Contrary to belief, study finds bariatric Surgery safe in cirrhosis

A new study presented at Digestive Disease week reports that patients with non-alcoholic steatohepatitis and cirrhosis can benefit from bariatric surgery using vertical sleeve gastrectomy.

According to the lead author of the study Khalid Mumtaz, the first of its kind of large study showed that bariatric surgery is not linked to increased mortality in patients with compensated cirrhosis as compared to noncirrhotics.

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The majority of patients who undergo bariatric surgery have NASH and obesity-related cirrhosis. A previous study had shown an increased risk for death within 10 years after bariatric surgery in patients with NASH.

“However, there have been many advances in bariatric surgical techniques and postoperative care since that study, which looked at surgeries performed between 1997 and 2004,” said Dr. Mumtaz, an associate professor of medicine at the Ohio State University Wexner Medical Center, in Columbus.

The researchers analyzed the safety of bariatric surgery in patients with compensated and decompensated cirrhosis and collected data on patients who underwent either Roux-en-Y gastric bypass or vertical sleeve gastrectomy in the United States between 2008 and 2013. They obtained information about demographics, health care utilization and in-hospital outcomes, and compared hospital mortality, length of stay and cost of care between patients with no cirrhosis, compensated cirrhosis, and decompensated cirrhosis.

Of the 558,017 patients who underwent bariatric surgery during the study period, 3,189 (0.57%) had compensated cirrhosis and 103 (0.02%) had decompensated cirrhosis. The researchers then analyzed mortality in patients with compensated cirrhosis to that in those without cirrhosis. However, mortality was higher in patients with decompensated cirrhosis.

“We think that the improvement in outcomes is multifactorial,” Dr. Mumtaz said. “The majority of the patients underwent sleeve gastrectomy, which is a much less invasive surgery than the Roux-en-Y procedure. We also found that patients do better in larger centers that do more than 100 bariatric surgeries per month—more experience with better outcomes.”

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However, he stressed that patients with decompensated cirrhosis—patients with ascites, jaundice, and hepatitis B or C—should not be considered for bariatric surgery. “We found that these patients had a 98 times increased risk of mortality. If our goal is to save lives, we would not recommend an elective procedure like a gastric bypass for these patients. And lastly, older patients with comorbid medical conditions also did not do well with bariatric surgery,” Dr. Mumtaz added.

According to Naim Alkhouri, MD, the director of the Metabolic Health Center at the Texas Liver Institute, the study clearly shows that patients with compensated cirrhosis can benefit from bariatric surgery.

The study concluded that cirrhosis continues to be associated with increased use of health care resources which requires careful selection of patients, procedure, and size of surgical center so that it can help in improving outcomes and health care utilization in patients with cirrhosis undergoing bariatric surgery.