Obesity Surgery

, Volume 21, Issue 11, pp 1714–1720 | Cite as

Nonalcoholic Steatohepatitis (NASH) Does Not Increase Complications After Laparoscopic Bariatric Surgery

  • Toby N. Weingarten
  • James M. Swain
  • Michael L. Kendrick
  • Michael R. Charlton
  • Brent J. Schroeder
  • Robert E. Citrowske Lee
  • Bradly J. Narr
  • Tarsila C. R. Ribeiro
  • Darrell R. Schroeder
  • Juraj SprungEmail author
Clinical Research



Advanced liver disease is associated with increased risk for postoperative complications. It is not well known whether the presence of nonalcoholic steatohepatitis (NASH) in morbidly obese patients contributes to the rate of postoperative complications. The main objective was to study the association between NASH and postoperative complications in bariatric patients.


A total of 340 contemporary sequential patients who underwent laparoscopic bariatric operations and who had intraoperative liver biopsies were studied. The rates of severe postoperative complications were compared across three patient groups—those with (1) no liver disease or with simple steatosis, (2) mild nonalcoholic NASH [steatosis with necroinflammation and mild fibrosis (stage 0–1)], and (3) advanced NASH [steatosis, necroinflammation, and more advanced fibrosis (stage ≥ 2)].


Of 340 patients, 141 (42%) had no NASH, and 151 (44%) and 48 (14%) had mild and advanced NASH, respectively. Superobesity (P = 0.037), diabetes (P < 0.001), and cerebrovascular disease (P = 0.013) had highest frequencies in patients with advanced NASH. Hypertension was highly prevalent in cohort (57%) but similarly distributed across three groups. Forty-five patients experienced at least one complication (pulmonary 4, cardiovascular 8, surgical 16, and acute kidney injury 21). The complications rate did not differ significantly across NASH categories. Median hospital stay was 3 days (IQR 2, 3), and it was not associated with NASH severity. There were no 30-day postoperative deaths.


Despite the high prevalence of NASH among morbidly obese surgical patients, this condition was not associated with increased risk for postoperative complications. Postoperative acute kidney injury was the most frequent single complications.


Anesthesia: general Surgery bariatric Complications: perioperative Nonalcoholic fatty liver disease Steatohepatitis Acute kidney injury 



We are thankful to Dr. Thomas Smyrk, associate professor of Pathology, for sharing histopathology slides and advice, Miss Ashley Nadeau (statistical programmer/analyst) for data management and statistical assistance. This work was supported by the Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.

Conflicts of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J Clin Gastroenterol. 2006;40 Suppl 1:S5–S10.PubMedGoogle Scholar
  2. 2.
    Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA. 2002;287:356–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Ribeireiro T, Swain J, Sarr M, et al. NAFLD and insulin resistance do not increase the risk of postoperative complications among patients undergoing bariatric surgery—a prospective analysis. Obes Surg. 2011;21:310–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Angulo P. Nonalcoholic fatty liver disease. N Engl J Med. 2002;346:1221–31.PubMedCrossRefGoogle Scholar
  5. 5.
    Caldwell S, Argo C. The natural history of non-alcoholic fatty liver disease. Dig Dis. 2010;28:162–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Clark JM, Diehl AM. Nonalcoholic fatty liver disease: an underrecognized cause of cryptogenic cirrhosis. JAMA. 2003;289:3000–4.PubMedCrossRefGoogle Scholar
  7. 7.
    del Olmo JA, Flor-Lorente B, Flor-Civera B, et al. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg. 2003;27:647–52.PubMedCrossRefGoogle Scholar
  8. 8.
    Garrison RN, Cryer HM, Howard DA, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg. 1984;199:648–55.PubMedCrossRefGoogle Scholar
  9. 9.
    Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132:1261–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Kooby DA, Fong Y, Suriawinata A, et al. Impact of steatosis on perioperative outcome following hepatic resection. J Gastrointest Surg. 2003;7:1034–44.PubMedCrossRefGoogle Scholar
  11. 11.
    de Meijer VE, Kalish BT, Puder M, et al. Systematic review and meta-analysis of steatosis as a risk factor in major hepatic resection. Br J Surg. 97:1331–9.Google Scholar
  12. 12.
    McCormack L, Petrowsky H, Jochum W, et al. Hepatic steatosis is a risk factor for postoperative complications after major hepatectomy: a matched case–control study. Ann Surg. 2007;245:923–30.PubMedCrossRefGoogle Scholar
  13. 13.
    Fernandes NF, Schweisinger WH, Hilsenbeck SG, Gross WW, Bay MK, Sirinek KR, et al. Laparoscopic cholecystectomy and cirrhosis: a case–control study of outcomes. Liver Transplantation. 2000;6:330–44.CrossRefGoogle Scholar
  14. 14.
    Belghiti J, Hiramatsu K, Benoist S, et al. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection. J Am Coll Surg. 2000;191:38–46.PubMedCrossRefGoogle Scholar
  15. 15.
    Ji W, Li LT, Wang ZM, et al. A randomized controlled trial of laparoscopic versus open cholecystectomy in patients with cirrhotic portal hypertension. World J Gastroenterol. 2005;11:2513–7.PubMedGoogle Scholar
  16. 16.
    Targher G, Bertolini L, Padovani R, et al. Prevalence of nonalcoholic fatty liver disease and its association with cardiovascular disease among type 2 diabetic patients. Diabetes Care. 2007;30:1212–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Weingarten TN, Flores AS, McKenzie JA, et al. Obstructive sleep apnoea and perioperative complications in bariatric patients. Br J Anaesth. 2011;106:131–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Hosking MP, Warner MA, Lobdell CM, et al. Outcomes of surgery in patients 90 years of age and older. JAMA. 1989;261:1909–15.PubMedCrossRefGoogle Scholar
  19. 19.
    Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11:R31.PubMedCrossRefGoogle Scholar
  20. 20.
    Brunt EM, Janney CG, Di Bisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. Am J Gastroenterol. 1999;94:2467–74.PubMedCrossRefGoogle Scholar
  21. 21.
    Castillo J, Fabrega E, Escalante CF, et al. Liver transplantation in a case of steatohepatitis and subacute hepatic failure after biliopancreatic diversion for morbid obesity. Obes Surg. 2001;11:640–2.PubMedCrossRefGoogle Scholar
  22. 22.
    Grimm IS, Schindler W, Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol. 1992;87:775–9.PubMedGoogle Scholar
  23. 23.
    Thakar CV, Kharat V, Blanck S, et al. Acute kidney injury after gastric bypass surgery. Clin J Am Soc Nephrol. 2007;2:426–30.PubMedCrossRefGoogle Scholar
  24. 24.
    Borthwick E, Ferguson A. Perioperative acute kidney injury: risk factors, recognition, management, and outcomes. BMJ. 2010;341:c3365.PubMedCrossRefGoogle Scholar
  25. 25.
    Hong S, Youn YN, Yoo KJ. Metabolic syndrome as a risk factor for postoperative kidney injury after off-pump coronary artery bypass surgery. Circ J. 2010;74:1121–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Kheterpal S, Tremper KK, Englesbe MJ, et al. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology. 2007;107:892–902.PubMedCrossRefGoogle Scholar
  27. 27.
    Abassi Z, Bishara B, Karram T, et al. Adverse effects of pneumoperitoneum on renal function: involvement of the endothelin and nitric oxide systems. Am J Physiol Regul Integr Comp Physiol. 2008;294:R842–50.PubMedCrossRefGoogle Scholar
  28. 28.
    Abuelo JG. Normotensive ischemic acute renal failure. N Engl J Med. 2007;357:797–805.PubMedCrossRefGoogle Scholar
  29. 29.
    Comfere T, Sprung J, Kumar MM, et al. Angiotensin system inhibitors in a general surgical population. Anesth Analg. 2005;100:636–44.PubMedCrossRefGoogle Scholar
  30. 30.
    Feldman HI, Kinman JL, Berlin JA, et al. Parenteral ketorolac: the risk for acute renal failure. Ann Intern Med. 1997;126:193–9.PubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2011

Authors and Affiliations

  • Toby N. Weingarten
    • 1
  • James M. Swain
    • 2
  • Michael L. Kendrick
    • 2
  • Michael R. Charlton
    • 3
  • Brent J. Schroeder
    • 1
  • Robert E. Citrowske Lee
    • 1
  • Bradly J. Narr
    • 1
  • Tarsila C. R. Ribeiro
    • 5
  • Darrell R. Schroeder
    • 4
  • Juraj Sprung
    • 1
    Email author
  1. 1.Department of Anesthesiology, College of MedicineMayo ClinicRochesterUSA
  2. 2.Department of Surgery, College of MedicineMayo ClinicRochesterUSA
  3. 3.Department Gastroenterology and Hepatology, College of MedicineMayo ClinicRochesterUSA
  4. 4.Department of Health Sciences Research Division of Biostatistics, College of MedicineMayo ClinicRochesterUSA
  5. 5.Department of Medicine, Gastroenterology Center, University Hospital of the Federal University of Juiz de ForaJuiz de ForaBrazil

Personalised recommendations