Myriam Moretto

The Role of Ultrasound in the Diagnosis of Hepatic Steatosis in Morbidly Obese Patients

Background: Hepatic steatosis is prevalent in obese patients. Although it requires histology for diagnosis, ultrasound may indicate its presence. We evaluated the importance of ultrasound in the diagnosis of steatosis in morbidly obese patients, and considered its clinical relevance for patients with BMI of 35-40 kg/m2 without co-morbidities. Methods: 187 morbidly obese patients submitted to bariatric surgery were prospectively studied. All patients had ultrasound before the operation, and hepatic biopsies during the operation, which were compared. Results: The prevalence of steatosis histologically was 91.4%. The sensitivity and specificity of ultrasound in diagnosing steatosis was 49.1% and 75%, respectively,with a positive predictive value of 95.4%. Conclusion: The biopsies found a very high prevalence of steatosis in the studied population. The ultrasound results yielded a high positive predictive value (95.4%), suggesting its use as a diagnostic tool for this co-morbidity in morbidly obese patients.The low sensitivity of the method could be related to the lack of objective criteria for the ultrasound diagnosis of steatosis, and probably, technical problems in performing ultrasound in such patients. We believe that in patients with a BMI of 35-40 kg/m2 without other comorbidities, the ultrasound finding of steatosis could be of value as an indication for bariatric surgery.

Effect of Bariatric Surgery on Liver Fibrosis

BackgroundAlthough bariatric surgery has been shown to improve hepatic steatosis in morbidly obese patients, the effect of weight loss on hepatic fibrosis has not been determined. Since the prognosis of patients with nonalcoholic fatty liver disease is closely related to the development of hepatic fibrosis, it is important to determine the hepatic histology of these patients after weight loss. We therefore evaluated the prevalence of hepatic fibrosis in morbidly obese patients undergoing bariatric surgery and assessed the correlation of histologic changes with weight loss.MethodsWe retrospectively evaluated 78 morbidly obese patients who underwent gastric bypass. Liver biopsies were taken during surgery and after weight loss, and the correlations between histologic findings and hepatic fibrosis were determined.ResultsOf the 78 patients, 35 (44.8%) had fibrosis at first biopsy, and 24 (30.8%) had hepatic fibrosis after weight loss, including 19 of the 35 patients (54.3%) with fibrosis at first biopsy and 5 of the 43 (11.6%) without hepatic fibrosis at first biopsy (P = 0.027).ConclusionsWeight loss in morbidly obese patients was associated with a reduction in the prevalence of hepatic fibrosis.

Hepatic Steatosis In Patients Undergoing Bariatric Surgery and its Relationship to Body Mass Index and Co-Morbidities

Background: Although non-alcoholic hepatitis usually is asymptomatic and benign, this condition may progress to cirrhosis and hepatic failure. Some findings are similar to alcoholic hepatitis, but there is no history of excessive alcohol consumption. Among the factors associated with non-alcoholic hepatitis, obesity, diabetes and dyslipidemia are the most important. Methods: 77 consecutive patients undergoing bariatric surgery had their liver biopsy compared to the presence of co-morbidities and BMI. Results: 67 patients (87.1%) had an abnormal liver biopsy, mostly due to steatosis (83.1%), but also steatohepatitis (2.6%) and cirrhosis (1.3%). The degree of liver damage was related to higher BMI scores. Co-morbidities were present in 46.9% of the patients with hepatic steatosis. Conclusions: The authors suggest that a liver biopsy should be performed in all patients at bariatric surgery, in order to evaluate possible liver damage and to assist postoperative care.

A Comparison of Wedge and Needle Hepatic Biopsy in Open Bariatric Surgery

Background: Morbidly obese patients, despite normal laboratory tests and no clinical evidence of liver disease, present a high prevalence of hepatic histological changes. Liver biopsy is able to provide the diagnosis, staging and assessment of follow-up of hepatic disease, thus helping to define clinical management. There is no agreement on which biopsy technique provides better material for analysis. Considering that subcapsular fibrosis is a common finding, sampling from deeper sites is necessary to achieve an adequate histological assessment. Methods: A study was done in 264 consecutive morbidly obese patients who underwent open Roux-en-Y gastric bypass between July 2001 and Sept 2004, in whom an intraoperative liver biopsy was taken. The first 107 were wedge biopsies, and the last 157 were needle biopsies. The histological degree of steatosis, presence of fibrosis and adequacy of material from the 2 biopsy techniques were compared. Results: Degree of steatosis in both sampling techniques showed no statistical difference (P=0.132). The presence of fibrosis in wedge biopsies (46.1% fibrosis, n 41) was significantly higher than in needle biopsies (13.7% fibrosis, n 20), P<0.001. As expected, sample size of needle biopsies was smaller than that obtained by the wedge technique (P<0.001), but there was no difference in the quality of material obtained (P=0.95). Conclusion: Needle biopsies were as effective as wedge biopsies in assessing the degree of steatosis in morbidly obese patients. More important, the presence of subcapsular fibrosis in needle biopsies was less than in wedge biopsies, suggesting an adequate tissue sample by the less invasive technique.

Laparoscopic sleeve gastrectomy with NOTES visualization--a step toward NOTES procedures.

BACKGROUND To demonstrate that bariatric procedures can be done with natural orifice visualization (NOTES) at 2 institutions (Nucleo Universitario de Estudos de Notes Centro de Cirurgia Experimental Vila do Conde-Junqueira, Vila do Conde, Portugal and Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, RS, Brasil). NOTES is a new surgical approach that is being developed. It consists of the use of a minimally invasive technique in which the surgical procedure is performed through natural orifices, thereby circumventing incisions through the skin. METHODS We performed vertical gastrectomy or laparoscopic sleeve gastrectomy in a porcine model using vaginal route visualization. RESULTS A laparoscopic vertical sleeve gastrectomy with NOTES visualization in a porcine model was performed with safety. CONCLUSION Bariatric procedures can be done with NOTES with results as good as those using laparoscopic techniques.

Gastric Carcinoid Tumor—Incidental Finding on Endoscopy Prior to Bariatric Surgery

A 32-year-old female patient with morbid obesity (body mass index 44.4) was submitted to upper digestive endoscopy performed routinely as a preoperative procedure in bariatric surgery. The examination identified multiple small polypoid lesions in the upper portion of the gastric body, some with small ulcerations. Anatomo-pathological findings were compatible with carcinoid tumor of the stomach. The patient was submitted to extended subtotal gastrectomy with loco-regional lymphadenectomy. Upper digestive endoscopy is performed routinely in some services for bariatric surgery, but its value has been questioned by some authors. In this case, endoscopic examination was of great importance, being responsible for a change in the surgical procedure. We did not find any report in the literature of a carcinoid tumor of the stomach in morbidly obese patients.