Gastroenterology

Gastroenterology

Volume 149, Issue 2, August 2015, Pages 379-388
Gastroenterology

Original Research
Full Report: Clinical—Liver
Bariatric Surgery Reduces Features of Nonalcoholic Steatohepatitis in Morbidly Obese Patients

https://doi.org/10.1053/j.gastro.2015.04.014Get rights and content

Background & Aims

The effects of bariatric surgery in patients with nonalcoholic fatty liver disease (NASH) are not well established. We performed a prospective study to determine the biological and clinical effects of bariatric surgery in patients with NASH.

Methods

From May 1994 through May 2013, one hundred and nine morbidly obese patients with biopsy-proven NASH underwent bariatric surgery at the University Hospital of Lille, France (the Lille Bariatric Cohort). Clinical, biological, and histologic data were collected before and 1 year after surgery.

Results

One year after surgery, NASH had disappeared from 85% of the patients (95% confidence interval [CI]: 75.8%−92.2%). Compared with before surgery, patients had significant reductions in mean ± SD body mass index (BMI, from 49.3 ± 8.2 to 37.4 ± 7) and level of alanine aminotransferase (from 52.1 ± 25.7 IU/L to 25.1 ± 20 IU/L); mean levels of γ-glutamyltransferases were reduced from 51 IU/L before surgery (interquartile range [IQR], 34−87 IU/L) to 23 IU/L afterward (IQR, 14−33 IU/L) and mean insulin resistance index values were reduced from 3.6 ± 0.5 to 2.9 ± 0.5 (P < .01 for each comparison). NASH disappeared from a higher proportion of patients with mild NASH before surgery (94%) than severe NASH (70%) (P < .05) according to Brunt score. In histologic analysis, steatosis was detected in 60% of the tissue before surgery (IQR, 40%−80%) but only 10% 1 year after surgery (IQR, 2.5%−21.3%); the mean nonalcoholic fatty liver disease score was reduced from 5 (IQR, 4−5) to 1 (IQR, 1−2) (each P < .001). Hepatocellular ballooning was reduced in 84.2% of samples (n = 69; 95% CI: 74.4−91.3) and lobular inflammation in 67.1% (n = 55; 95% CI: 55.8−77.1). According to Metavir scores, fibrosis was reduced in 33.8% of patients (95% CI: 23.6%−45.2%). Patients whose NASH persisted 1 year after surgery (n = 12) had lost significantly less weight (change in BMI, 9.1 ± 1.5) than those without NASH (change in BMI, 12.3 ± 0.6) (P = .005). Patients who underwent laparoscopic gastric banding lost less weight (change in BMI, 6.4 ± 0.7) than those who underwent gastric bypass (change in BMI, 14.0 ± 0.5) (P < .0001), and a higher proportion had persistent NASH (30.4% vs 7.6% of those with gastric bypass; P = .015).

Conclusions

Bariatric surgery induced the disappearance of NASH from nearly 85% of patients and reduced the pathologic features of the disease after 1 year of follow-up. It could be a therapeutic option for appropriate morbidly obese patients with NASH who do not respond to lifestyle modifications. More studies are needed to determine the long-term effects of bariatric surgery in morbidly obese patients with NASH.

Section snippets

Outcomes

The primary outcome was the disappearance of NASH. The secondary outcomes were the changes between baseline and 1 year in the NAFLD activity score and in individual scores for hepatocellular ballooning, lobular and portal inflammation, steatosis, and fibrosis. Other outcomes were the changes between baseline and 1 year in clinical and biological parameters: BMI, alanine aminotransferase (ALT), γ-glutamyltransferase (GGT), serum triglycerides, total cholesterol, fasting blood glucose and fasting

Characteristics of Patients Before Bariatric Surgery

Histologic NASH was diagnosed in 115 of 1489 (7.7%) cases. Among NASH patients, 109 were included and 6 excluded due to poor quality of the liver biopsy (flow chart, Figure 1). Surgical procedures in 109 NASH patients included 70 (64.2%) gastric bypasses, 32 (29.4%) gastric bands, 6 (5.5%) sleeve gastrectomies, and 1 (0.9%) biliointestinal bypass.

The characteristics of the population are summarized in Table 1. A description of the cohort has also been presented in relation to the severity of

Discussion

This prospective study using a planned program of sequential liver biopsies showed that bariatric surgery induces disappearance of NASH in around 85% of cases and reduces fibrosis.

The major impact of NASH on the subsequent risk of cirrhosis emphasizes an urgent need for effective therapy to reverse NASH, an objective rarely obtained with available therapy. The limited efficacy of lifestyle therapy26 is related to the fact that the required minimal threshold of 10% weight loss9, 10 is rarely

Acknowledgments

We gratefully acknowledge Shirley Balik, Marie Clement, Aurelie Lobez, and Sarah Surmont, for their daily work on prospective data collection.

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    This article has an accompanying continuing medical education activity on page e15. Learning Objective: Upon completion of this test, successful learners will be able to discuss the diagnosis of nonalcoholic steatohepatitis, calculate the Nonalcoholic Fatty Liver Disease Fibrosis Score, and discuss the impact of bariatric surgery on the natural history of nonalcoholic steatohepatitis.

    Conflicts of interest The authors disclose no conflicts.

    Funding This work was supported by grants from the French Ministry of Health (Programme Hospitalier de Recherche Clinique) and from the Conseil Régional Nord-Pas de Calais (ARCIR Obésité et Alcool), Agence National de la Recherche (European Genomic Institute for Diabetes, E.G.I.D., ANR-10-LABX-46), and European commission (FEDER).

    Author names in bold designate shared co-first authorship.

    Authors share co-first authorship.

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