MS, FACS), Professor of Surgery, Department of Surgical Disciplines, AIIMS, and lead author of the study.
A subsequent systematic review and meta-analysis published by Dr Aggarwal et al in SOARD (Agarwal L, Sahu AK, Baksi A, Agarwal A, Aggarwal S. Safety of metabolic and bariatric surgery in obese patients with liver cirrhosis: a systematic review and meta-analysis. Surg Obes Relat Dis. 2021 Mar;17(3):525-537. Doi: 10.1016/j.soard.2020.11.004. Epub 2020 Nov 13. PMID: 33339694) found that only 4.6% patients with cirrhosis (total 471 patients) undergoing bariatric surgery had liver related complications with a low liver related mortality (0.08%).
“The liver decompensation is usually not sinister and resolves with conservative treatment, Dr Aggarwal added. Any complication occurring in a cirrhotic patient post bariatric surgery requires a strict vigilance. Late complications in patients with advanced liver disease are more of a concern. Whether they are due to Bariatric surgery, or a result of the natural course of the disease is difficult to say. The risk of complications following bariatric surgery in cirrhotic surgery is still high as compared to non-cirrhotic patients,” explained Dr Aggarwal. “However, it should not preclude the cirrhotic patients from the vast benefits of bariatric surgery. The liver damage can be halted or even reversed and the weight loss can also increase the candidature for liver transplantation. A multidisciplinary approach including a hepatologist and a critical care specialist is essential for the holistic management of such patients.”
In total, 76% of the patients in this series underwent sleeve gastrectomy. Only two patients required oversewing of the staple line because of bleeding. One of them had portal hypertension with gastric varices. The complications were similar among the patients undergoing a sleeve or a bypass procedure; however, the numbers were too few for a strong conclusion. Knowing the fact that malabsorption can result in worsening of the liver disease as well as possible need for future endoscopies, sleeve gastrectomy appears to be a safer procedure in cirrhotic patients who are planned for bariatric surgery.
One of the major challenges in this field is the preoperative detection of liver fibrosis. Transient elastography (Fibroscan) is a novel and non-invasive technique to measure liver stiffness (an indicator of fibrosis) and steatosis. At AIIMS, Fibroscan (TE) is routinely performed as a part of the work-up of patients planned for bariatric surgery. Based on the LSM values based on the previous studies by Dr Aggarwal and his team at AIIMS, the patients are preoperatively warned about the possibility of liver cirrhosis or advanced liver fibrosis and a change in planned procedure to sleeve gastrectomy if indicated.
Overall, bariatric surgery (preferably sleeve gastrectomy) can be safely performed in patients with advanced liver fibrosis (F3) and Child’s class A cirrhosis with a reasonably low rate of hepatic decompensation post-operatively and a favourable impact on liver fibrosis in majority. In order to reduce postoperative complications and ensure the safety of patients with advanced liver disease after bariatric surgery, meticulous technique is important besides quality of surgical stapler. Among others, Panther Healthcare Surgical Stapler helps to deliver good hemostasis and safety with reliable staple line integrity during the bariatric procedures in these high risk patients.
“This risk of hepatic decompensation should not preclude the patients from benefits of bariatric surgery including weight loss, resolution of comorbidities including NAFLD and increasing their acceptability for liver transplant,” added Dr Aggarwal. “However detailed counselling of the patient and his family for the decision making is absolutely mandatory.”
Dr Aggarwal and his team are carrying out further studies to identify the best non-invasive investigation for evaluation of patients with NAFLD planned for bariatric surgery.
The article was authored by Dr Sandeep Aggarwal (MBBS, MS, FACS), Professor of Surgery, Department of Surgical Disciplines, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
This article is sponsored by Panther Healthcare.
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