Reply: Severe Protein Malnutrition After Bariatric Surgery and Liver Failure: a Dangerous Sequence

Abstract

To the Editor: I would like to thank the Editor-in-Chief Dr. Scott Shikora for the invitation to submit this letter. I have especially enjoyed reading this letter titled Severe protein malnutrition after bariatric surgery and liver failure: a dangerous sequence, and I would like to thank the authors for their interest in our recent publication The Hardship of Recovering a Patient from Liver Failure after One Anastomosis Gastric Bypass [1]. Furthermore, we commend the authors on their systematic review on bariatric surgeryrelated liver failure. The authors highlighted that liver failure and transplantation occurred with procedures where large amounts of the small bowel were bypassed similar to what happened in this case [2]. Eilenberg et al. in their case series of post-gastric bypass patients both Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) presenting with liver dysfunction reported that dysfunction occurred at a median of 15 months. The increase in transaminases was moderate and occurred only 70% of the time with mean levels of aspartate aminotransferase (AST), alanine transaminase (ALT), and gamma-glutamyl transferase (GGT) of 32.5 U/L, 26 U/L, and 28.5 U/L, respectively. Encephalopathy also happened in 30% only of this special patient population. However, 100% had hypoalbuminemia, and 80% had impaired coagulation parameters [3]. These findings apply to our patient where AST, ALT, and alkaline phosphatase (ALP) were 65U/L, 60 U/L, and 174 U/L, respectively, keeping in mind that this patient was at another institution for around 2 weeks where she reportedly had higher transaminases and international normalized ratio (INR) level, was started on nutrition, and was given fresh frozen plasma and vitamin K before transfer. In this case and intraoperatively, the liver certainly appeared grossly normal which was not unexpected after the prolonged and intense preoperative nutrition and optimization. Thus, we did not feel the need to obtain a liver biopsy. The key step intraoperatively was to measure and document all limb lengths. We completely agree with the key points the letter highlighted. Firstly, liver failure, liver dysfunction, and malnutrition after bariatric surgery are life-threatening, should not be taken lightly, and must be managed in a timely fashion in a multidisciplinary center with the ability to perform complex revisional procedures. Secondly, standard RYGB is a safe option that behaves more like a restrictive procedure and should be considered as an option in revising malabsorptive procedures instead of reversal to normal anatomy. I am certain that as bariatric surgeons, we will be encountering more of these cases. With the rise of some procedures, like OAGB which utilizes longer limbs, becoming the third most commonly performed procedure worldwide the incidence and rate of such events might rise [4]. In both the IFSO MENAC (Middle East & North Africa chapter of IFSOInternational Federation for the Surgery of Obesity) and the IFSO worldwide surveys, OAGB surgeons reported that their most commonly performed procedure before switching to OAGB was LSG, and the majority (>50%) had never or rarely performed RYGB before. This will lead to surgeons with no experience in intestinal bypass procedures bypassing large amounts of the small bowel [5, 6]. In the end, I recommend reading a well-written publication by Nimeri titled Making sense of gastric/intestinal bypass surgeries: forget the name and remember the degree of restriction and malabsorption the surgeries provide pinpointing the key concept of the biliopancreatic limb, alimentary limb, roux limb, and common channel lengths and percentages in a various intestinal bypass procedure [7]. * Ashraf Haddad [email protected]