**4. Bariatric surgery and cirrhosis of the liver**

Bariatric surgery carries an increased risk of morbidity and mortality in patients with cirrhosis of the liver due to NAFLD. Risk assessment should be done by evaluating the severity of liver disease and presence of hepatic reserve. The Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score can predict postoperative mortality. The presence of portal hypertension (HVPG >10 mm Hg) indicates worse outcome. Clinically patients may have gastroesophageal varices, ascites, and splenomegaly with thrombocytopenia [50]. Transjugular intrahepatic portosystemic shunt (TIPS) placement is an option for these patients to reduce postoperative complications [51]. There has been no randomized clinical trial of doing bariatric surgery on cirrhotic patients due to NAFLD. Most of the studies were done on unsuspected compensated cirrhotic patients. Brolin et al. published a study in 1998 on unsuspected cirrhotic patients discovered during surgery. Four percent of patients died in the perioperative period, and 8% died late due to liver disease [52]. Mosko et al. reviewed nationwide data collection of patients who had bariatric surgery in the United States between 1998 and 2007 [53]. Non-cirrhotic patients had less mortality and shorter length

**67**

**Table 4.**

*Non-alcoholic Fatty Liver Disease and Surgery DOI: http://dx.doi.org/10.5772/intechopen.86146*

tions or bleeding [55].

mentioned in **Table 4**.

**Type of surgery**

Laparoscopic RYGB

Laparoscopic sleeve gastrectomy

of hospital stay in comparison with compensated and decompensated cirrhotic patients (mortality 0.3 vs. 0.9 and 16.3%, respectively, and length of stay 3.2 vs. 4.4 and 6.7 days, respectively). The study also found that high-volume centers (performing >100 surgeries per year) had lower mortality rate (0.2 vs. 0.7%; p < 0.0001) than low volume centers (performing <50 surgeries per year). Shimizu et al. did a study on 22 Child's A and 1 Child's B cirrhotic patients who underwent laparoscopic RYGB, laparoscopic sleeve gastrectomy, and LAGB between 2004 and 2011. No patient had decompensation of liver disease after surgery [54]. Pestana et al. did a retrospective review on 14 Child's A cirrhotic patients (4 with portal hypertension and 10 without portal hypertension) who had bariatric surgeries (sleeve gastrectomy and gastric bypass) between 2009 and 2011. Significant weight loss with improvement of hepatic steatosis, diabetes mellitus, hypertension, and dyslipidemia occurred. None of them had peri- or postoperative surgical complica-

From the above studies, it is apparent that bariatric surgeries can be safely performed in high-volume centers with acceptable morbidity and mortality in carefully selected compensated cirrhotic patients. The next question comes: What type of bariatric surgery is suitable for cirrhotic patients? Currently, three types of bariatric surgery are most commonly done. These include laparoscopic RYGB, laparoscopic sleeve gastrectomy, and LAGB. Each type has its own pros and cons which are

Modality of gastric bypass surgery should be individualized according to patients' comorbidities and pros and cons of each type of surgery. Sleeve gastrectomy is becoming more popular. Although bariatric surgery poses significant risks to patients with cirrhosis due to NAFLD, the considerable benefits of significant

> 1.Endoscopic access to the excluded stomach is difficult if there is a need to deal with gastroduodenal bleeding, biliary obstruction, pancreatic mass, or cyst when patients may need laparoscopic gastroduodenoscopy [56] or EUS-guided transgastric access for ERCP and

2.Malabsorption of micronutrients and vitamin may cause progressive liver dysfunction 3.Alteration of anatomy may complicate future

Foreign device implantation may cause infection, particularly in the presence of ascites Currently contraindicated by the FDA to be placed in

Risk of significant bleeding in patients with

EUS/FNA [57, 58]

liver transplantation

cirrhosis of the liver [59]

gastric varices

**Pros Cons**

Most significant weight loss out of the three procedures

4.Technically less challenging to the surgeon with short operating time 5.Does not cause malabsorption of micronutrients and

6.No requirement of foreign device implantation

*Pros and cons of different types of bariatric surgery in cirrhosis of the liver.*

*EUS, endoscopic ultrasound; ERCP, endoscopic retrograde cholangiopancreatography; FNA, fine needle aspiration.*

LAGB Least invasive procedure out of the three

vitamins

*Non-alcoholic Fatty Liver Disease and Surgery DOI: http://dx.doi.org/10.5772/intechopen.86146*

*Liver Disease and Surgery*

Bariatric surgery reduces insulin resistance by decreasing production of proin-

3.By improving dyslipidemia: NAFLD is associated with increased levels of serum triglyceride (TG) and low-density lipoprotein (LDL) and decreased level of high-density lipoprotein (HDL). As they are the main risk factors for the development atherosclerosis and coronary artery disease, cardiovascular disease is the main cause of mortality in NAFLD patients [42]. Bariatric surgery significantly improves the dyslipidemic state, and most of the patients

4.By improving the metabolic hormone profile: Gastrointestinal hormones play important roles in the success of weight loss and thus improve manifestations of metabolic syndrome following bariatric surgery. Ghrelin is the hunger hormone (orexigenic) mainly produced in oxyntic glands of gastric fundus [44]. Ghrelin also increases gastrointestinal motility and decreases insulin secretion [45]. In patients with Roux-en-Y gastric bypass, sleeve gastrectomy, and BPD with DS, ghrelin levels are profoundly low, and this may explain loss of hunger sensation and rapid weight loss in these patients [46, 47]. Glucagonlike peptide-1 (GLP-1) is secreted by the L cells in the distal ileum and colon. It promotes glucose-dependent insulin secretion, inhibits glucagon secretion, delays gastric emptying, inhibits gastric acid secretion, and reduces hunger sensation. Peptide tyrosine-tyrosine (PYY) is co-secreted with GLP-1 by the L cells of the distal ileum and colon after ingestion of food. It reduces hunger [48], delays gastric emptying, and decreases gastric acid secretion [49]. Serum levels of GLP-1 and PYY are high in post-RYGB patients because of rapid delivery of nutrients to the distal gut. As a result, the post-RYGB patients experience early satiety, their blood glucose and triglyceride levels decrease, and HDL level increases. The metabolic improvement can be seen as early as 2 days after surgery and do not correlate with the degree of weight loss. Many patients' diabetes mellitus, hypertension, and dyslipidemia either disappear or get under control. The improvement of components of metabolic syndrome

Bariatric surgery carries an increased risk of morbidity and mortality in patients

with cirrhosis of the liver due to NAFLD. Risk assessment should be done by evaluating the severity of liver disease and presence of hepatic reserve. The Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score can predict postoperative mortality. The presence of portal hypertension (HVPG >10 mm Hg) indicates worse outcome. Clinically patients may have gastroesophageal varices, ascites, and splenomegaly with thrombocytopenia [50]. Transjugular intrahepatic portosystemic shunt (TIPS) placement is an option for these patients to reduce postoperative complications [51]. There has been no randomized clinical trial of doing bariatric surgery on cirrhotic patients due to NAFLD. Most of the studies were done on unsuspected compensated cirrhotic patients. Brolin et al. published a study in 1998 on unsuspected cirrhotic patients discovered during surgery. Four percent of patients died in the perioperative period, and 8% died late due to liver disease [52]. Mosko et al. reviewed nationwide data collection of patients who had bariatric surgery in the United States between 1998 and 2007 [53]. Non-cirrhotic patients had less mortality and shorter length

flammatory cytokines and improving the adiponectin level.

do not need anymore lipid-lowering agents [43].

has positive effects on NAFLD.

**4. Bariatric surgery and cirrhosis of the liver**

**66**

of hospital stay in comparison with compensated and decompensated cirrhotic patients (mortality 0.3 vs. 0.9 and 16.3%, respectively, and length of stay 3.2 vs. 4.4 and 6.7 days, respectively). The study also found that high-volume centers (performing >100 surgeries per year) had lower mortality rate (0.2 vs. 0.7%; p < 0.0001) than low volume centers (performing <50 surgeries per year). Shimizu et al. did a study on 22 Child's A and 1 Child's B cirrhotic patients who underwent laparoscopic RYGB, laparoscopic sleeve gastrectomy, and LAGB between 2004 and 2011. No patient had decompensation of liver disease after surgery [54]. Pestana et al. did a retrospective review on 14 Child's A cirrhotic patients (4 with portal hypertension and 10 without portal hypertension) who had bariatric surgeries (sleeve gastrectomy and gastric bypass) between 2009 and 2011. Significant weight loss with improvement of hepatic steatosis, diabetes mellitus, hypertension, and dyslipidemia occurred. None of them had peri- or postoperative surgical complications or bleeding [55].

From the above studies, it is apparent that bariatric surgeries can be safely performed in high-volume centers with acceptable morbidity and mortality in carefully selected compensated cirrhotic patients. The next question comes: What type of bariatric surgery is suitable for cirrhotic patients? Currently, three types of bariatric surgery are most commonly done. These include laparoscopic RYGB, laparoscopic sleeve gastrectomy, and LAGB. Each type has its own pros and cons which are mentioned in **Table 4**.

Modality of gastric bypass surgery should be individualized according to patients' comorbidities and pros and cons of each type of surgery. Sleeve gastrectomy is becoming more popular. Although bariatric surgery poses significant risks to patients with cirrhosis due to NAFLD, the considerable benefits of significant


#### **Table 4.**

*Pros and cons of different types of bariatric surgery in cirrhosis of the liver.*

weight loss (including decreasing the risk of cardiovascular diseases and malignancy) and candidacy for liver transplantation may overweigh the risks. The AASLD guidelines published in January 2018 do not recommend bariatric surgery to patients with cirrhosis of the liver attributed to NAFLD as the type, safety, and efficacy of bariatric surgery are not yet established in this group of patients [60].
