Cirrhosis following single anastomosis duodeno-ileal switch: A case report

INTRODUCTION: Single anastomosis duodeno-ileal switch (SADI-S) involves a single, loop duodeno-ileal anastomosis with omission of the traditional Roux-en-Y distal ileo-ileal anastomosis. Not much has been published on the complications of SADI-S. PRESENTATION OF CASE: The patient is a 40 year-old male who underwent robot-assisted SADI-S three years prior. At the time of surgery, his body mass index (BMI) was 69 kg/m(2). His BMI was 31 kg/m(2) at the time of presentation. Computed tomography of the abdomen and pelvis showed a liver with a nodular appearance and moderate ascites throughout the abdomen and above the liver. Liver function showed AST 73 U/L, ALT 63 U/L, alkaline phosphatase 128 U/L, bilirubin 1.0 mg/dL, and albumin 2.8 g/dL. He underwent diagnostic and therapeutic paracentesis with removal of 6L of fluid that was negative for infection or malignant cells. Esophagogastroduodenoscopy showed grade I esophageal varices and diffuse mild gastritis. DISCUSSION: Mild hepatic dysfunction is common after biliopancreatic diversion and usually manifests as a temporary rise in liver enzymes that peak several months after surgery and normalize by one year. Cirrhosis and liver failure are rare sequelae that may develop at any time after surgery. Potential mechanisms include the absorption of hepatotoxic compounds from the bypassed small intestine in the context of bacterial overgrowth, protein malnutrition, and excessive free fatty acid mobilization causing steatosis and oxidative damage to hepatocytes. CONCLUSION: Close laboratory monitoring is important after SADI-S in order to detect worsening hepatic dysfunction, which may occur many years after the surgery in the absence of other etiologies for liver failure.