Bariatric surgery in patients with cirrhosis was thought to be contraindicated due to the potential excessive risk of complications and mortality. More recently, however, studies involving cirrhotic patients have shown reasonable and lower rates of complication after bariatric surgery (see section on safety of bariatric surgery in patients with cirrhosis). The estimated prevalence of cirrhotic patients undergoing bariatric surgery is approximately 2%, with the diagnosis usually made incidentally at the time of surgery [14] (Fig. 14.3). Recent trends suggest that patients with known cirrhosis are being referred for bariatric surgery to improve both liver and CV-related outcomes. Patients with obesity and cirrhosis may benefit from bariatric surgery through both weight loss and resolution of metabolic comorbidities [15, 16]. Furthermore, surgically induced weight loss in patients with end-stage liver disease may enable them to qualify for liver transplantation based on the preoperative BMI requirement (BMI < 35 kg/m²).

Bariatric surgery is the only therapeutic intervention that has been proven to produce clinically significant and sustained weight loss for over 5 years in the severely obese. Typically, surgery results in 20 and 50 kg of weight loss and a 10–15 kg/m² BMI reduction. Weight loss varies between the bariatric procedures. In the SOS trial [17] of the long-term effects of bariatric surgery compared with nonsurgical weight management in patients with a BMI >34 kg/m², the mean weight loss after 10 years for gastric band plication, vertical banded gastroplasty, and gastric bypass was 14 kg, 16 kg, and 25 kg, respectively. The mean changes of body weight after 10, 15, and 20 years were −17%, −16%, and −18% in bariatric surgical groups as compared to control group; 1%, −1%, and −1%, respectively. A meta-analysis by Buchwald et al. [18] showed that overall excess weight loss was 55.9% after bariatric surgery.

Weight loss in cirrhotic patients is comparable to noncirrhotic patients who underwent bariatric surgery (Child Pugh A or B; reported by Dallal et al. [19], 30 patients and Shimizu et al. [15], 23 patients). The 1-year excess weight loss was 62% and 67.4%, respectively.

Studies involving bariatric patients with NASH have shown significant improvement in liver function studies, steatosis, inflammation, and fibrosis after surgery [5–7]. Rabl et al. [20] in a systematic review reported that NASH improved histologically after bariatric surgery irrespective of procedure type (Table 14.1). Mattar et al. [21] showed that there was a significant improvement in liver steatosis (from 88% to 8%, p < 0.001), inflammation (from 23% to 2%), and fibrosis (from 31% to 13%). Inflammation and fibrosis resolved in 37% and 20% of patients, respectively, corresponding to an improvement of 82% in grade and 39% in stage of liver disease (p < 0.001). Weight loss after bariatric surgery results in a reduction of visceral fat and an increase in insulin sensitivity, which is a major drive of histological improvement of NAFLD [2].

Due to the infrequency of bariatric surgery performed in patients with frank cirrhosis, data on histological changes in cirrhosis after bariatric surgery are limited. However, in this systemic review, Rabl et al. [20] showed that in patients with NASH and advanced liver disease, all the histological components of cirrhosis including steatosis, inflammation, and fibrosis generally improved with bariatric procedures, especially RYGB. Kral et al. [22] showed that after BPD in patients with cirrhosis (n = 11/14, with pre- and postoperative biopsy), steatosis, inflammation, and fibrosis all improved significantly. However, in this study there were three patients without fibrosis at baseline who developed cirrhosis on follow-up. Whether bariatric surgery definitely results in histological improvement in frank cirrhosis requires further study.

The prevalence of T2D in patients with severe obesity and cirrhosis is 70–80% [15, 19]. Bariatric surgery has shown significant improvement and sometimes resolution of T2D in both observational and randomized control trials (RCTs). A recent systemic review involving 73 studies with 19,543 patients showed 73% remission/improvement for T2D at a mean follow-up of 57.8 months [23]. Buchwald et al. [18] showed that diabetic patients had an overall 78.1% rate of complete resolution and an 86.6% rate of improvement in T2D. At 2 years, BPD-DS has the best T2D resolution (95.9%), followed by gastric bypass (70.9%), and gastric band (58.3%). In the STAMPEDE trial, Schauer et al. [24] showed that at 3 years after bariatric surgery versus intensive medical therapy, glycated hemoglobin level of 6.0% or less was achieved by 38% in the gastric bypass group, 24% in the sleeve gastrectomy group, and 5% in the medical-therapy group (p < 0.001). Shimizu et al. [15] reported 85.7% improvement in T2D with remission rate of 66.7% in the cirrhotic patients who underwent bariatric procedures (RYGB, SG, and LAGB).

Bariatric surgery has also shown improvement in obesity-related comorbidities such as hypertension, hyperlipidemia and CVD. The SOS trial [17] showed significantly decreased rates of myocardial infarction, stroke, CV mortality and all causes of CV risk, and cancer in women after bariatric surgery. Bolen et al. [25] showed 53% resolution or improvement in hypercholesterolemia in 5 years and Sugerman et al. [26] showed 66% of resolution or improvement in hypertension in 7 years. In a systematic review of CV outcomes after bariatric surgery, Vest et al. [23] showed that there was improvement and resolution of hypertension (63%) and hyperlipidemia (65%), and reduction in all-cause mortality compared to nonoperative controls. The study also showed evidence of left ventricular hypertrophy regression and improvement in diastolic function post bariatric surgery. In patients with advanced liver disease and NASH, Mattar et al. showed that bariatric surgery resulted in improvements in all metabolic conditions including diabetes, hypertension, and dyslipidemia [21]. In 23 patients with cirrhosis, Shimizu et al. [15] reported improvement of hypertension and dyslipidemia at rates of 88.9% and 66.7%, respectively, following bariatric surgery.

Patients with cirrhosis undergoing major abdominal surgery have a greater than tenfold higher mortality risk (9%) than patients without cirrhosis [27]. For this reason, the safety of bariatric surgery in cirrhotic patients has raised concern. Mosko et al. [28] conducted a study involving the Nationwide Inpatient Sample (NIS) Database from 1998 to 2007 and demonstrated that the mortality rate of bariatric surgery for patients without cirrhosis, decompensated cirrhosis and decompensated cirrhosis was 0.3%, 0.9%, and 16.3%, respectively. High-volume centers (>100 cases/year) compared to medium volume (50–100 cases/year) and lower volume (<50 cases/year) centers have significantly lower mortality rates (0.2%, 0.4%, and 0.7%, respectively) suggesting that bariatric surgery in cirrhotic patients should be performed in high volume centers.

A recent systemic review (11 studies including 122 patients) of patients with Child Pugh A cirrhosis who underwent bariatric surgery demonstrated major morbidity and mortality rates much lower than expected: 21.3% and 1.6%, respectively. Postsurgical liver decompensation was seen in only 6.6%, and the delayed mortality rate (>30 days) was only 2.5% [16]. Despite the greater risk of bariatric surgery in cirrhotic patients, both Dallal et al. [19] and Shimizu et al. [15] reported no postsurgical (1–3 years follow up) liver decompensation or related mortality in their series. These studies suggest that bariatric surgery in cirrhotic patients (Child Pugh A) is relatively safe with an overall benefit in terms of weight loss, metabolic improvement, and CV risk reduction. Outcomes of patients with more advanced cirrhosis (Child–Pugh B and C) are not well documented. Appropriate perioperative management of the cirrhotic patient with a multidisciplinary team approach is likely a key factor in achieving low complication rates in this population.

Complications following bariatric surgery are often influenced by preexisting risk factors and illness. Cirrhotic patients have higher morbidity and rates of postoperative complications compared to the general population. Jan et al. [16] showed that cirrhotic patients who underwent “restrictive” procedures (LAGB and SG) had less complications and mortality than those having malabsorptive procedures (RYGB and BPD) (Table 14.2). This study also reported that delayed mortality was observed, albeit rarely, in the RYGB and BPD groups due to liver decompensation and fulminant hepatic failure. Liver decompensation in cirrhotic patients postbariatric surgery may be related to malnutrition and malabsorption resulting from these procedures. The relative increase in risk of the malabsorptive procedures must be balanced with the relatively less effective weight loss and metabolic improvement observed with the “restrictive” procedures.

Other common postoperative complications include infection, bleeding, and venous thromboembolism (VTE). Infection can include wound infections, intra-abdominal abscesses, catheter-related infections, pneumonia, and surgical site infections. Cirrhotic patients with ascites have a higher risk of wound infections and breakdown. Therefore, prophylactic antibiotic such as a cephalosporin is recommended. Cirrhotic patients are often coagulopathic and demonstrate platelet dysfunction that can result in intra-abdominal bleeding. Therefore, careful tissue handling and hemostasis are essential and the usage of anticoagulants is recommended with caution.

Finally, the incidence of VTE is higher in obese patients and it is one of the main causes of mortality after bariatric surgery. More than 80% of these episodes of VTE occur after discharge [29]. Prophylactic perioperative VTE prophylaxis, as well as extended VTE prophylaxis in high risk surgical patients is recommended with caution. There is no standard guideline regarding type, dose and duration of VTE prophylaxis available for bariatric patients with cirrhosis but the American Society for Metabolic and Bariatric Surgery (ASMBS) [30] has recommended the following general recommendations for patients undergoing bariatric surgery; Mechanical VTE prophylaxis such as sequential compression devices or elastic compression stockings, and early ambulation are recommended in all bariatric surgical patients. Chemoprophylaxis is recommended for patients undergoing bariatric surgery provided there is no significant increased risk for major bleeding.

General indications for bariatric surgery are based on the NIH Consensus Conference of 1991 [31]. More recently, international guidelines for patients with diabetes and metabolic disease suggest that bariatric surgery or metabolic surgery also be considered for patients with inadequately controlled T2D diabetes and a BMI as low as 30 kg/m² (27.5 kg/m² for high-risk populations such as Asians) [32]. A multidisciplinary team approach plays an important role in the care of obese patients, as does family and social support. There is no published clinical practice guideline for bariatric surgery in cirrhotic patients; the data available is only based on a few clinical studies. For patients with Child–Pugh B and C cirrhosis, any major surgical procedure carries a higher perioperative risk and mortality. Notable to this textbook on surgery in patients with cirrhosis, with the exception of liver transplantation, bariatric, and metabolic surgery, is the only surgery that may actually improve cirrhosis.

Indications for bariatric surgery:

Relative Contraindications for bariatric surgery:

Bariatric Procedure Selection for Cirrhotic Patients

The choice of which type of bariatric procedure is appropriate for each cirrhotic patient is based on the criteria below: