Rajasekhara R. Mummadi

Effect of Bariatric Surgery on Nonalcoholic Fatty Liver Disease: Systematic Review and Meta-Analysis

BACKGROUND & AIMS Weight loss in overweight or obese individuals results in marked improvement or resolution of hypertension, diabetes mellitus, and hyperlipidemia. However, the overall effect of weight loss on nonalcoholic fatty liver disease (NAFLD) remains unclear. This systematic review and meta-analysis is an effort to explore the effect of weight loss after bariatric surgical procedures on NAFLD. METHODS We performed an electronic literature search of published articles on bariatric surgery and liver histology since inception to September of 2007. Primary outcome measures were improvement and/or resolution in the 3 components of NAFLD (steatosis, steatohepatitis, and fibrosis) after bariatric surgery-induced weight loss. A pooled proportion of patients with improvement or resolution was calculated for steatosis, steatohepatitis, and fibrosis using a random effects model. Heterogeneity among the studies was assessed using the I(2) (inconsistency) statistic and subgroup analyses. RESULTS A total of 15 studies (766 paired liver biopsies) were selected for final data extraction. The percentage reduction in mean body mass index after bariatric surgeries ranged from 19.11 to 41.76. The pooled proportion of patients with improvement or resolution in steatosis was 91.6% (95% confidence interval [CI], 82.4%-97.6%), in steatohepatitis was 81.3% (95% CI, 61.9%-94.9%), in fibrosis was 65.5% (95% CI, 38.2%-88.1%), and for complete resolution of nonalcoholic steatohepatitis was 69.5 (95% CI, 42.4%-90.8%). CONCLUSIONS Steatosis, steatohepatitis, and fibrosis appear to improve or completely resolve in the majority of patients after bariatric surgery-induced weight loss.

Antiviral Therapy Reduces Risk of Hepatocellular Carcinoma in Patients With Hepatitis C Virus–Related Cirrhosis

BACKGROUND & AIMS The effects of antiviral therapy on prevention of hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV)-related cirrhosis are unclear. We performed a systematic review and meta-analysis to assess HCC risk reduction in patients with HCV-related cirrhosis who have received antiviral therapy. METHODS Twenty studies (4700 patients) were analyzed that compared untreated patients with those given interferon (IFN) alone or ribavirin. Risk ratios (RRs) determined effect size using a random effects model. RESULTS Pooled data showed reduced HCC risk in the treatment group (RR, 0.43; 95% confidence interval [CI], 0.33-0.56), although the data were heterogenous (chi(2) = 59.10). Meta-regression analysis showed that studies with follow-up durations of more than 5 years contributed to heterogeneity. Analysis of 14 studies (n = 3310) reporting sustained virologic response (SVR) rates with antiviral treatment showed reduced HCC risk in patients with an SVR, compared with nonresponders (RR, 0.35; 95% CI, 0.26-0.46); the maximum benefits were observed in patients treated with ribavirin-based regimens (RR, 0.25; 95% CI, 0.14-0.46). Meta-analysis of 4 studies assessing the role of maintenance IFN in nonresponders did not show HCC risk reduction (RR, 0.58; 95% CI, 0.33-1.03). No publication bias was detected by the Egger test analysis (P > 0.1). CONCLUSIONS The risk of HCC is reduced among patients with HCV who achieve an SVR with antiviral therapy. Maintenance therapy with IFN does not reduce HCC risk among patients who do not respond to initial therapy. View this articles video abstract atwww.cghjournal.org.

Hepatotoxicity Fears Contribute to Underutilization of Statin Medications by Primary Care Physicians

Introduction:The safety and efficacy of hydroxymethylglutaryl CoA reductase inhibitors (statins) have been extensively demonstrated, but in clinical practice, there remains significant underutilization of these medications. The authors hypothesized that this underutilization could stem in part from fear of liver damage caused by statins. The purpose was to determine whether concern about hepatotoxicity acts as a barrier among primary care physicians to prescribing statins for patients with elevated liver transaminase values and/or underlying liver disease. Method:The survey included 937 primary care physicians from 138 academic centers in the United States, and the following were measured: (1) comparison of statin prescribing for patients with clinical indications and (a) no mention of liver transaminase values, (b) elevated liver transaminase values and (c) underlying liver disease; (2) correlation between perception of statin hepatotoxicity and statin prescribing. Results:Seventy-one percent of respondents would prescribe statins in scenario 1, (45-year-old woman with low-density lipoprotein 240 mg/dL), whereas only 50% would prescribe statins if the baseline liver transaminase values were elevated to 1.5 times upper limit of normal (P < 0.001). This prescribing rate dropped even further to 40% in scenario 3 (55-year-old man with known coronary disease, low-density lipoprotein 250 mg/dL and hepatitis C). Thirty-seven percent of respondents had falsely elevated perceptions of statin hepatotoxicity risk, and these perceptions correlated inversely with statin prescribing. The method of survey administration prevented calculation of response rate, possibility of response bias exists. Conclusion:Despite extensive data documenting safety of statins, primary care physicians harbor significant hepatotoxicity concerns, and these concerns act as a barrier to statin utilization.

Effect of bisphosphonates on bone mineral density in liver transplant patients: a meta‐analysis and systematic review of randomized controlled trials

Bone mineral density (BMD) loss after liver transplantation (LT) results in considerable morbidity with the increased risk of fractures. Data on the efficacy of bisphosphonate use in post LT patients is scarce. This meta‐analysis aims to summarize the results from published randomized controlled trials (RCTs) on the topic of interest. Electronic databases were searched to identify relevant publications. A total of 157 articles were identified and reviewed. Individual authors were contacted from relevant RCTs to obtain individual patient data where necessary to uniformly quantify BMD values post LT pre‐ and post LT. A total of six RCTs were used for final data extraction. (i) Lumbar Spine: In 364 patients (six studies, 182 in intervention and control groups each), bisphosphonate therapy improved BMD by 0.03 g/cm2 (95% C.I. 0.01–0.05 g/cm2; P = 0.02) at 12 months post LT. (ii) Femoral neck: In 268 patients (four studies, 130 bisphosphonate, 138 control), bisphosphonate use did not result in a statistically significant change in BMD at the end of 1 year. None of the studies noted serious adverse effects related to bisphosphonate administration. Data on incident fractures could not be pooled because of heterogeneity. Bisphosphonate therapy during the first year in LT recipients appears to reduce accelerated bone loss and improve bone mineral density at the lumbar spine.

The Eagle or the Snake: Platforms for NOTES and Radical Endoscopic Therapy

It has only been about 3 years since natural orifice translumenal endoscopic surgery (NOTES) first began to gather the attention of the medical and surgical community at large. The concepts behind NOTES, however, have been under development for almost a decade. It is important to revisit some basic concepts regarding therapeutic flexible endoscopy and in the process understand the fundamental premises on which a sound technology development program for NOTES should be built. This article provides such a review and emphasizes general principles rather than specific embodiments, which are very much at a nascent stage.

Neutropenic enterocolitis: An unusual complication of HCV combination therapy with PEG-IFN and ribavirin

Drug induced neutropenia as a consequence of intensive chemotherapy for hematological malignancies and solid tumors is known to be associated with severe, life-threatening infections such as neutropenic enterocolitis. However, the neutropenia associated with HCV combination therapy with Pegylated Interferon [PEG-IFN] and ribavirin is considered to be well tolerated in patients without other co-morbidities. We present a case of a severe gastrointestinal complication in a patient receiving HCV combination therapy and advocate caution in continuing therapy in patients with neutropenia, especially in the presence of underlying co-morbidities such as cirrhosis.

Is the histologic quality of polyps affected by the type of electrosurgical generator used in resection

Is the histologic quality of polyps affected by the type of electrosurgical generator used in resection?