Bariatric Surgery in the Setting of Liver Cirrhosis with Portal Hypertension: the Confection and Particularities of Roux
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MULTIMEDIA ARTICLE
Bariatric Surgery in the Setting of Liver Cirrhosis with Portal Hypertension: the Confection and Particularities of Roux-en-Y Gastric Bypass in a High-Risk Patient Sebastien Frey 1,2 & Niccolo Petrucciani 2,3 & Antonio Iannelli 1,2,4,5 Received: 8 April 2020 / Revised: 14 May 2020 / Accepted: 15 May 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Introduction Morbid obesity is associated with the occurrence of non-alcoholic fatty liver disease, which may progress to cirrhosis. Although weight loss is the treatment of choice, surgical management can be challenging at the stage of cirrhosis. The aim of this video report is to present the confection and the features of a Roux-en-Y gastric bypass (RYGB) in the setting of liver cirrhosis. Methods We present the case of a 60-year-old man with a weight of 115 kg and a corresponding BMI of 38.9 kg/m2, with non-alcoholic steatohepatitis (NASH)-related liver cirrhosis. The latter was compensated (Child–Turcott–Pugh score at A6) but the patient had already undergone three esophageal variceal ligations. Portal hypertension with splenomegaly was clearly visible on preoperative workup. Results In this video, we show how to perform RYGB in a case of liver cirrhosis, with a focus on common pitfalls. The main risks remain perioperative bleeding due to portal hypertension and impaired coagulation, as well as the decompensation of the cirrhosis. A careful preoperative nutritional and hepatological evaluation is mandatory since the perioperative risk of morbidities is higher. Conclusion RYGB is a feasible option in selected patients with morbid obesity and cirrhosis. These patients ideally should be managed in centers having experience in bariatric surgery and hepatology. Keywords Bariatric surgery . Gastric bypass . Cirrhosis . Morbid obesity . NASH . NAFLD
Introduction Morbid obesity with or without metabolic syndrome is known to be responsible for the occurrence of nonElectronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-020-04715-w) contains supplementary material, which is available to authorized users. * Antonio Iannelli [email protected] 1
Université Côte d’Azur, Nice, France
2
Digestive Surgery and Liver Transplantation Unit, Centre Hospitalier Universitaire de Nice, Archet 2 Hospital, Nice, France
3
Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea Hospital, Rome, Italy
4
Inserm, U1065, Team 8 “Hepatic complications of obesity and alcohol”, Nice, France
5
Department of Digestive Surgery, Archet II Hospital, University of Nice-Sophia-Antipolis, 151 Route de Saint-Antoine, 06200 Nice, France
alcoholic fatty liver disease which may progress to cirrhosis [1]. Obesity is a risk factor for primary liver cancer and for the decompensation of liver cirrhosis [2]. Furthermore, where there is the potential of future liver transplantation (LT), bariatric surgery (BS) has be
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