Intraoperative finding of liver cirrhosis in bariatric surgery, the role of sleeve gastrectomy: A report of two consecutive cases

Miguel A Zapata Martinez, MD, Julio C Gallardo Baez, MD, Ulises Caballero-de la Pena, MD, Marco A Juarez-Parra, MD, David J Orozco-Agüet, MD, Jeronimo Monterrubio-Rodriguez, MD. Hospital Christus Muguerza Sur – Universidad de Monterrey

Introduction:

Obesity is a reported risk factor for non-alcoholic steatohepatitis (NASH), which is a common cause of cirrhosis. The estimated prevalence of nonalcoholic fatty liver disease (NAFLD) ranges from 84%-96% and for NASH 25%-55%. Up to 25% of patients with NASH will progress to liver cirrhosis. Cirrhosis is recognized incidentally in 1.4% of patients undergoing elective bariatric surgery.

Even though the marked improvement in liver fibrosis after laparoscopic Roux-en-Y gastric bypass (LRYGB), concern exists about the inaccessible gastric remnant if variceal bleeding occurs or if endoscopic access to the biliary tree is necessary. Laparoscopic sleeve gastrectomy (SG) has demonstrated to be well-tolerated in cirrhotic patients and can be as a risk reduction procedure. However, mortality rates are increased in cirrhotic patients undergoing bariatric surgery from 0.3% to 1.2%.

We present 2 cases of patients scheduled for LRYGB in who the intraoperative finding of a cirrhotic liver change the surgical conduct.

Case report:

A 38-year-old female with personal pathologic history of type II diabetes, hypothyroidism, morbid obesity, and NASH; BMI 51.6. A 39-year-old male with chronic alcoholism and multiple tattoos; BMI 40.3. Both patients were referred for LRYGB and preoperatory laboratory test results were within normal parameters.

Upon entering the abdominal cavity, dilated gastro-epiploic vessels, and a multinodular liver were found. With these findings the surgical procedure was changed to a sleeve gastrectomy on both patients. After cutting the gastroepiploic and short gastric vessels with bipolar energy, the gastric sleeve was manufactured using six golden lineal staplers, then a hemostatic running polyglicolic acid suture was placed. Pneumatic methylene blue test was performed without evidence of leaks. Liver wedge biopsies were taken and a drain placed.

They were admitted to the surgical ward, with NPO for 1 day, started liquid diet on the second day and a had a hidrosoluble contrast test was ordered, without evidence of leaks. They were discharged on PO day 3 on clear liquid diet. Pathological analysis demonstrated liver cirrhosis in both patients.

Conclusion:

Liver cirrhosis has an eightfold increase of risk for mortality and morbidity after abdominal surgery and most of the patients have concomitant comorbidities like metabolic syndrome and cardiovascular disease. Mal absorptive changes and GI tract modification associated with LRYGB might put these patient at risk for further complications.

Weight loss achieved with laparoscopic bariatric surgery in patients with cirrhosis offers a better outcome of their comorbidities, and even normalization in liver histology. Sleeve gastrectomy as a mainly restrictive procedure, is a safer option in patients with liver cirrhosis with reduction of the complication rate.

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