Zubaidah Nor Hanipah, MD1, Suriya Punchai, MD1, Gautam Sharma, MD2, Stacy Brethauer, MD1, Ali Aminian, MD1, Philip Schauer, MD1. 1Bariatric and Metabolic Institute, Cleveland Clinic, 2Section of Surgical Endoscopy, Dept. of General Surgery, Cleveland Clinic
Introduction: Studies on bariatric patients with cirrhosis and portal hypertension are scarce. The aim of this study was to review our experience in cirrhotic patients with portal hypertension who had bariatric surgery.
Methods: All cirrhotic patients with portal hypertension (PH) who underwent primary laparoscopic bariatric surgery (BS) at a single academic center from 2007 to 2015 were identified. Data collected included baseline demographics, co-morbidities, perioperative parameters, adverse events, and the weight loss and co-morbidities resolution. Data was summarized as the median and interquartile range (IQR) for continuous variables and as counts and percentages for categorical variables. A paired t-test was used to analyze the differences between the last follow-up point and the baseline at the time of surgery.
Results: Out of 6777 patients who underwent bariatric surgery, twelve (0.2%) patients were cirrhotic with portal hypertension; seven (58.3%) were female, median age was 55 years (IQR 48-60), and median BMI was 48 kg/m2 (IQR 43-56). Portal hypertension was diagnosed based on endoscopy (n=9), imaging (n=6), and intraoperative increased venous collateral (n=1). Comorbidities include diabetes mellitus (n=11, 92%), hypertension (n=9, 75%), sleep apnea (n=9, 75%), dyslipidemia (n=5, 42%), nonalcoholic steatohepatitis (NASH) (n=11, 98%), alcoholic hepatitis (n=1, 8%) and hepatitis C infection (n=1, 8%). There were 5 patients who had trans-intrahepatic portal systemic shunt (TIPS); 2 of them had TIPS after bariatric surgery due to recalcitrant ascites.
The bariatric procedures include sleeve gastrectomy (n=10, 83%) and Roux-en-Y gastric bypass (n=2, 17%). The median length of hospital stay was 3 days (IQR 2-4). The 30-day complications occurred in two patients including wound infection requiring debridement (n=1), and intra-abdominal hematoma secondary to anticoagulation managed conservatively (n=1). There was no perioperative mortality. Late mortality occurred in one patient 8 months after sleeve gastrectomy due to pseudomembranous colitis which led to sepsis and multiple organ failure.
The median %excess weight loss (%EWL) at 1-year and at 2-years were 37.5% and 49.0% respectively. There was a significant reduction in baseline to last follow-up point (median 2-years follow-up); fasting blood glucose from140.7mg/dL to 96.8mg/dL, (p=0.013) and glycated hemoglobin 7.0 to 5.0, (p=0.009). Remission or improvement in obesity-related comorbidities at 1 year for diabetes, hypertension, and dyslipidemia were 100%, 50%, and 60%, respectively.
Conclusion: This is the largest series to date evaluating outcome of bariatric surgery in patients with cirrhosis and portal hypertension. Bariatric surgery in highly selected cirrhotic patients with portal hypertension is relatively safe and effective.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80040
Program Number: P503
Presentation Session: Poster (Non CME)
Presentation Type: Poster