Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.1055/s-0041-1731705
Risks and Rewards of Bariatric Surgery in Advanced Chronic Liver Diseases
Funding Y.P.M. and C.B. received financial support from the Stiftung für Leberkrankheiten Bern.![](https://www.thieme-connect.de/media/sld/202104/lookinside/thumbnails/10-1055-s-0041-1731705_2100027-1.jpg)
Abstract
The burden of obesity and metabolic syndrome has determined a sharp increase in bariatric surgery (BS) procedures, which lead to marked weight loss, improved metabolic syndrome, reduced cardiovascular risk, and even improvement in nonalcoholic steatohepatitis (NASH). Despite these promising results, BS in patients with chronic liver disease can rarely lead to worsening of liver function, progression to cirrhosis and its complications, and even liver transplantation. On the other hand, since obesity in patients with cirrhosis is a major cofactor for progression to a decompensated stage of the disease and a risk factor for hepatocellular carcinoma, BS has been used to achieve weight loss in this population. In this review, we critically analyze the existing data on outcomes of BS in patients with cirrhosis and the possible mechanisms leading to fibrosis progression and worsening liver function in patients undergoing BS. Finally, we propose a set of measures that could be taken to improve the multidisciplinary management of liver disease in patients undergoing BS, including early recognition of malnutrition and alcohol misuse.
Keywords
cirrhosis - nonalcoholic fatty liver disease - sarcopenia - malnutrition - alcohol use disorders* Yuly P. Mendoza and Chiara Becchetti equally contributed and share the first authorship.
# Kymberly D. Watt and Annalisa Berzigotti equally contributed and share the senior authorship.
Authors' Contributions
Y.P.M. and C.B. contributed towards conception, literature review, and drafting the manuscript; K.D.W. contributed towards critical revision of the manuscript for important intellectual content and editing the manuscript; A.B. contributed towards conception, critical revision of the manuscript for important intellectual content, drafting, and editing the manuscript. All the authors approved the final version of the manuscript.
Publication History
Article published online:
09 July 2021
© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet 2017; 390 (10113): 2627-2642
- 2 English WJ, DeMaria EJ, Hutter MM. et al. American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States. Surg Obes Relat Dis 2020; 16 (04) 457-463
- 3 Meek CL, Lewis HB, Reimann F, Gribble FM, Park AJ. The effect of bariatric surgery on gastrointestinal and pancreatic peptide hormones. Peptides 2016; 77: 28-37
- 4 Ryan KK, Tremaroli V, Clemmensen C. et al. FXR is a molecular target for the effects of vertical sleeve gastrectomy. Nature 2014; 509 (7499): 183-188
- 5 Adams TD, Davidson LE, Hunt SC. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med 2018; 378 (01) 93-96
- 6 Thereaux J, Lesuffleur T, Czernichow S. et al. Long-term adverse events after sleeve gastrectomy or gastric bypass: a 7-year nationwide, observational, population-based, cohort study. Lancet Diabetes Endocrinol 2019; 7 (10) 786-795
- 7 European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, European Association for the Study of the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol 2019; 70 (01) 172-193
- 8 Belle SH, Berk PD, Chapman WH. et al; LABS Consortium. Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. Surg Obes Relat Dis 2013; 9 (06) 926-935
- 9 Eslam M, Newsome PN, Sarin SK. et al. A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement. J Hepatol 2020
- 10 Chalasani N, Younossi Z, Lavine JE. et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018; 67 (01) 328-357
- 11 Froylich D, Corcelles R, Daigle C, Boules M, Brethauer S, Schauer P. Effect of Roux-en-Y gastric bypass and sleeve gastrectomy on nonalcoholic fatty liver disease: a comparative study. Surg Obes Relat Dis 2016; 12 (01) 127-131
- 12 von Schönfels W, Beckmann JH, Ahrens M. et al. Histologic improvement of NAFLD in patients with obesity after bariatric surgery based on standardized NAS (NAFLD activity score). Surg Obes Relat Dis 2018; 14 (10) 1607-1616
- 13 Fakhry TK, Mhaskar R, Schwitalla T, Muradova E, Gonzalvo JP, Murr MM. Bariatric surgery improves nonalcoholic fatty liver disease: a contemporary systematic review and meta-analysis. Surg Obes Relat Dis 2019; 15 (03) 502-511
- 14 Lassailly G, Caiazzo R, Buob D. et al. Bariatric surgery reduces features of nonalcoholic steatohepatitis in morbidly obese patients. Gastroenterology 2015; 149 (02) 379-388 , quiz e15–e16
- 15 Lee Y, Doumouras AG, Yu J. et al. Complete resolution of nonalcoholic fatty liver disease after bariatric surgery: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2019; 17 (06) 1040-1060.e11
- 16 Chavez-Tapia NC, Tellez-Avila FI, Barrientos-Gutierrez T, Mendez-Sanchez N, Lizardi-Cervera J, Uribe M. Bariatric surgery for non-alcoholic steatohepatitis in obese patients. Cochrane Database Syst Rev 2010; (01) CD007340
- 17 Eilenberg M, Langer FB, Beer A, Trauner M, Prager G, Staufer K. Significant liver-related morbidity after bariatric surgery and its reversal—a case series. Obes Surg 2018; 28 (03) 812-819
- 18 Mahawar KK, Parmar C, Graham Y. et al. Monitoring of liver function tests after Roux-en-Y gastric bypass: an examination of evidence base. Obes Surg 2016; 26 (10) 2516-2522
- 19 Addeo P, Cesaretti M, Anty R, Iannelli A. Liver transplantation for bariatric surgery-related liver failure: a systematic review of a rare condition. Surg Obes Relat Dis 2019; 15 (08) 1394-1401
- 20 Mendoza YP, Becchetti C, Wan T. et al. Malnutrition and alcohol in patients presenting with severe complications of cirrhosis after laparoscopic bariatric surgery. Obes Surg 2021; 31 (06) 2817-2822
- 21 Pestana L, Swain J, Dierkhising R, Kendrick ML, Kamath PS, Watt KD. Bariatric surgery in patients with cirrhosis with and without portal hypertension: a single-center experience. Mayo Clin Proc 2015; 90 (02) 209-215
- 22 Patton H, Heimbach J, McCullough A. AGA clinical practice update on bariatric surgery in cirrhosis: expert review. Clin Gastroenterol Hepatol 2021; 19 (03) 436-445
- 23 Mosko JD, Nguyen GC. Increased perioperative mortality following bariatric surgery among patients with cirrhosis. Clin Gastroenterol Hepatol 2011; 9 (10) 897-901
- 24 Are VS, Knapp SM, Banerjee A. et al. Improving outcomes of bariatric surgery in patients with cirrhosis in the United States: a nationwide assessment. Am J Gastroenterol 2020; 115 (11) 1849-1856
- 25 Jan A, Narwaria M, Mahawar KK. A systematic review of bariatric surgery in patients with liver cirrhosis. Obes Surg 2015; 25 (08) 1518-1526
- 26 Izzy M, Angirekula M, Abu Dayyeh BK, Bazerbachi F, Watt KD. Bariatric surgery proves long-term benefit in patients with cirrhosis. Gastroenterol Rep (Oxf) 2020; 1-5
- 27 Reverter E, Cirera I, Albillos A. et al. The prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery. J Hepatol 2019; 71 (05) 942-950
- 28 Hanipah ZN, Punchai S, McCullough A. et al. Bariatric surgery in patients with cirrhosis and portal hypertension. Obes Surg 2018; 28 (11) 3431-3438
- 29 Bosch J, Abraldes JG, Berzigotti A, García-Pagan JC. The clinical use of HVPG measurements in chronic liver disease. Nat Rev Gastroenterol Hepatol 2009; 6 (10) 573-582
- 30 Markowitz JS, Seu P, Goss JA. et al. Liver transplantation for decompensated cirrhosis after jejunoileal bypass: a strategy for management. Transplantation 1998; 65 (04) 570-572
- 31 Lowell JA, Shenoy S, Ghalib R. et al. Liver transplantation after jejunoileal bypass for morbid obesity. J Am Coll Surg 1997; 185 (02) 123-127
- 32 Geerts A, Darius T, Chapelle T. et al. The multicenter Belgian survey on liver transplantation for hepatocellular failure after bariatric surgery. Transplant Proc 2010; 42 (10) 4395-4398
- 33 Ayloo S, Buchs NC, Addeo P, Bianco FM, Giulianotti PC. Robot-assisted sleeve gastrectomy for super-morbidly obese patients. J Laparoendosc Adv Surg Tech A 2011; 21 (04) 295-299
- 34 Lefere S, Stroobant L, Verhelst X. et al. Bariatric surgery patients are at risk for alcoholic liver disease with need for liver transplantation. Obes Surg 2020; 30 (11) 4659-4664
- 35 Kalinowski P, Paluszkiewicz R, Ziarkiewicz-Wróblewska B. et al. Liver function in patients with nonalcoholic fatty liver disease randomized to Roux-en-Y gastric bypass versus sleeve gastrectomy: a secondary analysis of a randomized clinical trial. Ann Surg 2017; 266 (05) 738-745
- 36 Adam R, Karam V, Cailliez V. et al; all the other 126 contributing centers (www.eltr.org) and the European Liver and Intestine Transplant Association (ELITA). 2018 annual report of the European Liver Transplant Registry (ELTR)—50-year evolution of liver transplantation. Transpl Int 2018; 31 (12) 1293-1317
- 37 Doycheva I, Issa D, Watt KD, Lopez R, Rifai G, Alkhouri N. Nonalcoholic steatohepatitis is the most rapidly increasing indication for liver transplantation in young adults in the United States. J Clin Gastroenterol 2018; 52 (04) 339-346
- 38 Idriss R, Hasse J, Wu T. et al. Impact of prior bariatric surgery on perioperative liver transplant outcomes. Liver Transpl 2019; 25 (02) 217-227
- 39 Sharpton SR, Terrault NA, Posselt AM. Outcomes of sleeve gastrectomy in obese liver transplant candidates. Liver Transpl 2019; 25 (04) 538-544
- 40 Heimbach JK, Watt KD, Poterucha JJ. et al. Combined liver transplantation and gastric sleeve resection for patients with medically complicated obesity and end-stage liver disease. Am J Transplant 2013; 13 (02) 363-368
- 41 Zamora-Valdes D, Watt KD, Kellogg TA. et al. Long-term outcomes of patients undergoing simultaneous liver transplantation and sleeve gastrectomy. Hepatology 2018; 68 (02) 485-495
- 42 García-Sesma A, Calvo J, Manrique A. et al. Morbidly obese patients awaiting liver transplantation-sleeve gastrectomy: safety and efficacy from a liver transplant unit experience. Transplant Proc 2019; 51 (01) 33-37
- 43 Lin MY, Tavakol MM, Sarin A. et al. Safety and feasibility of sleeve gastrectomy in morbidly obese patients following liver transplantation. Surg Endosc 2013; 27 (01) 81-85
- 44 Cheng YL, Elli EF. Outcomes of bariatric surgery after solid organ transplantation. Obes Surg 2020; 30 (12) 4899-4904
- 45 Lopez-Lopez V, Ruiz-Manzanera JJ, Eshmuminov D. et al. Are we ready for bariatric surgery in a liver transplant program? A meta-analysis. Obes Surg 2021; 31 (03) 1214-1222
- 46 Suraweera D, Dutson E, Saab S. Liver transplantation and bariatric surgery: best approach. Clin Liver Dis 2017; 21 (02) 215-230
- 47 Peters RL, Gay T, Reynolds TB. Post-jejunoileal-bypass hepatic disease. Its similarity to alcoholic hepatic disease. Am J Clin Pathol 1975; 63 (03) 318-331
- 48 Craig RM, Neumann T, Jeejeebhoy KN, Yokoo H. Severe hepatocellular reaction resembling alcoholic hepatitis with cirrhosis after massive small bowel resection and prolonged total parenteral nutrition. Gastroenterology 1980; 79 (01) 131-137
- 49 Vespasiani-Gentilucci U, Vorini F, Carotti S. et al. Hepatic complications of bariatric surgery : the reverse side of the coin. Acta Gastroenterol Belg 2017; 80 (04) 505-513
- 50 Mocanu ICS, Costa P, Palma R. Liver failure after bariatric surgery—clinical case and literature review. J Gastroenterol Metabol. 2018; 1: 104
- 51 Schrager MA, Metter EJ, Simonsick E, Ble A, Bandinelli S, Lauretani F. et al. Sarcopenic obesity and inflammation in the InCHIANTI study. J Appl Physiol (1985) 2007; 102 (03) 919-925
- 52 Koo BK, Kim D, Joo SK. et al. Sarcopenia is an independent risk factor for non-alcoholic steatohepatitis and significant fibrosis. J Hepatol 2017; 66 (01) 123-131
- 53 Bhanji RA, Narayanan P, Allen AM, Malhi H, Watt KD. Sarcopenia in hiding: The risk and consequence of underestimating muscle dysfunction in nonalcoholic steatohepatitis. Hepatology 2017; 66 (06) 2055-2065
- 54 King WC, Chen JY, Courcoulas AP. et al. Alcohol and other substance use after bariatric surgery: prospective evidence from a U.S. multicenter cohort study. Surg Obes Relat Dis 2017; 13 (08) 1392-1402
- 55 Orellana ER, Jamis C, Horvath N, Hajnal A. Effect of vertical sleeve gastrectomy on alcohol consumption and preferences in dietary obese rats and mice: a plausible role for altered ghrelin signaling. Brain Res Bull 2018; 138: 26-36
- 56 Mellinger JL, Shedden K, Winder GS. et al. Bariatric surgery and the risk of alcohol-related cirrhosis and alcohol misuse. Liver Int 2021; 41 (05) 1012-1019
- 57 Ibrahim N, Alameddine M, Brennan J, Sessine M, Holliday C, Ghaferi AA. New onset alcohol use disorder following bariatric surgery. Surg Endosc 2019; 33 (08) 2521-2530
- 58 King WC, Chen JY, Mitchell JE. et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA 2012; 307 (23) 2516-2525
- 59 Svensson PA, Anveden Å, Romeo S. et al. Alcohol consumption and alcohol problems after bariatric surgery in the Swedish obese subjects study. Obesity (Silver Spring) 2013; 21 (12) 2444-2451
- 60 Steffen KJ, Engel SG, Wonderlich JA, Pollert GA, Sondag C. Alcohol and other addictive disorders following bariatric surgery: prevalence, risk factors and possible etiologies. Eur Eat Disord Rev 2015; 23 (06) 442-450
- 61 Orellana ER, Covasa M, Hajnal A. Neuro-hormonal mechanisms underlying changes in reward related behaviors following weight loss surgery: ootential pharmacological targets. Biochem Pharmacol 2019; 164: 106-114
- 62 Johnson PM, Kenny PJ. Dopamine D2 receptors in addiction-like reward dysfunction and compulsive eating in obese rats. Nat Neurosci 2010; 13 (05) 635-641
- 63 Steele KE, Prokopowicz GP, Schweitzer MA. et al. Alterations of central dopamine receptors before and after gastric bypass surgery. Obes Surg 2010; 20 (03) 369-374
- 64 Reddy IA, Wasserman DH, Ayala JE, Hasty AH, Abumrad NN, Galli A. Striatal dopamine homeostasis is altered in mice following Roux-en-Y gastric bypass surgery. ACS Chem Neurosci 2014; 5 (10) 943-951
- 65 Blackburn AN, Hajnal A, Leggio L. The gut in the brain: the effects of bariatric surgery on alcohol consumption. Addict Biol 2017; 22 (06) 1540-1553
- 66 Acevedo MB, Teran-Garcia M, Bucholz KK. et al. Alcohol sensitivity in women after undergoing bariatric surgery: a cross-sectional study. Surg Obes Relat Dis 2020; 16 (04) 536-544
- 67 Ivezaj V, Benoit SC, Davis J. et al. Changes in alcohol use after metabolic and bariatric surgery: predictors and mechanisms. Curr Psychiatry Rep 2019; 21 (09) 85
- 68 European Association for Study of Liver, Asociacion Latinoamericana para el Estudio del Higado. EASL-ALEH clinical practice guidelines: non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol 2015; 63 (01) 237-264
- 69 Newsome PN, Cramb R, Davison SM. et al. Guidelines on the management of abnormal liver blood tests. Gut 2018; 67 (01) 6-19
- 70 Castera L, Friedrich-Rust M, Loomba R. Noninvasive assessment of liver disease in patients with nonalcoholic fatty liver disease. Gastroenterology 2019; 156 (05) 1264-1281.e4
- 71 Papatheodoridi M, Hiriart JB, Lupsor-Platon M. et al. Refining the Baveno VI elastography criteria for the definition of compensated advanced chronic liver disease. J Hepatol 2020
- 72 Neuberger J, Patel J, Caldwell H. et al. Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology. Gut 2020; 69 (08) 1382-1403
- 73 Mahmud N, Fricker Z, Hubbard RA. et al. Risk prediction models for post-operative mortality in patients with cirrhosis. Hepatology 2021; 73 (01) 204-218
- 74 Martin Mateos R, Garcia de la Filia Molina I, Albillos A. Pre-surgical risk assessment in patients with cirrhosis. Acta Gastroenterol Belg 2020; 83 (03) 449-453
- 75 Parikh M, Johnson JM, Ballem N. American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS position statement on alcohol use before and after bariatric surgery. Surg Obes Relat Dis 2016; 12 (02) 225-230
- 76 Miller-Matero LR, Coleman JP, LaLonde L, Martens KM, Hamann A, Carlin AM. Patient recall of education about the risks of alcohol use following bariatric surgery. Obes Surg 2019; 29 (08) 2707-2710
- 77 Mechanick JI, Youdim A, Jones DB. et al; American Association of Clinical Endocrinologists, Obesity Society, American Society for Metabolic & Bariatric Surgery. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring) 2013; 21 (Suppl. 01) S1-S27
- 78 El Sherif O, Dhaliwal A, Newsome PN, Armstrong MJ. Sarcopenia in nonalcoholic fatty liver disease: new challenges for clinical practice. Expert Rev Gastroenterol Hepatol 2020; 14 (03) 197-205
- 79 Hydes T, Gilmore W, Sheron N, Gilmore I. Treating alcohol-related liver disease from a public health perspective. J Hepatol 2019; 70 (02) 223-236
- 80 Heinberg LJ, Ashton K, Coughlin J. Alcohol and bariatric surgery: review and suggested recommendations for assessment and management. Surg Obes Relat Dis 2012; 8 (03) 357-363
- 81 Connor JP, Haber PS, Hall WD. Alcohol use disorders. Lancet 2016; 387 (10022): 988-998
- 82 Sogg S, Lauretti J, West-Smith L. Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. Surg Obes Relat Dis 2016; 12 (04) 731-749
- 83 Kalarchian MA, King WC, Devlin MJ. et al. Psychiatric disorders and weight change in a prospective study of bariatric surgery patients: a 3-year follow-up. Psychosom Med 2016; 78 (03) 373-381
- 84 Jumbe S, Hamlet C, Meyrick J. Psychological aspects of bariatric surgery as a treatment for obesity. Curr Obes Rep 2017; 6 (01) 71-78
- 85 Cruz-Jentoft AJ, Bahat G, Bauer J. et al; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019; 48 (01) 16-31
- 86 Lai JC, Covinsky KE, Dodge JL. et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology 2017; 66 (02) 564-574
- 87 Carey EJ, Lai JC, Wang CW. et al; Fitness, Life Enhancement, and Exercise in Liver Transplantation Consortium. A multicenter study to define sarcopenia in patients with end-stage liver disease. Liver Transpl 2017; 23 (05) 625-633
- 88 Ebadi M, Bhanji RA, Tandon P, Mazurak V, Baracos VE, Montano-Loza AJ. Review article: prognostic significance of body composition abnormalities in patients with cirrhosis. Aliment Pharmacol Ther 2020; 52 (04) 600-618
- 89 Wang CW, Lebsack A, Chau S, Lai JC. The range and reproducibility of the liver frailty index. Liver Transpl 2019; 25 (06) 841-847
- 90 Lai JC, Dodge JL, Kappus MR. et al; Multi-Center Functional Assessment in Liver Transplantation (FrAILT) Study. Changes in frailty are associated with waitlist mortality in patients with cirrhosis. J Hepatol 2020; 73 (03) 575-581
- 91 Małczak P, Pisarska M, Piotr M, Wysocki M, Budzyński A, Pędziwiatr M. Enhanced recovery after bariatric surgery: systematic review and meta-analysis. Obes Surg 2017; 27 (01) 226-235
- 92 Williams FR, Berzigotti A, Lord JM, Lai JC, Armstrong MJ. Review article: impact of exercise on physical frailty in patients with chronic liver disease. Aliment Pharmacol Ther 2019; 50 (09) 988-1000
- 93 Frame-Peterson LA, Megill RD, Carobrese S, Schweitzer M. Nutrient deficiencies are common prior to bariatric surgery. Nutr Clin Pract 2017; 32 (04) 463-469
- 94 Nuzzo A, Czernichow S, Hertig A. et al. Prevention and treatment of nutritional complications after bariatric surgery. Lancet Gastroenterol Hepatol 2021; 6 (03) 238-251
- 95 Shah K, Gislason H. Roux-en-Y gastric bypass reversal: a novel technique with functional reversal—case series. Obes Surg 2020; 30 (04) 1589-1595
- 96 Orlandini B, Gallo C, Boškoski I, Bove V, Costamagna G. Procedures and devices for bariatric and metabolic endoscopy. Ther Adv Gastrointest Endosc 2020; 13: 2631774520925647
- 97 Bazerbachi F, Vargas EJ, Rizk M. et al. Intragastric balloon placement induces significant metabolic and histologic improvement in patients with nonalcoholic steatohepatitis. Clin Gastroenterol Hepatol 2021; 19 (01) 146-154.e4
- 98 Lee YM, Low HC, Lim LG. et al. Intragastric balloon significantly improves nonalcoholic fatty liver disease activity score in obese patients with nonalcoholic steatohepatitis: a pilot study. Gastrointest Endosc 2012; 76 (04) 756-760
- 99 Salomone F, Sharaiha RZ, Boškoski I. Endoscopic bariatric and metabolic therapies for non-alcoholic fatty liver disease: evidence and perspectives. Liver Int 2020; 40 (06) 1262-1268