Unsuspected cirrhosis discovered during elective obesity operations

Objective: To determine the incidence and outcome of cirrhosis encountered unexpectedly during gastric bariatric operations. Design: A cohort study. Setting: A tertiary care center. Patients: One hundred twenty-five patients in whom cirrhosis was discovered during gastric bariatric operations. Cirrhosis may have been caused by severe obesity in 93 (74%) of the patients. Interventions: A questionnaire survey of bariatric surgeons worldwide, including one of us (R.E.B.). Results: One hundred twenty-six (52%) of the 243 surgeons responded to the survey. Planned bariatric operations were performed in 91 (73%) of the cases. Seventeen (14%) of the remaining cases were closed after the discovery of cirrhosis. There were no intraoperative deaths. However, the perioperative mortality rate was 4% and there were 7 late deaths, 6 due to complications of liver disease. Eleven other patients are described as alive with progressive hepatic dysfunction. The remaining 50 patients are "alive and well." The survey also included opinion questions. Regarding the appropriate operation to perform after discovering cirrhosis, 40% replied "perform liver biopsy only and close"; the remaining 60% would perform a bariatric procedure. Regarding bariatric operations that can be safely performed in patients with cirrhosis, 59% would perform banded gastroplasty, 39% would perform standard Roux-en-Y gastric bypass, 5% would perform biliopancreatic bypass, and 27% would perform none of the above. Conclusion: Although operative mortality is higher in cirrhotic vs other bariatric patients, most surveyed surgeons believe that gastric restrictive operations can be performed safely in this group of patients.