Will gastric bypass surgery worsen Non-Alcoholic Steatohepatitis (NASH) cirrhosis?

Gastric Bypass Surgery in NASH Cirrhosis: Safety and Efficacy Considerations

Gastric bypass surgery should generally be avoided in patients with established NASH cirrhosis due to increased perioperative mortality risk and potential for hepatic decompensation, with laparoscopic sleeve gastrectomy being the preferred option only in carefully selected patients with well-compensated cirrhosis. 1

Risk Assessment in Cirrhotic Patients

Bariatric surgery carries significantly different risk profiles depending on the stage of liver disease:

• Compensated cirrhosis: Perioperative mortality is 0.9% (compared to 0.3% in non-cirrhotic patients) 2, 1
• Decompensated cirrhosis: Perioperative mortality rises dramatically to 16.3% 2, 1

Portal hypertension, which commonly accompanies cirrhosis, further increases surgical risk and requires careful preoperative assessment 1.

Procedure Selection for Cirrhotic Patients

When bariatric surgery is considered in a patient with cirrhosis, the type of procedure matters significantly:

• Laparoscopic sleeve gastrectomy (LSG) is the preferred procedure for patients with cirrhosis because it:

  • Preserves endoscopic access to the stomach and biliary tree
  • Does not induce malabsorption
  • Results in more gradual weight loss
  • Shows better improvement in liver enzymes 1

• Roux-en-Y gastric bypass (RYGB) carries higher risks in cirrhotic patients:

  • Greater risk of sarcopenia
  • More rapid weight loss that may impair liver function
  • Higher risk of delisting from liver transplant lists 1, 3

Evidence on Liver Histology Outcomes

While bariatric surgery can improve NASH in non-cirrhotic patients, the evidence in cirrhotic patients is more nuanced:

• In patients with NASH without cirrhosis, bariatric surgery has shown resolution of NASH in up to 85% of cases 2
• A prospective study by Mathurin et al. found that while steatosis and inflammation improved after bariatric surgery, there was a minor but statistically significant increase in mean fibrosis score at 5 years post-surgery 2
• In patients with established cirrhosis, the data on fibrosis improvement is limited and mixed 2

Institutional Requirements

Bariatric surgery in cirrhotic patients should only be performed at centers with:

• Surgical and anesthesia teams experienced in operating on patients with portal hypertension and cirrhosis
• Medical teams experienced in treating postoperative patients with cirrhosis
• Ability to evaluate potential candidacy for liver transplantation as part of pre-operative assessment 1

Current Guideline Recommendations

Multiple professional societies have addressed this issue:

1. American Association for the Study of Liver Diseases (2018):

   • "The type, safety, and efficacy of foregut bariatric surgery in otherwise eligible obese individuals with established cirrhosis attributed to NAFLD are not established." 2
   • "In otherwise eligible patients with compensated NASH or cryptogenic cirrhosis, foregut bariatric surgery may be considered on a case-by-case basis by an experienced bariatric surgery program." 2

2. American Gastroenterological Association (2012):

   • "The type, safety and efficacy of foregut bariatric surgery in otherwise eligible obese individuals with established cirrhosis due to NAFLD are not established." 2
   • "It is premature to consider foregut bariatric surgery as an established option to specifically treat NASH." 2

Practical Approach to Decision-Making

For patients with NASH cirrhosis considering bariatric surgery:

1. Assess cirrhosis status:

   • Child-Pugh classification (A, B, or C)
   • Presence of portal hypertension
   • History of decompensation events

2. Risk stratification:

   • Well-compensated (Child A) without significant portal hypertension: May consider LSG
   • Any decompensation or Child B/C: Bariatric surgery contraindicated

3. Surgical considerations if proceeding:

   • Refer to high-volume center with expertise in both bariatric surgery and liver disease
   • Prefer LSG over RYGB
   • Ensure close post-operative monitoring for signs of decompensation

Common Pitfalls and Caveats

• Rapid weight loss risk: Rapid weight loss following bariatric procedures may rarely lead to liver failure in cirrhotic patients 1
• Transplant considerations: Patients with previous bariatric surgery evaluated for liver transplantation have a higher risk of delisting and death on the transplant list (33% versus 10%) 1
• Malabsorption concerns: Malabsorptive procedures may worsen nutritional status in cirrhotic patients who may already have compromised nutrition 2
• Medication absorption: Altered anatomy after RYGB may affect absorption of medications, including immunosuppressants if transplantation becomes necessary 1

In conclusion, while bariatric surgery offers significant benefits for NAFLD and early NASH, its role in established NASH cirrhosis remains limited and should be approached with extreme caution, with LSG being the preferred option only in carefully selected patients with well-compensated cirrhosis at experienced centers.