Bariatric surgery: blessing or sometimes curse for the liver?

Introduction
Nowadays morbid obesity has become a worldwide health issue and the use of bariatric surgery undoubtedly results not only in weight reduction but also in the improvement of comorbidities. Although bariatric surgery is the optimal choice for metabolic syndrome resolution and hepatic function improvement, there is evidence that in rare cases it may lead to aggressive steatohepatitis, acute liver failure, fibrosis, and deterioration of the overall prognosis, without having fully understood the underlying pathophysiological mechanisms.

Case report
In this case report we present a 45-year-old female patient with morbid obesity, body mass index 80, who underwent long-limb Roux en Y gastric bypass (LL-RYGB) and was admitted to the emergency department with jaundice and impaired liver function laboratory tests on postoperative day 90. The examinations revealed elevated bilirubin and transaminases, with prolonged prothrombin time and low albumin levels. A liver biopsy was performed and showed active steatohepatitis. The hepatic values were gradually further impaired and the decision for surgery, in order to reverse the hepatic dysfunction, was taken. A gastrostomy in the bypassed stomach was performed and the activation of the closed biliopancreatic loop led to clinical improvement and amelioration of the prognosis.

Conclusions
Patients at high risk for hepatic failure after bariatric surgery should be better evaluated preoperatively and a tailor-made approach should be applied in order to avoid such a disastrous complication.