Management of NASH/cirrhosis patients in a tertiary bariatric surgery center
Darya M. Herscovici*1, Thuy Duong Doan1, Lyle Suh1, Richard Perugini2
1UMASS Chan Medical School, Worcester, MA; 2Department of Surgery, UMASS Memorial Health, Worcester, MA
Objective
Nonalcoholic steatohepatitis (NASH) and alcoholic liver disease, recently unseated hepatitis C as the leading causes of advanced liver disease for those awaiting transplant. Bariatric surgery (BS) leads to significant and sustained weight loss, correcting metabolic abnormalities associated with NASH, and offers an important intervention in the management of NASH. However, cirrhosis with associated portal hypertension and hepatic synthetic dysfunction increase the risk of BS. We present the results of a multidisciplinary approach to the management of cirrhosis in a population with severe obesity.
Design
Retrospective chart review for patients seen in BS clinic with concurrent diagnosis of cirrhosis. Those identified with non-alcoholic fatty liver disease (NAFLD), or NASH were assessed for hepatic synthetic function and for portal hypertension with sinusoidal gradient. If cirrhosis was discovered at time of BS, patients underwent BS with concurrent liver biopsy, if there was no evidence of portal hypertension. A third subset of patients were referred for bariatric surgery after they had undergone prior liver transplant. All patients underwent longitudinal sleeve gastrectomy (LSG). We assessed the perioperative outcomes and weight loss following LSG. Patients were followed by hepatology for routine screening for liver tumor.
Setting
Large, academic medical center that serves as the tertiary care referral center for region.
Patients (or Other Participants)
Patients age ≥18 evaluated by the BS program and had or developed a diagnosis of cirrhosis from October 2017 - March 2023.
Interventions (if any)
N/A
Main Outcome Measure (s)
Successful completion of LSG, serious adverse events (SAE), postoperative weight loss
Results
32 patients were identified that met inclusion criteria. The average age was 55 + 10 years, BMI was 47 + 7, with 19 (59%) female, and 22 (69%) of patients with type 2 diabetes. Nine (28%) patients were identified with cirrhosis preoperatively and were evaluated with determination of sinusoidal gradient. Three of these patients with sinusoidal gradient > 8 mm Hg were deemed not candidates for BS and referred for metabolic weight loss program. Five of the remaining six underwent LSG. Sixteen (50%) patients were discovered to have cirrhosis post BS work-up. Nine of these patients underwent LSG. Seven (22%) patients were referred for BS after a liver transplant; of these 4 underwent LSG. There were no SAE, or 30 day readmissions. Excess body weight loss 1 year is 43 + 24% .
Conclusion
Cirrhosis is an important comorbidity of obesity, and requires the combined efforts of bariatric surgery, hepatology, transplant surgery, and metabolic weight loss programs. A standardized algorithm of care, utilizing measures such as transjugular assessment of sinusoidal gradient to assess degree of portal hypertension, aids in achieving optimal outcomes. We plan to follow this series to assess impact of LSG on cirrhosis and on graft survival.
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