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Hepatic Complications of Bariatric Surgery : the Reverse Side of the Coin

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Hepatic Complications of Bariatric Surgery : the Reverse Side of the Coin REVIEW 505 Hepatic complications of bariatric surgery : the reverse side of the coin U. Vespasiani-Gentilucci*1, F. Vorini*1, S. Carotti2, A. De Vincentis1, G. Galati1, P. Gallo1, N. Scopinaro3, A. Picardi1 (1) Internal Medicine and Hepatology Unit ; (2) Laboratory of Microscopic and Ultrastructural Anatomy, CIR ; University Campus Bio-Medico of Rome, Italy; (3) Department of Surgery, Ospedale San Martino, University of Genoa, Italy. Abstract Indeed, several studies demonstrated an association between weight loss and regression of nonalcoholic fatty Background : Even if the jejunoileal bypass has been definitely abandoned due to the high rate of hepatic complications, cases of liver disease (NAFLD) and non-alcoholic steatohepatitis liver injury after the new bariatric procedures are still reported. We (NASH) (5,9-11), and others proved a significant rate of aimed to review the available literature concerning liver damage fibrosis – and even cirrhosis – regression after bariatric associated with the older and newer types of bariatric surgeries. Methods : An extensive literature search of MEDLINE was surgery (12). On the other side, from the middle ’70s, performed using different combinations of the following terms: several reports have focused on the high rate of hepatic “bariatric surgery OR biliopancreatic diversion OR jejunoileal complications following the first widely diffused bariatric bypass OR roux-en-y gastric bypass OR vertical banded gastro- plasty OR laparoscopic adjustable gastric banding” AND “hepatic/ technique, the jejunoileal bypass (JIB) (13-17), which led liver damage OR hepatic/liver impairment OR hepatic/liver to its progressive abandonment, even if some opposing failure”. opinions still exist (18). Results : Although weight loss after bariatric surgery frequently induces an improvement of non-alcoholic fatty liver disease and Since the issue of hepatic complications following non-alcoholic steatohepatitis, and even the regression of hepatic bariatric procedures is missing, we aimed to examine fibrosis, bariatric procedures have been also associated with cases of the available literature concerning liver injury following acute liver failure or of chronic liver disease evolving until cirrhosis. After the jejunoileal bypass has been definitely abandoned, most of bariatric surgery, and theorize the possible underlying the recently described cases concern biliopancreatic diversion with/ physiopathological mechanisms. without duodenal switch, but liver damage has been reported after almost all types of bariatric surgeries. Protein-calorie malnutrition, bacterial overgrowth, lipotoxicity and genetic background are Bariatric surgery procedures likely to play a central role in the physiopathology of hepatic injury. Conclusions : Understanding the inner mechanisms underlying Bariatric procedures can be schematically divided into acute or chronic liver injury after bariatric surgery can help in the prevention, early recognition and treatment of these rare but restrictive and malabsorptive, or a combination of the concrete cases. (Acta gastroenterol. belg., 2017, 80, 505-513). two. The first bariatric procedure is the JIB. Introduced in Key words : Bariatric surgery, liver injury, bacterial overgrowth, protein-calorie malnutrition, lipotoxicity. the ‘50s, it revealed as a purely malabsorptive technique, and consists on the resection of a variable-long portion of the small intestine (generally 90-95%) (19), connecting Introduction the extremity of the remainder with an end-to-end or end- to-side anastomosis (Fig. 1, Panel A). This procedure Since the early 1960s, bariatric surgery has represented gained a remarkable success in losing excess weight and the only effective treatment against severe morbid obesity maintaining weight loss, but it is now abandoned because (1), allowing patients to gain a long-term effective loss of of the short- and long-term complications. 50-70% of their excess weight (2,3). It is indicated for The vertical banded gastroplasty (VBG) represents a any adult with BMI >35 kg/m2 and severe comorbidities purely restrictive procedure. It gained a certain popularity (life-threatening cardiopulmonary problems, severe during the 1980s, with the decline of JIB, but it fell into diabetes mellitus), or BMI >40 kg/m2 (4). Moreover, disfavor because of the inadequate attitude in maintaining bariatric surgery demonstrated clear metabolic benefits: the weight loss (19). According to this technique, the it improves glucose tolerance in type-2 diabetic patients stomach is partitioned with a 4-parallel reinforced row of and rebalances glucose homeostasis (5-7) ; it reduces staples, allowing the bolus to pass only through a small urate levels (8), blood pressure and LDL cholesterol levels and it increases HDL cholesterol levels (5,6,9) ; it Correspondence to : Umberto Vespasiani-Gentilucci, M.D., University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy. Tel : has beneficial effects on metabolic syndrome (5,10,11) ; +3906225411446 ; Fax : +39-0622541456. it seems beneficial also on obstructive sleep apnea (2). E-mail : [email protected] Concerning the liver, the effects of bariatric surgery Submission date : 05/08/2016 are double-sided and this issue deserves special attention. Acceptance date : 04/07/2017 Acta Gastro-Enterologica Belgica, Vol. LXXX, October-December 2017 09-Gentilucci.indd 505 12/12/17 14:33 506 U. Vespasiani Gentilucci et al. Fig. 1. — Vespasiani-Gentilucci et al. Schematic representations of the different types of bariatric surgery (See text for further details). PANEL A : Jejunoileal bypass ; PANEL B : Laparoscopic adjustable gastric banding ; PANEL C : Vertical banded gastroplasty ; PANEL D : Roux-en-y gastric bypass ; PANEL E : Biliopancreatic diversion ; PANEL F : Duodenal switch ; PANEL G : Laparoscopic Sleeve Gastrectomy. “stoma”, strengthened with a band of prosthetic material Considering the combined procedures, the Roux- (Fig. 1, Panel F). en-Y gastric bypass (RYGB) is a both restrictive and Similarly, the laparoscopic adjustable gastric banding malabsorptive procedure. It consists of a partitioning (LAGB) is a purely restrictive procedure. It is performed of the upper stomach, creating a small gastric pouch, through the positioning of a band 1-2 cm below the which is connected to an extremity of the transected gastro-oesophageal junction, creating a small pouch small intestine; this portion takes the name of Roux (~30 mL); the degree of constriction is adjustable thanks Limb, and extends from the gastrojejunostomy to the to the injection of an amount of saline contained in a jejunojejunostomy, with an end-to-side or end-to-end subcutaneous port, connected to the band (Fig. 1, Panel anastomosis. A biliopancreatic limb, extending from E). It is effective at producing weight loss gradually and the Treitz to the jejunojejunostomy, drains biliary and presents the lowest rate of post-operative mortality and pancreatic juices to the common limb, the remainder of complications among bariatric surgery procedures, but the small intestine (Fig. 1, Panel D). its usage was progressively limited by the risk of band The biliopancreatic diversion (BPD) is also a combined migration and by weight loss failure on the long-term restrictive and malabsorptive procedure, generated with (20). the purpose of avoiding the stasis associated with intestinal Acta Gastro-Enterologica Belgica, Vol. LXXX, October-December 2017 09-Gentilucci.indd 506 12/12/17 14:33 Hepatic injury after bariatric surgery 507 bypass and ensuring the flow of bile and pancreatic juices developing other severe complications further than through the biliopancreatic limb. The common channel hepatic damage, such as renal failure (37%), diarrhea and has variable length (50-125 cm), according to the desired electrolytic impairment (29%), nephrolithiasis (29%) and amount of malabsorption. The procedure includes a death, this surgical technique was definitively abandoned subtotal gastrectomy and eventually a cholecystectomy (16). (Fig. 1, Panel B). The Duodenal Switch variation To date, there is no evidence supporting the occur- (BPD/DS) admits the preservation of the pylorus, with rence of liver injury following LAGB and sleeve gastrec- the construction of an ileoduodenostomy distal to the tomy. Consequently, these procedures deserve to be pylorus, the removal of the greater curve portion of the considered safe under this profile. There are no long-term stomach and the creation of a longer common channel complications associated with them, with LAGB showing (Fig. 1, Panel C). a higher and more stable weight loss. To note, however, Finally, the laparoscopic sleeve gastrectomy (LSG) Papakonstantinou et al. reported a case of severe acute is a recently-introduced restrictive procedure which hepatic failure from a pool of 260 morbid obese patients has rapidly gained an increasing popularity, due to its undergoing VBG (47). Actually, the total absence of technical simplicity, its good results and its low post- concordant or similar reports in the medical literature, operative mortality rates (21), becoming - to date - the together with the rapidity of the hepatic failure onset (the second most performed bariatric procedure worldwide patient died fourteen days after the intervention) (47), (22). The LSG consists of a partial, longitudinal suggest that some complication generically related to gastrectomy, removing the entire great gastric curvature surgery, rather than to the specific type of surgery, was
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