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Ostojic A, Mahmud N, Reddy KR. Surgical risk stratification in patients with cirrhosis. Hepatol Int 2024:10.1007/s12072-024-10644-y. [PMID: 38472607 DOI: 10.1007/s12072-024-10644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.
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Affiliation(s)
- Ana Ostojic
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA.
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Singhal R, Cardoso VR, Wiggins T, Rajeev Y, Ludwig C, Gkoutos GV, Hanif W, Mahawar K. Safety outcomes of bariatric surgery in patients with advanced organ disease: the ONWARD study: a prospective cohort study. Int J Surg 2024; 110:95-110. [PMID: 37800588 PMCID: PMC10793784 DOI: 10.1097/js9.0000000000000781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/10/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Increasing numbers of patients with advanced organ disease are being considered for bariatric and metabolic surgery (BMS). There is no prospective study on the safety of BMS in these patients. This study aimed to capture outcomes for patients with advanced cardiac, renal, or liver disease undergoing BMS. MATERIALS AND METHODS This was a multinational, prospective cohort study on the safety of elective BMS in adults (≥18 years) with advanced disease of the heart, liver, or kidney. RESULTS Data on 177 patients with advanced diseases of heart, liver, or kidney were submitted by 75 centres in 33 countries. Mean age and BMI was 48.56±11.23 years and 45.55±7.35 kg/m 2 , respectively. Laparoscopic sleeve gastrectomy was performed in 124 patients (70%). The 30-day morbidity and mortality were 15.9% ( n =28) and 1.1% ( n =2), respectively. Thirty-day morbidity was 16.4%, 11.7%, 20.5%, and 50.0% in patients with advanced heart ( n =11/61), liver ( n =8/68), kidney ( n =9/44), and multi-organ disease ( n =2/4), respectively. Cardiac patients with left ventricular ejection fraction less than or equal to 35% and New York Heart Association classification 3 or 4, liver patients with model for end-stage liver disease score greater than or equal to 12, and patients with advanced renal disease not on dialysis were at increased risk of complications. Comparison with a propensity score-matched cohort found advanced disease of the heart, liver, or kidney to be significantly associated with higher 30-day morbidity. CONCLUSION Patients with advanced organ disease are at increased risk of 30-day morbidity following BMS. This prospective study quantifies that risk and identifies patients at the highest risk.
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Affiliation(s)
- Rishi Singhal
- Upper GI Unit
- Birmingham City University, 15 Bartholomew Row
| | - Victor Roth Cardoso
- Institute of Cancer and Genomic Sciences, University of Birmingham
- Health Data Research UK Midlands
| | | | - Yashasvi Rajeev
- Paediatrics Department, Hillingdon Hospital, Hillingdon Hospitals NHS Foundation Trust, London
| | | | - Georgios V. Gkoutos
- Institute of Cancer and Genomic Sciences, University of Birmingham
- Health Data Research UK Midlands
- NIHR Experimental Cancer Medicine Centre
- NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham
| | - Wasim Hanif
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust
- Birmingham City University, 15 Bartholomew Row
| | - Kamal Mahawar
- Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK
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Orekondy N, Lee D, Malik R. PRO: Should patients with nonalcoholic steatohepatitis fibrosis undergo bariatric surgery as primary treatment? Clin Liver Dis (Hoboken) 2022; 20:5-8. [PMID: 35899236 PMCID: PMC9306429 DOI: 10.1002/cld.1224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/09/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Nayantara Orekondy
- Liver CenterDivision of Gastroenterology and HepatologyTufts Medical CenterBostonMassachusettsUSA
| | - David Lee
- Division of Gastroenterology & HepatologyUniversity of Maryland Medical CenterBaltimoreMarylandUSA
| | - Raza Malik
- Liver CenterDivision of Gastroenterology and HepatologyTufts Medical CenterBostonMassachusettsUSA
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Cusi K, Isaacs S, Barb D, Basu R, Caprio S, Garvey WT, Kashyap S, Mechanick JI, Mouzaki M, Nadolsky K, Rinella ME, Vos MB, Younossi Z. American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: Co-Sponsored by the American Association for the Study of Liver Diseases (AASLD). Endocr Pract 2022; 28:528-62. [PMID: 35569886 DOI: 10.1016/j.eprac.2022.03.010] [Citation(s) in RCA: 285] [Impact Index Per Article: 142.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations regarding the diagnosis and management of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) to endocrinologists, primary care clinicians, health care professionals, and other stakeholders. METHODS The American Association of Clinical Endocrinology conducted literature searches for relevant articles published from January 1, 2010, to November 15, 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RECOMMENDATION SUMMARY This guideline includes 34 evidence-based clinical practice recommendations for the diagnosis and management of persons with NAFLD and/or NASH and contains 385 citations that inform the evidence base. CONCLUSION NAFLD is a major public health problem that will only worsen in the future, as it is closely linked to the epidemics of obesity and type 2 diabetes mellitus. Given this link, endocrinologists and primary care physicians are in an ideal position to identify persons at risk on to prevent the development of cirrhosis and comorbidities. While no U.S. Food and Drug Administration-approved medications to treat NAFLD are currently available, management can include lifestyle changes that promote an energy deficit leading to weight loss; consideration of weight loss medications, particularly glucagon-like peptide-1 receptor agonists; and bariatric surgery, for persons who have obesity, as well as some diabetes medications, such as pioglitazone and glucagon-like peptide-1 receptor agonists, for those with type 2 diabetes mellitus and NASH. Management should also promote cardiometabolic health and reduce the increased cardiovascular risk associated with this complex disease.
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Pomenti S, Mehta S, Guo A, Wattacheril J. Bariatric Surgery in the Peritransplant Period. Clin Liver Dis (Hoboken) 2021; 17:282-291. [PMID: 33968390 PMCID: PMC8087907 DOI: 10.1002/cld.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver DiseasesDepartment of MedicineColumbia University Irving Medical Center
| | - Sanket Mehta
- Columbia University Vagelos College of Physicians and Surgeons
| | - Averill Guo
- Department of MedicineColumbia University Irving Medical CenterNew YorkNY
| | - Julia Wattacheril
- Division of Digestive and Liver DiseasesDepartment of MedicineColumbia University Irving Medical Center
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Patton H, Heimbach J, McCullough A. AGA Clinical Practice Update on Bariatric Surgery in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2021; 19:436-45. [PMID: 33393473 DOI: 10.1016/j.cgh.2020.10.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
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Alkharaiji M, Anyanwagu U, Crabtree T, Idris I. The metabolic and liver-related outcomes of bariatric surgery in adult patients with insulin-treated type 2 diabetes and nonalcoholic fatty liver disease at high risk of liver fibrosis. Surg Obes Relat Dis 2020; 17:792-798. [PMID: 33676874 DOI: 10.1016/j.soard.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/23/2020] [Accepted: 11/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease, with a prevalence estimated to between 20% and 30% of the general population and approximately 70% of stage 2 obese people with type 2 diabetes (T2D) with normal liver enzymes. OBJECTIVES To investigate the metabolic and liver-related outcomes of bariatric surgery among patients with insulin-treated T2D and NAFLD who are at high risk of liver fibrosis. SETTING More than 600 locations within the United Kingdom. METHODS The study comprises a retrospective cohort comparison of patients with NAFLD and a fibrosis 4 (Fib-4) score > 1.45 who received a bariatric intervention versus comparable patients who received no bariatric intervention. Metabolic outcomes (glycated hemoglobin [HbA1C] level, weight, body mass index [BMI], and Fib-4 score) and composite liver-related outcomes (cirrhosis, portal hypertension, liver failure, and hepatoma) were compared between groups over a period of 5 years. The outcomes were adjusted for baseline and time-varying covariates. RESULTS The study sample included 4108 patients, 45 of whom underwent bariatric surgery. The mean age at baseline was 62.4 ± 12.4 years; 43.8% of patients were female; the mean weight was 89.5 ± 20.8 kg; the mean BMI was 31.7 ± 7.6 kg/m2; and the mean HbA1C level was 68.4 ± 16.7 mmol/mol. In addition, the median Fib-4 score was 2.3 (interquartile range, 1.7-4.2). During the 5 years during which follow-up outcomes were recorded, the weight and BMI reductions were significantly lowered compared with baseline in the bariatric surgery group. Similarly, the HbA1C levels were lower in the bariatric surgery group, with statistically significant differences observed in the first and second postintervention years (bariatric surgery versus non-bariatric surgery patient levels at 1 year, 63.1 mmol/mol versus 68.1 mmol/mol, respectively [P = .042], and at 2 years, 62.7 mmol/mol versus 68.1 mmol/mol, respectively [P = .028]). No significant difference was observed between groups in the proportion of patients with liver fibrosis or the likelihood of developing composite liver disease during the follow-up period (bariatric surgery group, 8.9%; non-bariatric surgery group, 4.7%; X2 = 1.75; P = .18). CONCLUSION Bariatric surgery amongst patients with insulin-treated T2D with NAFLD who were at high risk of liver fibrosis was associated with significant improvements in metabolic outcomes. No significant adverse effects were observed with regards to liver-related outcomes.
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Affiliation(s)
- Mohammed Alkharaiji
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Derby, United Kingdom; Faculty of Public Health, College of Health Sciences, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Uchenna Anyanwagu
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Derby, United Kingdom
| | - Thomas Crabtree
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Derby, United Kingdom
| | - Iskandar Idris
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Derby, United Kingdom.
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Are VS, Knapp SM, Banerjee A, Shamseddeen H, Ghabril M, Orman E, Patidar KR, Chalasani N, Desai AP. Improving Outcomes of Bariatric Surgery in Patients With Cirrhosis in the United States: A Nationwide Assessment. Am J Gastroenterol 2020; 115:1849-1856. [PMID: 33156104 PMCID: PMC8021461 DOI: 10.14309/ajg.0000000000000911] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION With increasing burden of obesity and liver disease in the United States, a better understanding of bariatric surgery in context of cirrhosis is needed. We described trends of hospital-based outcomes of bariatric surgery among cirrhotics and determined effect of volume status and type of surgery on these outcomes. METHODS In this population-based study, admissions for bariatric surgery were extracted from the National Inpatient Sample using International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes from 2004 to 2016 and grouped by cirrhosis status, type of bariatric surgery, and center volume. In-hospital mortality, complications, and their trends were compared between these groups using weighted counts, odds ratios [ORs], and logistic regression. RESULTS Among 1,679,828 admissions for bariatric surgery, 9,802 (0.58%) had cirrhosis. Cirrhosis admissions were more likely to be in white men, had higher Elixhauser Index, and higher in-hospital complications rates including death (1.81% vs 0.17%), acute kidney injury (4.5% vs 1.2%), bleeding (2.9% vs 1.1%), and operative complications (2% vs 0.6%) (P < 0.001 for all) compared to those without cirrhosis. Overtime, restrictive surgeries have grown in number (12%-71%) and complications rates have trended down in both groups. Cirrhotics undergoing bariatric surgery at low-volume centers (<50 procedures per year) and nonrestrictive surgery had a higher inpatient mortality rate (adjusted OR 4.50, 95% confidence interval 3.14-6.45, adjusted OR 4.00, 95% confidence interval 2.68-5.97, respectively). DISCUSSION Contemporary data indicate that among admissions for bariatric surgery, there is a shift to restrictive-type surgeries with an improvement in-hospital complications and mortality. However, patients with cirrhosis especially those at low-volume centers have significantly higher risk of worse outcomes (see Visual abstract, Supplementary Digital Content, http://links.lww.com/AJG/B648).
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Affiliation(s)
- Vijay S. Are
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon M. Knapp
- University of Arizona Health Sciences and Bio5 Institute, Tucson, Arizona, USA
| | - Ambar Banerjee
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Aminian A. Bariatric procedure selection in patients with type 2 diabetes: choice between Roux-en-Y gastric bypass or sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:332-9. [DOI: 10.1016/j.soard.2019.11.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/10/2019] [Accepted: 11/02/2019] [Indexed: 12/24/2022]
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Rogers AM. Comment on: Impact of a preoperative low-calorie diet on liver histology in patients with fatty liver disease undergoing bariatric surgery. Surg Obes Relat Dis 2019; 15:e33-e34. [PMID: 31653569 DOI: 10.1016/j.soard.2019.09.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/12/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Ann M Rogers
- The Pennsylvania State University, College of Medicine
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Polyzos SA, Kountouras J, Mantzoros CS. Obesity and nonalcoholic fatty liver disease: From pathophysiology to therapeutics. Metabolism 2019; 92:82-97. [PMID: 30502373 DOI: 10.1016/j.metabol.2018.11.014] [Citation(s) in RCA: 599] [Impact Index Per Article: 119.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/24/2018] [Accepted: 11/24/2018] [Indexed: 02/06/2023]
Abstract
The obesity epidemic is closely associated with the rising prevalence and severity of nonalcoholic fatty liver disease (NAFLD): obesity has been linked not only with simple steatosis (SS), but also with advanced disease, i.e., nonalcoholic steatohepatitis (NASH), NASH-related cirrhosis and hepatocellular carcinoma. As a consequence, apart from increasing all-cause mortality, obesity seems to increase liver-specific mortality in NAFLD patients. Given the lack of approved pharmacological interventions for NAFLD, targeting obesity is a rational option for its management. As the first step, lifestyle modification (diet and exercise) is recommended, although it is difficult to achieve and sustain. When the first step fails, adding pharmacotherapy is recommended. Several anti-obesity medications have been investigated in NAFLD (e.g., orlistat, glucagon-like peptide-1 analogs), other anti-obesity medications have not been investigated (e.g., lorcaserin, phentermine hydrochloric, phentermine/topiramate and naltrexone/bupropion), whereas some medications with weight-lowering efficacy have not been approved for obesity (e.g., sodium-glucose cotransporter-2 inhibitors, farnesoid X receptor ligands). If the combination of lifestyle modification and pharmacotherapy also fails, then bariatric surgery should be considered in selected morbidly obese individuals. This review summarizes best evidence linking obesity with NAFLD and presents related therapeutic options.
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Affiliation(s)
- Stergios A Polyzos
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Jannis Kountouras
- Second Medical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
| | - Christos S Mantzoros
- Section of Endocrinology, VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Seth A Waits
- Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Kyle H Sheetz
- Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Amir A Ghaferi
- Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor
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Fitzpatrick E, Dhawan A. Childhood and Adolescent Nonalcoholic Fatty Liver Disease: Is It Different from Adults? J Clin Exp Hepatol 2019; 9:716-722. [PMID: 31889753 PMCID: PMC6926239 DOI: 10.1016/j.jceh.2019.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Paediatric nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in childhood and adolescence. Although the condition is similar in many ways to NAFLD in adults, there are important differences in predisposition, presentation, differential diagnosis and potentially also in optimal management. Antenatal and early childhood exposures and the particular vulnerabilities to environmental influences in a growing child, present unique opportunities for intervention and modification of risk. The prevalence of significant fibrosis on biopsy in preadolescent children in the context of NAFLD should not be ignored, but the relevance of this fibrosis to long-term outcome is as yet unknown. The approach to children and adolescents with suspected NAFLD needs to include an assessment of risk factors in addition to exclusion of alternative or coexisting liver diseases. Liver biopsy is indicated for younger children and for those without clear predisposing factors leading to metabolic syndrome, also for those in whom significant fibrosis is suspected. The histology in children and adolescents differs from adults in whom type 2 NAFLD may be more prevalent, which is associated in turn with more significant fibrosis. Management in children and adolescents needs to focus on lifestyle intervention, which when weight loss is achieved, demonstrates excellent results in terms of resolution of disease. Appropriate intervention in childhood and adolescence may prove instrumental in avoiding the need for later transplantation while also decreasing all-cause mortality in these at-risk individuals.
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Affiliation(s)
| | - Anil Dhawan
- Address for correspondence: Anil Dhawan, Professor, Paediatric Liver, GI and Nutrition Centre, King's College Hospital, Denmark Hill, London, SE5 9PJ, UK.
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Goh GBB, Schauer PR, McCullough AJ. Considerations for bariatric surgery in patients with cirrhosis. World J Gastroenterol 2018; 24:3112-3119. [PMID: 30065557 PMCID: PMC6064959 DOI: 10.3748/wjg.v24.i28.3112] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/17/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
With the ever increasing global obesity pandemic, clinical burden from obesity related complications are anticipated in parallel. Bariatric surgery, a treatment approved for weight loss in morbidly obese patients, has reported to be associated with good outcomes, such as reversal of type two diabetes mellitus and reducing all-cause mortality on a long term basis. However, complications from bariatric surgery have similarly been reported. In particular, with the onslaught of non-alcoholic fatty liver disease (NAFLD) epidemic, in associated with obesity and metabolic syndrome, there is increasing prevalence of NAFLD related liver cirrhosis, which potentially connotes more risk of specific complications for surgery. Bariatric surgeons may encounter, either expectedly or unexpectedly, patients with non-alcoholic steatohepatitis (NASH) and NASH related cirrhosis more frequently. As such, the issues and considerations surrounding their medical care/surgery warrant careful deliberation to ensure the best outcomes. These considerations include severity of cirrhosis, liver synthetic function, portal hypertension and the impact of surgical factors. This review explores these considerations comprehensively and emphasizes the best approach to managing cirrhotic patients in the context of bariatric surgery.
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Affiliation(s)
- George Boon-Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore 169608, Singapore
- Duke-NUS Graduate Medical School, Singapore 169608, Singapore
| | - Philip R Schauer
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Arthur J McCullough
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH 44195, United States
- Department of Pathobiology, Cleveland Clinic, Cleveland, OH 44195, United States
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Minhem MA, Sarkis SF, Safadi BY, Fares SA, Alami RS. Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program. Obes Surg 2018; 28:2844-51. [PMID: 29696572 DOI: 10.1007/s11695-018-3259-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Chronic liver disease is prevalent in obese patients presenting for bariatric surgery and is associated with increased postoperative morbidity and mortality (M&M). There are no comparative studies on the safety of different types of bariatric operations in this subset of patients. OBJECTIVE The aim of this study is to compare the 30-day postoperative M&M between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-Y-gastric bypass (LRYGB) in the subset of patients with a model of end-stage liver disease (MELD) score ≥ 8. METHODS Data for LSG and LRYGB were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2012 and 2013. MELD score was calculated using serum creatinine, bilirubin, INR, and sodium. Postoperative M&M were assessed in patients with a score ≥ 8 and compared for the type of operation. This was followed by analysis for MELD subcategories. Multiple logistic regression was performed to adjust for confounders. RESULTS Out of 34,169, 9.8% of cases had MELD ≥ 8 and were included. Primary endpoint, 30-day M&M, was significantly lower post-LSG (9.5%) compared to LRYGB (14.7%); [AOR = 0.66(0.53, 0.83)]. Superficial wound infection, prolonged hospital stay, and unplanned readmission were more common in LRYGB. M&M post-LRYGB (30.6%) was significantly higher than LSG (15.7%) among MELD15-19 subgroup analysis. CONCLUSION LRYGB is associated with a higher postoperative risk than LSG in patients with MELD ≥ 8. The difference in postoperative complications between procedures was magnified with higher MELD. This suggests that LSG might be a safer option in morbidly obese patients with higher MELD scores, especially above 15.
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Haskins IN, Chang J, Nor Hanipah Z, Singh T, Mehta N, McCullough AJ, Brethauer SA, Schauer PR, Aminian A. Patients with clinically metabolically healthy obesity are not necessarily healthy subclinically: further support for bariatric surgery in patients without metabolic disease? Surg Obes Relat Dis 2018. [DOI: 10.1016/j.soard.2017.11.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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