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Bariatric Surgery Improves Histological Features of Nonalcoholic Fatty Liver Disease and Liver Fibrosis

  • 2014 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Nonalcoholic fatty liver disease (NAFLD) is prevalent in obese patients. We sought to determine the effects of bariatric surgery on the histological features of NAFLD. Two blinded pathologists graded liver biopsies done during bariatric procedures and subsequent operations in 160 patients using the Brunt classification. Data are mean ± SD. Interval between biopsies was 31 ± 26 months. Initial biopsies demonstrated steatosis 77 %, lobular inflammation 39 %, and chronic portal inflammation 56 %. Steatohepatitis was present in 27 %. Grade 2–3 fibrosis was present in 27 %, and cirrhosis was present in one patient. On post-bariatric biopsy, steatosis resolved in 75 %, lobular inflammation resolved in 75 %, chronic portal inflammation resolved in 49 %, and steatohepatitis resolved in 90 %. Fibrosis of any grade resolved in 53 % and improved in another 3 % of patients. Grade 2 fibrosis resolved in 58 %, improved in 3 %, and did not worsen in 11 %. Bridging fibrosis resolved in 29 %, improved in 29 %, and did not worsen in 29 %. Bariatric surgery is associated with resolution of steatosis or steatohepatitis in the majority of patients. More importantly, grade 2 or 3 (bridging) fibrosis is resolved or improved in 60 % of patients. Bariatric surgery should be considered as a treatment of NAFLD in severely obese patients.

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Authors and Affiliations

  1. Department of Surgery, University of South Florida, Tampa General Hospital (TGH), Tampa, FL, USA

    Andrew A. Taitano, John Paul Gonzalvo & Michel M. Murr

  2. Department of Pathology, University of South Florida, Tampa General Hospital (TGH), Tampa, FL, USA

    Michael Markow, Jon E. Finan & Donald E. Wheeler

  3. TGH + USF Bariatric Center, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA

    Andrew A. Taitano, Michael Markow, Jon E. Finan, Donald E. Wheeler, John Paul Gonzalvo & Michel M. Murr

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  1. Andrew A. Taitano
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  2. Michael Markow
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Correspondence to Michel M. Murr.

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Discussant

Dr. Guilherme M. R Campos (Madison, WI):

The paper is an important contribution as it evaluated one of the larger cohorts of patients with paired liver biopsies at bariatric surgery and after significant weight loss as to study changes in liver histology for established markers of NAFLD. An important concept associated to the study is that individuals with predisposition to preferential accumulation of fat in the liver, in excess of deposits in the subcutaneous tissue or in other viscera are at higher risk for liver related diseases and other metabolic consequences. In other words, abnormal deposit of fat in the liver and the metabolic syndrome comes hand in hand, and bariatric surgery promotes loss of liver fat and improvements in liver histology and in the metabolic syndrome. This study documents the significant impact of surgically induced weight loss on specific NAFLD markers including improvement of liver fibrosis in 56 % of patients. It is important to underscore that the magnitude of histological improvements observed in this study is far greater than the observed with maximal nonoperative therapy and that till about 10 years ago liver fibrosis was considered, by most, to be an irreversible finding.

My questions to the authors are: 1. Were you able to identify any patient, surgical technique, the degree of weight loss or any other factor that correlated with improvement or worsening in the histologic markers of NAFLD and NASH?, 2. Because different bariatric surgical techniques provide for different weight loss outcomes and have different mechanisms that are independent of weight loss, some with a direct impact in liver physiology, should presence and severity of NAFLD, NASH or cirrhosis play a role in choosing a specific procedure or no procedure at all? and 3. Should a liver biopsy be considered a standard part of bariatric surgical procedures?

Closing Discussant

Dr. Taitano:

Thank you, Dr. Campos, for your comments and questions. There was no correlation between weight loss and improvement or worsening of histologic features. Patients who started at a higher BMI had an increased prevalence of steatosis and a higher frequency of grade 3 steatosis, but the degree of weight loss did not correlate with improvement or worsening of histologic features, and in particular it did not predict improvement or worsening of fibrosis. Using bivariate analysis, the only factors that were associated with worsening fibrosis were the presence of steatosis or steatohepatitis on initial biopsy.

Regarding different operations, the majority of patients in our study had a laparoscopic gastric bypass as their index operation and the small numbers of other operations such as gastric sleeve or banding do not allow for a valid comparison between operations. Despite this, we recommend weight loss surgery in general, and in particular, roux-en-y gastric bypass as a safe and effective treatment option for patients with fatty liver disease and severe obesity.

The findings on our earlier work of 660 liver biopsies done at the time of bariatric surgery suggest that although preoperative evaluation including clinical, radiology, and laboratory biomarkers are highly predictive of the presence of NAFLD, there is no current test available that predicts the presence of steatohepatitis or fibrosis with good sensitivity. We found a higher incidence of steatohepatitis and fibrosis when we performed routine liver biopsy compared to when we performed selective liver biopsy. Because of these findings, we have adopted routine liver biopsy for all our patients undergoing bariatric surgery, and we agree that it is the gold standard for the diagnosis of NASH and liver fibrosis.

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Taitano, A.A., Markow, M., Finan, J.E. et al. Bariatric Surgery Improves Histological Features of Nonalcoholic Fatty Liver Disease and Liver Fibrosis. J Gastrointest Surg 19, 429–437 (2015). https://doi.org/10.1007/s11605-014-2678-y

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