Digestive Diseases and Sciences, Vol. 49, No. 10 (October 2004), pp. 1563–1568 ( C  2004) CASE REPORT Hepatic Decompensation After Gastric Bypass Surgery for Severe Obesity SCOTT J. COTLER, MD,* JOSEPH M. VITELLO, MD,† GRACE GUZMAN, MD,‡ GIULIANO TESTA, MD,§ ENRICO BENEDETTI, MD,§ and THOMAS J. LAYDEN, MD* KEY WORDS: gastric bypass; obesity; nonalcoholic fatty liver disease; cirrhosis; hepatic decompensation. Obesity is a pervasive and growing problem in the United States. A Centers for Disease Control and Prevention sur- vey conducted in 2000 estimated that 20% of the U.S. pop- ulation was obese (body mass index [BMI], ≥30 kg/m 2 ), up from 12% in 1991 (1, 2). The prevalence of severe obe- sity (BMI, ≥40 kg/m 2 ) was 2% (1). The rise in obesity has fueled an increasing demand for bariatric surgery. Jejuno-ileal bypass was performed in the late 1960s through the early 1980s to achieve long-term weight loss (3). The procedure was abandoned due to complications including diarrhea, electrolyte abnormalities, nephrolithi- asis, cholelithiasis, metabolic bone disease, and mortality related to acute liver failure and cirrhosis (4–6). Gastric re- striction procedures such as gastric stapling, gastric band- ing, Roux Y gastric bypass (RNY-GBP), and biliopan- creatic diversion have provided means to achieve weight loss without severe metabolic complications. Roux Y gas- tric bypass is currently the most commonly performed procedure. A study of the Swedish Obese Subjects Co- hort showed that persons who underwent RNY-GBP had a greater weight loss than those who had other gastric restriction procedures or biliopancreatic diversion (7). A number of reports have described the presence of nonalcoholic fatty liver disease (NAFLD) including cir- rhosis in liver biopsy specimens obtained at the time of bariatric surgery (8–12). Hepatic decompensation was re- ported in a patient 18 months after biliopancreatic di- version (13). However, limited information is available regarding whether RNY-GBP predisposes to progressive liver injury (8). We describe three patients who developed Manuscript received May 20, 2004; accepted June 8, 2004. From the *Section of Hepatology, †Division of General Surgery, ‡Department of Pathology, and §Division of Transplantation Surgery, the University of Illinois at Chicago, Chicago, Illinois, USA. Address for reprint requests: Scott Cotler, MD, Section of Hepatology (MC 787), 840 South Wood Street, Chicago, Illinois 60612, USA; scotler@uic.edu. hepatic decompensation after RNY-GBP with an extended Roux limb for severe obesity. CASE REPORTS Surgical Technique. Three hundred thirty-two RNY-GBP with an extended Roux limb were performed at our institution for the treatment of severe obesity between January 2001 and June 2003. A 225-cm Roux limb was used based on data show- ing superior weight loss with extended versus short Roux limbs in severely obese patients (14). According to standard proce- dure, the stomach was divided, creating a 30-ml gastric pouch. The small bowel was divided approximately 4 ft distal to the lig- ament of Treitz and a 225-cm Roux limb was created. A side-to- side jejunojejunostomy was performed to reestablish intestinal continuity. The Roux limb was brought into a retrocolic and ret- rogastric position and an anastomosis was performed to the gas- tric pouch. Three of 332 patients (0.9%) presented with evidence of severe hepatic dysfunction, 7 to 17 months after operation. Patient 1. A 34-year-old woman with a BMI of 86 kg/m 2 underwent a RNY-GBP with an extended Roux limb. She pre- sented 17 months later with marked muscle wasting, weakness, fatigue, tender hepatomegaly, and anasarca. Her oral intake was limited to water and small amounts of pureed food. She had lost 128 kg since her operation, or 51% of her body weight. Laboratory data are listed in Table 1. Laboratory tests for viral and autoimmune causes of chronic liver disease were neg- ative. The patient did not drink alcohol. An abdominal ultra- sound showed ascites and splenomegaly. Steatosis with steato- hepatitis and cirrhosis were present on a transjugular liver biopsy (Figures 1a and 1b). The right atrial-wedged hepatic vein gradi- ent was elevated, at 30 mm Hg. Parenteral nutrition was provided briefly, followed by nasoen- teral feedings. There was a modest improvement in laboratory parameters (Table 1). However, the patient’s course has been complicated by persistent ascites requiring large volume para- centesis every 6 to 8 weeks, and two episodes of spontaneous bacterial peritonitis. She is awaiting liver transplantation. Patient 2. A 37-year-old woman with a history of hyperten- sion and a BMI of 61 kg/m 2 underwent a RNY-GBP with an extended Roux limb. She presented 7 months later with jaun- dice, hepatic encephalopathy, and renal insufficiency. The pa- tient had a 48-kg weight loss (27% of body weight) from the Digestive Diseases and Sciences, Vol. 49, No. 10 (October 2004) 1563 0163-2116/04/1000-1563/0 C  2004 Springer Science+Business Media, Inc.