Flipping the Switch

Abstract

Bariatric surgery is an increasingly popular approach for effecting significant weight reduction in obese patients with comorbidities, including hepatic steatosis. Here we report a novel case of advanced nonalcoholic steatohepatitis (NASH) fibrosis with portal hypertension after duodenal switch bariatric surgery, resolving histopathologically with partial reversal of the malabsorptive procedure.1 BPD/DS, biliopancreatic diversion with duodenal switch; CPT, Childs-Pugh-Turcotte; DM, diabetes mellitus; JIB, jejunoileal bypass; MELD, model for endstage liver disease; NASH, nonalcoholic steatohepatitis. A 50-year-old male with a history of morbid obesity and no alcohol prior to presentation presented to the Hepatology Clinic with cirrhosis secondary to NASH. Three years prior, the patient underwent biliopancreatic diversion with duodenal switch (BPD/DS). Two years postsurgery he had lost 188 pounds with resolution of hypertension and diabetes mellitus (DM). At presentation the patient was noted to have extensive bridging fibrosis on percutaneous liver biopsy with trichrome staining (Fig. 1) complicated by portal hypertensive ascites and mild hepatic encephalopathy. Computed tomography (CT) of the abdomen noted diminished size with nodular contour of the liver and moderate ascites. His initial model for endstage liver disease (MELD) was 19 (international normalized ratio [INR] 1.50, total bilirubin 1.9 mg/dL, creatinine 1.8 mg/dL; weight = 193 lbs; body mass index [BMI] = 29.3; albumin = 3.4 gm/dL [after albumin infusions]) and he was Childs-Pugh-Turcotte (CPT) Class B. After supportive care including albumin and titration of diuretics his MELD declined to 15 (INR 1.50, total bilirubin 1.5 mg/dL, Cr 1.3 mg/dL). Successful transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites was then performed. Unfortunately, he continued to do poorly despite diuresis and nutritional support (1 month post-TIPS weight = 176 lbs; BMI = 26.8; albumin = 2.4 gm/dL). Liver Biopsy after partial reversal of duodenal switch demonstrating near total resolution of steatohepatitis and fibrosis. (Trichrome) At a MELD of 11 (INR 1.40, total bilirubin 1.1 mg/dL, creatinine 1.1 mg/dL) and CPT class B (albumin 2.0 mg/dL) the BPD/DS was partially reversed, due to protein malnutrition (weight = 149 lbs; BMI = 22.7; albumin = 2.0 gm/dL). By way of laparoscopy with conversion to open procedure, a jejunojejunostomy was created with the duodenal switch limb. A side-to-side anastomosis of the biliopancreatic limb and the alimentary limb was made at least 100 cm proximal to origination of the existing 50-cm common channel. Six months after partial reversal his ascites resolved and his MELD declined to 6 (weight = 178 lbs; BMI = 27.1; albumin = 3.6 gm/dL [with no albumin infusion support]). Open liver biopsy during ventral hernia repair with trichrome staining 6 months post-reversal of BPD/DS demonstrated mild portal inflammation with mild to moderate portal fibrosis, mirroring an overall clinical improvement (Fig. 2). An abdominal ultrasound 9 months after the improved liver biopsy noted the liver to be normal in size with increased echogenicity. Liver biopsy before duodenal switch reversal demonstrating steatohepatitis and advanced fibrosis. (Trichrome) This is a unique case of resolution of decompensated cirrhosis with histologic regression of fibrosis following partial reversal BPD/DS. BPD/DS is a restrictive/malabsorptive surgery involving a pylorus-sparing vertical sleeve gastrectomy and creation of a Roux limb and duodenoileostomy with a short common channel. BPD/DS is advocated for patients with very severe obesity (BMI ≥50 gm/m2), and has been associated with improved weight loss against historical controls.2 As with other bariatric procedures, BPD/DS improves obesity comorbidities, such as hypertension, dyslipidemia, and DM.3 Complications are well documented after BPD/DS. In general, bariatric surgery complications are proportional to the amount of excess body weight loss (EBWL), with BPD-DS being the greatest (38%).4 Adverse events include anastomotic leak/stenosis, bleeding, nutritional deficits, wound complications, and hepatic steatosis. An earlier bariatric surgery, the jejunoileal bypass (JIB), was also a popular procedure for its profound weight loss. However, it is no longer used today due to high morbidity and mortality. With JIB, up to 40% of patients developed hepatic abnormalities that could lead to cirrhosis and often persisted after surgical reversal.5 In this case, our patient underwent bariatric surgery with significant EBWL and diminished BMI but suffered intolerable hepatic dysfunction. After partial surgical reversal, both clinical and histologic improvement occurred. There have been previous reports noting hepatic dysfunction after duodenal switch; however, we found no documented histologic and clinical improvement after reversal.6