BOSTON — Morbidly obese patients who undergo bariatric surgery might benefit from an associated reduction in nonalcoholic steatohepatitis, commonly known as NASH.
"Bariatric surgery should be considered a therapeutic alternative after lifestyle changes fail in morbidly obese patients with NASH," said Guillaume Lassailly, MD, from the Centre Hospitalier Régional Universitaire de Lille in France.
He presented results from a prospective review of morbidly obese patients with proven NASH here at The Liver Meeting 2014. One year after bariatric surgery, there was an 85% reduction in fatty liver disease and improvement in fibrosis.
NASH, the severe form of nonalcoholic fatty liver disease, leads to liver cirrhosis and is a major risk factor for hepatocellular carcinoma.
Dr. Lassailly was involved in a previous study in which the prevalence of NASH in bariatric surgery cohorts was shown to be 7% to 10% (Gastroenterology. 2009;137:532-540).
Guidelines from the American Association for the Study of Liver Diseases (AASLD) on the management of nonalcoholic fatty liver disease recommend lifestyle changes, such as weight loss and increased exercise, for the prevention of NASH, said Dr. Lassailly (Hepatology. 2012;55:2005-2023).
"However, weight loss is rarely achieved in morbidly obese patients," he said.
The investigators decided to see what the effects of bariatric surgery would be on histologically proven NASH in morbidly obese patients.
They identified 109 morbidly obese patients with biopsy-confirmed NASH from a cohort of patients who underwent bariatric surgery from 1994 to 2013. Of this group, 82 patients underwent a second biopsy 1 year after surgery.
Surgeries in the cohort varied; 63% underwent gastric bypass surgery, 30% underwent gastric banding, 6% underwent sleeve gastrectomy, and 1% underwent a duodenal switch procedure.
One year after surgery, there was a significant decline in body mass index (BMI), as expected (P < .00001). There was an equally dramatic drop in mean alanine aminotransferase levels, and a significant decline in gamma-glutamyl transpeptidase levels.
Table: Changes in Liver Enzyme and Metabolic Parameters
| Parameter | Before Surgery | After Surgery | P Value |
| Alanine aminotransferase, IU/L | 52.1 | 25.1 | <.00001 |
| Gamma-glutamyl transpeptidase, IU/L | 74.2 | 41.5 | <.00001 |
| Insulin resistance index | 3.6 | 2.9 | <.00001 |
| Fasting glucose, g/L | 1.5 | 1.1 | <.00001 |
| Glycated hemoglobin, % | 7.6 | 6.0 | <.00001 |
| Serum triglycerides, mmol/L | 2.2 | 1.5 | <.00001 |
| Cholesterol, mmol/L | |||
| High-density lipoprotein | 1.1 | 1.3 | <.00001 |
| Low-density lipoprotein | 2.8 | 2.7 | .40000 |
| Total | 4.8 | 4.6 | .12000 |
NASH was assessed with the Brunt score before surgery; 63.4% of patients had grade 1 disease, 25.6% had grade 2 disease, and 11.0% had grade 3 disease. One year after surgery, NASH was undetectable in 85% of patients, 9.8% had grade 1 disease, 3.7% had grade 2 disease, and 1.2% had grade 3 disease.
After surgery, there were significant improvements in fatty liver disease activity score (P < .00001), an 84.2% improvement in ballooning necrosis (P < .00001), and a 67.1% improvement in lobular inflammation (P < .00001). There was also a significant 33.0% improvement in the Kleiner score for fibrosis (P < .003).
Patients with refractory NASH at 1 year generally had more severe disease at baseline, Dr, Lassailly reported.
This study provides important data on the potential effect of weight loss in general, and bariatric surgery in particular, on nonalcoholic fatty liver disease and NASH, said Adrian Di Bisceglie, MD, from the Saint Louis University School of Medicine in Missouri, who is president of the AASLD.
"Among adults, fatty liver disease is the condition that is rising at the fastest rate as an indication for liver transplantation. It also appears to be rising as a risk factor for liver cancer," he said.
As shown in this study, bariatric surgery appears to have a large beneficial effect on fatty liver disease. However, Di Bisceglie noted, there are likely many individuals who are obese and who have nonalcoholic fatty liver disease or NASH but who are not obese enough to qualify for bariatric surgery.
This study was funded by the French Ministry of Health and the Department of Nord Pas-de-Calais. Dr. Lassailly and Dr. Di Bisceglie have disclosed no relevant financial relationships.
The Liver Meeting 2014: American Association for the Study of Liver Diseases (AASLD). Abstract 213. Presented November 11, 2014.
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