Cirrhosis as a casual finding in a bariatric surgery

These findings should be verified in randomized controlled trials to obtain further evidence for decision-making on the most appropriate bariatric procedure for metabolically sick patients.

Here is a case in which it was decided to perform a sleeve gastrectomy on a patient with a unknown cirrhotic liver found intraoperatively.

Case

A 57 year old female patient with a previous history of T2DM and dyslipidemia suffered from morbid obesity with a BMI of 42 Kg/m2 and weighed 94 Kg.

An upper endoscopy, an esophagogastricoduodenal transit and an abdominal ultrasound were performed as a preoperative study highlighting only hepatic steatosis with an acalculous gold bladder. The rest of tests were conducted with normal limits.

Treatment

The patient is placed in the supine position with open legs. A total of 5 trocars were used. The classic configuration is a 12mm port in the supra umbilical position for a 30º scope, two additional 12-mm ports at each flank to serve as the working channel for the leading surgeon, two 5mm ports located at the epigastrium for retraction of the liver, and a final more lateral port at the left flank to perform traction of the omentum and the stomach.

At the beginning of the surgery we objectified a liver with major macroscopic signs of advanced cirrhosis. For this reason it was decided to perform a sleeve gastrectomy and a liver biopsy in the same surgical procedure.

The rest of the trocars were placed and a retractor clamp was carefully placed to separate the liver. We performed a gastric sleeve according to our standard technique. The first manouver is to create an inferior landmark for the section of the major omentum.

The stomach should be individualized from the retroperitoneal organs to achieve correct exposure during the gastrectomy.  The section should begin 5cm from the pylorus.

Then we continue with the dissection of the major curvature. The LigaSure is used for secure section close to the gastric wall. The assistant should perform traction from the omentum. Gradually release of the greater curvature is completed ensuring good hemostasis using the Ligasure, which is very important in this case for a cirrhotic patient, thus avoiding potential complications.

We then reach the superior landmark. This maneuver must be carefully performed to avoid bleeding. We must be careful with the spleen and the short vessels. We want  to expose the cardia and the left crus.  By means of meticulous dissection, we finally completed the release in the cardia to perform gastrectomy later.

To calibrate the gastrectomy we use a 35 French bougie to control the diameter of the remaining stomach. Subsequent stenosis must be avoided, and correct weight loss must be ensured.

During the different maneuvers and changes of position care must be taken not to injure the liver.

The next step is the Gastric transaction. The first mechanical suture used is purple in this case.  The assistant surgeon is crucial for this step, as correct traction exposes the stomach and enables the leading surgeon to prevent an angled or rotated gastrectomy. Placing the mechanical suture too close to the bougie should be avoided to prevent bleeding, stenosis and leakage.

Finally we continue with the section of the final part of the stomach. It must be performed 1cm from the angle of His as vascularization at this height is poor. With this strategy anastomotic leaks are prevented.

We were finally able to see the complete tube, which had a good size and no rotations. To end the surgery we made separate knots between the stapler line junction and the sectioned omentum. We did this to prevent complications such as bleeding and rotation.

Given the suspicion of unknown cirrhosis, we proceeded to perform a liver biopsy to confirm the diagnosis. It is important to ensure good hemostasis after puncture to avoid bleeding.

Outcome

The surgery took 90 minutes. The patient started oral intake 24 hours after the surgery and left hospital on the 2nd postoperative day.

The liver pathology results show chronic liver disease with advanced-stage cirrhosis, as well as signs of moderate steatosis and steatohepatitis. The patient is being currently monitored by the hepatology department.

The patient has had a successful outcome 1 month after surgery.