RAMB - Fevereiro 2017

ariatric

surgery

individuals

with

liver

cirrhosis

: A

narrative

review

ssoc

ras

2017; 63(2):190-194

191

strategy. The association between obesity and cirrhosis is

a complex situation for various reasons. Encouraging the

adoption of lifestyle changes in individuals with severe

liver diseases is difficult, and bariatric surgeries present

greater risks, with less favorable rates of morbidity and

mortality. In addition to the isolated risk of liver disease, in

patients with NAFLD and obesity, the existence of other

comorbidities, such as atherosclerotic cardiovascular disease,

diabetes, hypertension, dyslipidemia, metabolic syndrome

and chronic nephropathy, is common.

Given that the in-

tersection between obesity and NAFLD is increasingly com-

mon, a deeper understanding of these interconnections

and the possibilities of more suitable and safer management

for the proper treatment of both conditions is necessary.

bjective

To conduct a critical analysis of the existing literature on

the realization of bariatric surgery on patients with liver

cirrhosis.

ethod

A narrative review of the literature was conducted via an

online search of the MEDLINE (via Pubmed) and LILACS

(via Bireme) databases, using as keywords “bariatric surgery,”

“liver diseases” and “liver cirrhosis.” The articles were lo-

cated and reviewed, with an emphasis on those reporting

on the results of bariatric surgical techniques in individu-

als with cirrhosis and/or chronic liver diseases.

esults

and

iscussion

In subjects with mild to moderate liver disease without

cirrhosis, several studies have demonstrated the occur-

rence of regression of NAFLD after bariatric surgery, in-

cluding individuals with significant fibrosis.

10,11

This

improvement occurs not only due to weight loss, but is

also related to complex mechanisms linked to the struc-

tural and biochemical changes caused by the surgery, such

as improved insulin sensitivity, increased incretin and

adipokine activity, reduction of chronic inflammation

and decreased lipid supply in the portal system.

The main risk factors for postoperative impairment

after performing bariatric surgery in chronic liver dis-

eases are portal hypertension and hepatocytic insuffi-

ciency. In relation to severe cirrhotic liver transplant can-

didates, the choice of the most appropriate surgical

technique and the time for completion of the surgery are

relevant aspects that have not been completely established,

especially due to the scarce literature on these topics.

In patients with severe cirrhosis, perioperative mor-

bidity and mortality are higher than those observed in

the obese population. Takata et al.

assessed 15 patients

with severe liver disease (six of which were cirrhotic pa-

tients) treated with vertical sleeve gastrectomy and noted

a 33% loss of excess weight after one year, with periop-

erative complications in two (13.3%) patients, both of

whom were cirrhotic. In 26 transplant candidates submit-

ted to vertical sleeve gastrectomy assessed by Lin et al.,

perioperative complications were noted in 23.1%, with no

mortality. The average loss of excess weight after one year

was 50% and seven patients were submitted to transplant,

without complications related to the bariatric surgery.

In a retrospective study based on a database analysis

at the national level in the USA, Mosko et al.

noted

higher mortalities in clinically compensated (0.9%) and

non-compensated cirrhotic patients (16.3%) when com-

pared to individuals free of liver disease (0.3%). Further-

more, in centers with a low volume of bariatric surgery,

mortality reached 41% among individuals with decom-

pensated cirrhosis.

Incidental diagnosis of liver cirrhosis in the intraop-

erative period of bariatric surgery is not rare, and is re-

ported in 1 to 4% of cases.

16,17

Dallal et al.

analyzed a

sample in which 90% of patients with cirrhosis had been

diagnosed incidentally in the intraoperative period of the

bariatric intervention and noted that among individuals

with compensated cirrhosis (Child-Pugh A), the Roux-en-Y

gastric bypass had a mortality rate similar to the general

population, but with more episodes of transient renal

dysfunction, greater surgery time and more bleeding and

the need for blood products. Woodford et al.

studied 14

patients with intraoperative diagnosis of cirrhosis during

placement of an adjustable gastric band, without chang-

es in hepatocyte function or portal hypertension, and did

not note significant mortality or morbidity. Pestana et

al.

conducted a retrospective study comparing patients

with Child-Pugh A cirrhosis and without portal hyperten-

sion, noting similar morbidity and mortality and consid-

ering surgery as being well-tolerated and safe therapeutic

option in patients with compensated liver diseases and

mild portal hypertension.

In a systematic review, Lazzati et al.

found a 66%

loss of excess weight within two years, comparable to that

found in the general population. Vertical sleeve gastrec-

tomy was the procedure conducted the most, and peri-

operative mortality was similar to that in the general

population. However, the morbidity rate, in particular

the frequency of reoperations, and the mortality rate in

the first year were higher. The heterogeneity of the stud-

ies and the small number of individuals analyzed, even

after the compilation of data, have been identified as