Andrew Smith, Ahmad Elnahas, Allan Okrainec, Fayez Quereshy, Timothy Jackson. Division of General Surgery, University Health Network, University of Toronto, Toronto ON.
Non-alcoholic fatty liver disease (NAFLD) is an increasingly recognized cause of chronic liver disease. Due to its association with the metabolic syndrome, NAFLD is common in the bariatric population. While the natural history of NAFLD remains variable, morbidly obese individuals with hepatocyte fibrosis may progress to cirrhosis. Given the association of NAFLD and obesity, bariatric surgeons are increasingly being asked to consider cirrhotic patients as potential surgical candidates. The safety of bariatric procedures in patients with cirrhosis remains uncertain. The aim of the current study is to report the short-term outcomes of patients with cirrhosis undergoing elective bariatric procedures.
The American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) maintains a clinically rich database on outcomes after surgery for quality improvement and benchmarking purposes. We conducted a retrospective cohort study using ACS-NSQIP Participant Use File 2005-2011 to identify patients with cirrhosis undergoing elective bariatric procedures. CPT and ICD-9 codes were used to identify patients undergoing bariatric procedures. Patients with ascites and/or esophageal varices were included and considered as having cirrhosis. We measured 30-day morbidity and mortality captured with the database.
11 patients were identified as having a bariatric procedure in the setting of cirrhosis. Seven of these patients were female. The average age and BMI of the 11 patients was 52.5 years and 45.3 kg/m2 respectively. Five patients underwent laparoscopic Roux-en-Y gastric bypass while five underwent laparoscopic adjustable gastric band and one laparoscopic sleeve gastrectomy. The average operative time was 126.1 minutes. The average length of stay was 2.1 days. Eight of the 11 patients (72.7%) had evidence of ascites while seven of the 11 (63.6%) had evidence of esophageal varices. Variables to calculate MELD score were available for four patients. The average score of these four patients was 10.25. Only one patient had a post-operative urinary tract infection. No other post-operative complications were identified. There were no mortalities in this patient population.
Bariatric surgery was performed with minimal morbidity and no mortality in this small cohort of obese patients with cirrhosis. These findings suggest that bariatric surgery may be a potentially safe option in this high-risk patient population, although, these results should be considered within the context of a retrospective study with its inherent associated risk of bias and limitations. Additional prospective studies are needed to further define both the safety and clinical effectiveness of bariatric procedures with advanced NAFLD.