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World J Gastroenterol. Jul 28, 2018; 24(28): 3112-3119
Published online Jul 28, 2018. doi: 10.3748/wjg.v24.i28.3112
Considerations for bariatric surgery in patients with cirrhosis
George Boon-Bee Goh, Philip R Schauer, Arthur J McCullough
George Boon-Bee Goh, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore 169608, Singapore
George Boon-Bee Goh, Duke-NUS Graduate Medical School, Singapore 169608, Singapore
Philip R Schauer, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH 44195, United States
Arthur J McCullough, Department of Gastroenterology, Cleveland Clinic, Cleveland, OH 44195, United States
Arthur J McCullough, Department of Pathobiology, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: All the authors contributed to the writing of this review.
Conflict-of-interest statement: All Authors declare no conflict of interest for this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: George Boon-Bee Goh, MBBS, MRCP, Adjunct Professor, Department of Gastroenterology and Hepatology, Singapore General Hospital, 20 College Road, Academia, Singapore 169856, Singapore. goh.boon.bee@singhealth.com.sg
Telephone: +65-63266137
Received: April 5, 2018
Peer-review started: April 5, 2018
First decision: May 9, 2018
Revised: May 17, 2018
Accepted: June 25, 2018
Article in press: June 25, 2018
Published online: July 28, 2018
Abstract

With the ever increasing global obesity pandemic, clinical burden from obesity related complications are anticipated in parallel. Bariatric surgery, a treatment approved for weight loss in morbidly obese patients, has reported to be associated with good outcomes, such as reversal of type two diabetes mellitus and reducing all-cause mortality on a long term basis. However, complications from bariatric surgery have similarly been reported. In particular, with the onslaught of non-alcoholic fatty liver disease (NAFLD) epidemic, in associated with obesity and metabolic syndrome, there is increasing prevalence of NAFLD related liver cirrhosis, which potentially connotes more risk of specific complications for surgery. Bariatric surgeons may encounter, either expectedly or unexpectedly, patients with non-alcoholic steatohepatitis (NASH) and NASH related cirrhosis more frequently. As such, the issues and considerations surrounding their medical care/surgery warrant careful deliberation to ensure the best outcomes. These considerations include severity of cirrhosis, liver synthetic function, portal hypertension and the impact of surgical factors. This review explores these considerations comprehensively and emphasizes the best approach to managing cirrhotic patients in the context of bariatric surgery.

Keywords: Cirrhosis, Portal hypertension, Non-alcoholic fatty liver disease, Bariatric surgery, Complications

Core tip: Bariatric surgery can be performed in patients with well compensated cirrhosis, typically of Child’s A status, with minimal complication risks from surgical or hepatic factors. Patients need to be carefully selected and optimised, while surgical technique and modality also play equally important roles. With the onslaught of the non-alcoholic fatty liver disease epidemic and anticipated increase in patients with non-alcoholic steatohepatitis cirrhosis, bariatric surgery may provide an elixir as part of the armamentarium of therapeutic options.