Bariatric surgery in the setting of liver cirrhosis with portal hypertension: the confection and particularities of Roux-en-Y gastric bypass in a high-risk patient

Introduction: Morbid obesity is associated with the occurrence of non-alcoholic fatty liver disease, which may progress to cirrhosis. Although weight loss is the treatment of choice, surgical management can be challenging at the stage of cirrhosis. The aim of this video report is to present the confection and the features of a Roux-en-Y gastric bypass (RYGB) in the setting of liver cirrhosis. Methods: We present the case of a 60-year-old man with a weight of 115 kg and a corresponding BMI of 38.9 kg/m2, with non-alcoholic steatohepatitis (NASH)-related liver cirrhosis. The latter was compensated (Child–Turcott–Pugh score at A6) but the patient had already undergone three esophageal variceal ligations. Portal hypertension with splenomegaly was clearly visible on preoperative workup. Results: In this video, we show how to perform RYGB in a case of liver cirrhosis, with a focus on common pitfalls. The main risks remain perioperative bleeding due to portal hypertension and impaired coagulation, as well as the decompensation of the cirrhosis. A careful preoperative nutritional and hepatological evaluation is mandatory since the perioperative risk of morbidities is higher. Conclusion: RYGB is a feasible option in selected patients with morbid obesity and cirrhosis. These patients ideally should be managed in centers having experience in bariatric surgery and hepatology.