Bariatric Surgery in Cirrhosis: A Clinical Practice Update From the AGA

The American Gastroenterological Association (AGA) has issued a clinical practice update regarding bariatric surgery in cirrhosis, as published in Clinical Gastroenterology and Hepatology.

The AGA created 10 best practice advice statements that address key aspects of clinical management for obese patients with cirrhosis who are undergoing bariatric surgery, liver transplantation, or both (Table).

“The goal of this review is to provide guidance to clinicians caring for patients with chronic liver disease and obesity, for bariatric surgical programs evaluating patients with advanced liver fibrosis, and for liver transplant programs aiming to optimize long-term outcomes in candidates with significant obesity,” according to the AGA authors.

Although bariatric surgery is an effective obesity management strategy and improves many comorbidities, surgical risk in patients with cirrhosis is higher compared with the risk in those without. Determining the risk-to-benefit ratio in this patient population can be challenging and is further complicated by a lack of randomized controlled trials.

The authors searched the PubMed database to identify articles published from January 2000 to March 2020. They selected peer-reviewed articles that included randomized controlled trials, systematic reviews and meta-analyses, and observational studies published in English, with additional priority given to recent comparative studies.

Achieving effective, sustainable weight loss is particularly important for patients with liver disease. Among the noninvasive methods of weight management for patients with cirrhosis, behavioral therapy is challenging in clinical practice and is best achieved by a multidisciplinary team. Additionally, the most current obesity clinical practice guidelines recommend caution when considering weight-loss medications in patients with liver disease.

“Because obesity in cirrhosis is a major risk factor for complications, weight loss should be an important goal for these patients,” the AGA authors commented.

For obese patients with compensated cirrhosis who are unable to attain a desirable weight with lifestyle interventions, bariatric surgery may be considered. Bariatric surgery can achieve long-term weight loss, improve metabolic comorbidities, and diminish liver injury.

“Bariatric surgery in obese patients with compensated cirrhosis should only be performed by an experienced surgeon at a high-volume bariatric center after evaluation and management of comorbidities,” the AGA authors stated. “Assessment for clinically significant portal hypertension (CSPH) should be included in the preoperative evaluation for bariatric surgery in patients with cirrhosis.”

Survival benefit after bariatric surgery has been shown in general patient populations, but data for improved transplant-free survival in patients with cirrhosis are lacking. In addition, long-term data regarding the impact of weight loss–induced improvement in fibrosis and portal hypertension on liver-related morbidity and mortality are not available.

Preoperative assessment is advised in all bariatric surgical candidates and should include determining whether there is a history of alcohol use disorder (AUD), with ongoing assessment for alcohol use after surgery. “Potential candidates for bariatric surgery with cirrhosis warrant intensive assessment for AUD preoperatively and long-term efforts to mitigate risk for alcohol use after surgery.”

Evaluation for CSPH is advised before any elective surgical procedure in patients with cirrhosis. The practice update recommends that endoscopic bariatric therapies not be performed in patients with CSPH.

A number of endoscopic devices and procedures have shown efficacy in achieving weight loss by reducing calorie intake compared with lifestyle intervention or medical therapies. “Endoscopic bariatric procedures generally result in less weight loss than bariatric surgery but have a lower reported complication rate and shorter recovery time,” stated the authors.

All programs that offer bariatric surgical services for patients with cirrhosis should include surgical and anesthesia teams with experience in operating on patients with portal hypertension and cirrhosis, along with a medical team with experience in treating postoperative patients with cirrhosis, according to the AGA.

“The optimal bariatric surgical procedure for patients with cirrhosis is most likely a laparoscopic sleeve gastrectomy,” stated the authors. “The optimal timing is determined by the stage of liver disease. In decompensated liver disease, the only acceptable option at present is bariatric surgery concurrent with or after liver transplant.”

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program has created a set of standards that define the best practices for bariatric centers of excellence. These standards require a bariatric surgeon to meet specific training and annual center volume requirements, specialized anesthesia protocols, and a multidisciplinary team that includes registered dieticians, licensed behavioral health providers, and physical therapists.

The AGA group also recommends that bariatric care of patients with cirrhosis should include surgical and anesthesia teams with experience operating on patients with portal hypertension and cirrhosis. “A medical team with expertise in the perioperative care of patients with liver disease should optimize the management of liver-specific complications that may arise in the postoperative period,” the group stated.

Identifying safe and effective approaches to medically supervised weight loss in obese patients with cirrhosis is currently an unmet need, according to the AGA authors.

“Bariatric surgery is an effective, durable therapy for obesity and associated comorbidities, yet safe implementation in patients with cirrhosis poses unique challenges,” the AGA authors concluded. “A multidisciplinary approach at all phases of care is crucial for optimizing outcomes for obese patients with cirrhosis that aim to achieve gradual weight loss without compromise of lean muscle mass.”

Table. AGA’s Best Practice Advice Statements

Statement Number	Statement
	Because obesity in patients with cirrhosis is a major risk factor for hepatic decompensation, portal vein thrombosis, hepatocellular carcinoma, and the development of acute or chronic liver disease, weight loss should be an important therapeutic goal for these patients.
	The method and rapidity for obtaining a sustained loss of excess body fat in obese patients with cirrhosis need to be individualized and are dependent not only on the BMI but also the presence and degree of sarcopenia, edema/ascites, CSPH, whether the patient has compensated or decompensated cirrhosis, patient age, and potential candidacy for liver transplantation.
	Weight management, ideally ≥10% total body weight loss, via lifestyle modification may decrease portal hypertension and histologic progression; however, success in implementing these interventions in clinical practice and uncertainties regarding durability of this approach limit the use of this method for treatment of obese patients with cirrhosis.
	Bariatric surgery should be considered in selected patients with compensated cirrhosis to reduce risk for hepatocellular carcinoma and improve survival.
	Bariatric surgery in obese patients with cirrhosis should only be performed in those with compensated disease by an experienced surgeon at a high-volume bariatric center. Bariatric surgery in this patient population should only be performed after careful evaluation and management of extrahepatic comorbidities.
	Assessment for CSPH should be included in the preoperative evaluation for bariatric surgery in patients with cirrhosis. Pending data to validate noninvasive testing for this purpose, cross-sectional imaging, and upper endoscopy should be performed to evaluate features of CSPH.
	Bariatric surgery may be associated with significant changes in alcohol drinking habits and deleterious changes in alcohol metabolism. The consequences of alcohol consumption after bariatric surgery among patients with cirrhosis warrant intensive assessment of these candidates preoperatively and long-term efforts to mitigate risk after surgery.
	Currently approved endoscopic bariatric therapies include the intragastric balloon, a percutaneous gastric aspiration system, and endoscopic sleeve gastrectomy. Endoscopic bariatric therapies may have lower risk(s) compared with surgical approaches, although direct comparative studies to support this, as well as long-term efficacy data, are currently lacking. Endoscopic bariatric therapies should not be performed in patients with CSPH.
	Programs offering bariatric surgical services for patients with cirrhosis must include a surgical and anesthesia team with experience operating on patients with portal hypertension and cirrhosis, as well as a medical team with experience in treating a postoperative patient with cirrhosis. Potential candidacy for liver transplantation should be determined as part of the preoperative assessment of obese patients with cirrhosis.
	Because of preservation of endoscopic access to the biliary tree, gradual weight loss, and absence of malabsorption, the optimal bariatric surgical procedure for patients with cirrhosis is most likely a laparoscopic sleeve gastrectomy. The optimal timing is determined by the stage of liver disease. In decompensated liver disease, the only acceptable option at present is bariatric surgery concurrent with or after liver transplant.