H. Verkindt

Prospective Study of the Long-Term Effects of Bariatric Surgery on Liver Injury in Patients Without Advanced Disease

BACKGROUND & AIMS Severe obesity is implicated in development of nonalcoholic fatty liver disease (NAFLD). Bariatric surgery induces weight loss and increases survival time of obese patients, but little is known about its effects on liver damage. We performed a 5-year prospective study to evaluate fibrosis and nonalcoholic steatosis (NASH) in severely obese patients after bariatric surgery. METHODS Bariatric surgery was performed on 381 patients. Clinical and biological data, along with liver biopsies, were collected before and at 1 and 5 years after surgery. RESULTS Five years after surgery, levels of fibrosis increased significantly, but 95.7% of patients maintained a fibrosis score <or= F1. The percentage of patients with steatosis decreased from 37.4% before surgery to 16%, the NAFLD score from 1.97 to 1, ballooning from 0.2 to 0.1. Inflammation remained unchanged. The percentage of patients with probable or definite NASH decreased significantly over 5 years, from 27.4% to 14.2%. The kinetics of insulin resistance (IR) paralleled that of steatosis and ballooning; the greatest improvements occurred within the first year and were sustained 5 years later. Steatosis and ballooning occurred more frequently in patients with a refractory IR profile. In multivariate analysis, the refractory IR profile independently predicted the persistence of steatosis and ballooning 5 years later. CONCLUSIONS Five years after bariatric surgery for severe obesity, almost all patients had low levels of NAFLD, whereas fibrosis slightly increased. Steatosis and ballooning were closely linked to IR; long-term effects could be predicted by early improvement in IR.

Bariatric Surgery Reduces Features of Nonalcoholic Steatohepatitis in Morbidly Obese Patients

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.

Roux-en-Y gastric bypass versus adjustable gastric banding to reduce nonalcoholic fatty liver disease: a 5-year controlled longitudinal study.

Objectives:To compare the long-term benefit of gastric bypass [Roux-en-Y gastric bypass (RYGB)] versus adjustable gastric banding (AGB) on nonalcoholic fatty liver disease (NAFLD) in severely obese patients. Background:NAFLD improves after weight loss surgery, but no histological study has compared the effects of the various bariatric interventions. Methods:Participants consisted of 1236 obese patients (body mass index = 48.4 ± 7.6 kg/m2), enrolled in a prospective longitudinal study for up to 5 years after RYGB (n = 681) or AGB (n = 555). Liver biopsy samples were available for 1201 patients (97.2% of those at risk) at baseline, 578 patients (47.2%) at 1 year, and 413 patients (68.9%) at 5 years. Results:At baseline, NAFLD was present in 86% patients and categorized as severe [NAFLD activity score (NAS) ≥3] in 22% patients. RYGB patients had a higher body mass index (49.8 ± 8.2 vs 46.8 ± 6.5 kg/m2, P < 0.001) and more severe NAFLD (NAS: 2.0 ± 1.5 vs 1.7 ± 1.4, P = 0.004) than AGB patients. Weight loss at 5 years was 25.5% ± 11.8% after RYGB versus 21.4% ± 12.7% after AGB (P < 0.001). When analyzed with a mixed model, all NAFLD parameters improved after surgery (P < 0.001) and improved significantly more after RYGB than after AGB [steatosis (%): 1 year, 7.9 ± 13.7 vs 17.9 ± 21.5, P < 0.001/5 years, 8.7 ± 7.1 vs 14.5 ± 20.8, P < 0.05; NAS: 1 year, 0.7 ± 1.0 vs 1.1 ± 1.2, P < 0.001/5 years, 0.7 ± 1.2 vs 1.0 ± 1.3, P < 0.05]. In multivariate analysis, the superiority of RYGB was primarily but not entirely explained by weight loss. Conclusions:The improvement of NAFLD was superior after RYGB than after AGB.

Validation of noninvasive biomarkers (FibroTest, SteatoTest, and NashTest) for prediction of liver injury in patients with morbid obesity

Background Liver biopsy is considered as the gold standard for assessing nonalcoholic fatty liver disease (NAFLD) histologic lesions in patients with morbid obesity. The aim of this study was to determine the diagnostic utility of noninvasive markers of fibrosis (FibroTest), steatosis (SteatoTest), and steatohepatitis (NashTest, ActiTest) in these patients. Materials and methods Two hundred and eighty-eight patients presenting with interpretable baseline operative biopsy and biomarkers, in an ongoing prospective cohort of patients treated with bariatric surgery, were included. Histology (NAFLD activity score, or NAFLD scoring system) and biochemical measurements were centralized and blinded to other characteristics. The area under the receiver operating characteristic curves (AUROC), sensitivity, specificity, positive and negative predictive values were assessed. Weighted AUROC (Obuchowski method) was used to prevent multiple testings and a spectrum effect. Results The prevalence of advanced fibrosis (bridging) was 6.9%, advanced steatosis (>33%) was 48%, and steatohepatitis was 6.9% (NAFLD scoring system>4). Weighted AUROCs of the tests were as follows (mean, 95% confidence interval, significance): FibroTest for advanced fibrosis: 0.85, 0.83–0.87, P<0.0001; SteatoTest for advanced steatosis: 0.81, 0.79–0.83, P<0.0001; and ActiTest for steatohepatitis: 0.77, 0.73–0.81, P<0.0001. Conclusion In patients with morbid obesity, the diagnostic performances of the FibroTest, SteatoTest, and ActiTest were statistically significant, thereby possibly reducing the need for biopsy in this population.

Long-term metabolic outcome and quality of life after laparoscopic adjustable gastric banding in obese patients with type 2 diabetes mellitus or impaired fasting glucose

The long‐term outcome of type 2 diabetes mellitus after laparoscopic adjustable gastric banding (LAGB) is unknown.

Incidence and Predictive Factors of Postprandial Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass: A Five year Longitudinal Study.

Background: Postprandial hyperinsulinemic hypoglycemia (PHH) is often reported after Roux-en-Y gastric bypass (RYGB). In the absence of a prospective study, the clinical and biological determinants of PHH remain unclear. Objective: To determine the incidence and predictive factors of PHH after RYGB. Methods: Participants were 957 RYGB patients enrolled in an ongoing longitudinal cohort study. We analyzed the results of an oral glucose tolerance test (OGTT) routinely performed before surgery and 1 and/or 5 years after. PHH was defined as blood glucose < 50 mg/dL AND plasma insulin > 3 mU/L at 120 minutes post glucose challenge. Validated indices of insulin sensitivity (Matsuda index), beta-cell function (Insulinogenic index), and beta-cell mass (fasting C-peptide: glucose ratio) were calculated, from glucose, insulin, and c-peptide values measured during OGTT. Results: OGTT results were available in all patients at baseline, in 85.6% at 12 months and 52.8% at 60 months. The incidence of PHH was 0.5% at baseline, 9.1% * and 7.9%* at 12 months and 60 months following RYGB (*: P < 0.001). In multivariate logistic regression analysis, PHH after RYGB was independently associated with lower age (P = 0.005), greater weight loss (P = 0.031), as well as higher beta-cell function (P = 0.002) and insulin sensitivity (P < 0.001), but not with beta-cell mass (P = 0.381). A preoperative elevated beta-cell function was an independent predictor of PHH after RYGB (receiver operating characteristics curve area under the curve 0.68, P = 0.04). Conclusions: : The incidence of PHH significantly increased after RYGB but remained stable between 1 and 5 years. The estimation of beta-cell function with an OGTT before surgery can identify patients at risk for developing PHH after RYGB.

P144: Étude des freins et des attentes des médecins généralistes dans le suivi des patients après chirurgie bariatrique

Introduction et but de l’etude Le nombre de patients operes d’une chirurgie bariatrique dans la patientele des medecins generalistes ne cesse de croitre. La chirurgie bariatrique implique un suivi au long cours pour prevenir les complications et optimiser les resultats ponderaux a long terme. La place des medecins generalistes dans le suivi post-operatoire reste mal definie et leur opinion sur ce sujet peu connue. L’objectif de l’etude est de decrire le suivi realise par les medecins generalistes apres chirurgie bariatrique, leurs representations et mettre en evidence les freins a la prise en charge afin d’aboutir a des pistes d’amelioration et des outils d’aide a la prise en charge. Materiel et methodes Etude descriptive qualitative par entretiens semi-diriges aupres de dix medecins generalistes de la region lilloise d’avril a aout 2014, recrutes a partir des patients operes au CHU. Retranscription des entretiens sur le logiciel de traitement de texte Word®. Analyse informatique des entretiens par theorisation ancree approchee avec double codage a l’aide du logiciel NVivo10® permettant l’emergence de codes, regroupes en themes. Resultats et Analyse statistique L’analyse des entretiens a fait apparaitre des attitudes et des prises en charge tres variables selon les medecins. Des points communs ont ete mis en evidence. En majorite, les medecins ont precise ne pas realiser de suivi ou de consultations specifiques. Ils ont dit surveiller le poids et la survenue de carences. Tous ont explique surveiller les comorbidites et adapter les traitements sans forcement rattacher cette prise en charge au suivi post-operatoire. Concernant le suivi, peu de medecins se sont dits non concernes. En majorite, les medecins ont dit souhaiter un suivi conjoint, leur role etant d’assurer un suivi regulier de premier recours, complementaire des consultations plus rares du specialiste s’assurant de l’absence de complications specifiques a la chirurgie. Les difficultes rapportees etaient principalement un manque de temps, un manque de connaissances et un manque de communication avec l’equipe hospitaliere. Concernant les attentes des medecins, ces derniers souhaiteraient des documents precis d’aide au suivi, notamment concernant les supplementations vitaminiques post-operatoires. Concernant l’amelioration de la communication, certains ont propose la creation d’un site internet afin d’obtenir des reponses a leurs questions. D’autres ont propose la creation d’une ligne telephonique directe dediee aux medecins. La creation d’un carnet de suivi a ete proposee aux medecins. En majorite, ils se sont dits interesses a condition que ce carnet soit simple et pratique. La proposition de creer un guide de consultation precisant les elements importants a rechercher lors du suivi post-operatoire et les supplementations vitaminiques a egalement recu un accueil favorable. Certains ont precise preferer une version informatisee de ces documents. Conclusion Le medecin generaliste a besoin pour suivre les patients d’un accompagnement et d’un lien avec l’equipe specialisee. Un carnet de suivi, sous un format papier ou informatique, pourrait repondre aux attentes des medecins en y integrant un guide de consultation precisant les elements a surveiller apres chirurgie bariatrique. Il pourrait ameliorer la communication avec les equipes hospitalieres. Il permettrait egalement de responsabiliser le patient dont l’implication dans le suivi est indispensable.