Influence of Sleeve Gastrectomy on NASH and Type 2 Diabetes Mellitus

Compare the Combined Diagnostic Accuracy of Transient Elastography and Visual Liver Score in Assessing Non-Alcoholic Fatty Liver Disease (NAFLD) and Compare it with Liver Biopsy in Morbidly Obese Patients Undergoing Bariatric Surgery: An Observational Study

INTRODUCTION

A liver biopsy is the gold standard for the diagnosis of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). Here, we combine preoperative transient elastography (TE) and intraoperative standardized visual liver score (VLS) which is compared with intraoperative liver biopsy for prediction of NAFLD and NASH in patients undergoing bariatric surgery.

AIM

Evaluate the combined diagnostic accuracy of TE and VLS in assessing NAFLD or NASH and compare it with liver biopsy in patients undergoing bariatric surgery.

METHODS

In a prospective cohort of 70 morbidly obese undergoing bariatric surgery, preoperative TE and intraoperative VLS were calculated. Findings of TE and VLS were compared with histology from intraoperative liver biopsy.

RESULTS

Histologically, 44 (62.85%) had NAFLD (≥ S1). Significant steatosis was seen in 20 (28.57%) while significant fibrosis was visible in 18 (25.71%). Area Under the Receiver Operating Characteristics (AUROC) TE for diagnosis of NAFLD was excellent (0.844, p = 0.001). At the optimal cutoff of 8.1, the positive predictive value (PPV) was 92.9%, and diagnostic accuracy was 90.6%. VLS had a sensitivity of 90.9% for NAFLD. The combined sensitivity of TE + VLS was 95.5% for ruling out NAFLD. Fourteen (20%) had NASH. VLS had a diagnostic accuracy of 97% in identifying NASH in comparison to TE. AUROC-VLS was 0.987, p ≤ 0.001, and a sensitivity of 100%. The overall sensitivity of combined TE and VLS was 100% with a negative predictive value (NPV) of 100%.

CONCLUSION

TE when combined with intraoperative VLS is comparable to liver biopsy and can be used for the diagnosis of NAFLD and NASH in patients undergoing bariatric surgery.

Foregut bypass vs. restrictive bariatric procedures for nonalcoholic fatty liver disease: a meta-analysis of 3,355 individuals

Background

Bariatric surgery represents an important treatment option for severely obese patients with nonalcoholic fatty liver disease (NAFLD). However, there remains inadequate data regarding the effects of different bariatric procedures on various NAFLD parameters, especially for histological outcomes. Thus, this meta-analysis aimed to compare the effects of restrictive bariatric procedures and foregut bypass on the metabolic, biochemical, and histological parameters for patients with NAFLD.

Methods

Medline and Embase were searched for articles relating to bariatric procedures and NAFLD. Pairwise meta-analysis was conducted to compare efficacy of bariatric procedures pre- vs. post-procedure with subgroup analysis to further compare restrictive against foregut bypass procedures.

Results

Thirty-one articles involving 3,355 patients who underwent restrictive bariatric procedures (n=1,460) and foregut bypass (n=1,895) were included. Both foregut bypass (P<0.01) and restrictive procedures (P=0.03) significantly increased odds of fibrosis resolution. Compared to restrictive procedures, foregut bypass resulted in a borderline non-significant decrease in fibrosis score (P=0.06) and significantly lower steatosis score (P<0.001). For metabolic parameters, foregut bypass significantly lowered body mass index (P=0.003) and low-density lipoprotein (P=0.008) compared to restrictive procedures. No significant differences were observed between both procedures for aspartate aminotransferase (P=0.17) and alkaline phosphatase (P=0.61). However, foregut bypass resulted in significantly lower gamma-glutamyl transferase than restrictive procedures (P=0.01) while restrictive procedures resulted in significantly lower alanine transaminase than foregut bypass (P=0.02).

Conclusions

The significant histological and metabolic advantages and comparable improvements in biochemical outcomes support the choice of foregut bypass over restrictive bariatric procedures in NAFLD management.

Cardiovascular Effects of Weight Loss in Obese Patients with Diabetes: Is Bariatric Surgery the Additional Arrow in the Quiver?

Obesity is an increasingly widespread disease worldwide because of lifestyle changes. It is associated with an increased risk of cardiovascular disease, primarily type 2 diabetes mellitus, with an increase in major cardiovascular adverse events. Bariatric surgery has been shown to be able to reduce the incidence of obesity-related cardiovascular disease and thus overall mortality. This result has been shown to be the result of hormonal and metabolic effects induced by post-surgical anatomical changes, with important effects on multiple hormonal and molecular axes that make this treatment more effective than conservative therapy in determining a marked improvement in the patient's cardiovascular risk profile. This review, therefore, aimed to examine the surgical techniques currently available and how these might be responsible not only for weight loss but also for metabolic improvement and cardiovascular benefits in patients undergoing such procedures.

Mechanisms linking bariatric surgery to adipose tissue, glucose metabolism, fatty liver disease and gut microbiota

PURPOSE

In the last 20 years, bariatric surgery has achieved an important role in translational and clinical research because of obesity comorbidities. Initially, a tool to lose weight, bariatric surgery now has been shown to be involved in several metabolic pathways.

METHODS

We conducted a narrative review discussing the underlying mechanisms that could explain the impact of bariatric surgery and the relationship between obesity and adipose tissue, T2D, gut microbiota, and NAFLD.

RESULTS

Bariatric surgery has an impact in the relation between obesity and type 2 diabetes, but in addition  it induces the white-to-brown adipocyte trans-differentiation, by enhancing thermogenesis. Another issue is the connection of bariatric surgery with the gut microbiota and its role in the complex mechanism underlying weight gain.

CONCLUSION

Bariatric surgery modifies gut microbiota, and these modifications influence lipid metabolism, leading to improvement of non-alcoholic fatty liver disease.

Effect of Bariatric Surgery on Metabolic Diseases and Underlying Mechanisms

Obesity is a highly prevalent public health concern, attributed to multifactorial causes and limited in treatment options. Several comorbidities are closely associated with obesity such as the development of type 2 diabetes mellitus (T2DM), cardiovascular and cerebrovascular diseases, and nonalcoholic fatty liver disease (NAFLD). Bariatric surgery, which can be delivered in multiple forms, has been remarked as an effective treatment to decrease the prevalence of obesity and its associated comorbidities. The different types of bariatric surgery create a variety of new pathways for food to metabolize in the body and truncate the stomach's caliber. As a result, only a small quantity of food is tolerated, and the body mass index noticeably decreases. This review describes the improvements of obesity and its comorbidities following bariatric surgery and their mechanism of improvement. Additionally, endocrine function improvements after bariatric surgery, which contributes to the patients' health improvement, are described, including the role of glucagon-like peptide-1 (GLP-1), fibroblast growth factors 19 and 21 (FGF-19, FGF-21), and pancreatic peptide YY (PYY). Lastly, some of the complications of bariatric surgery, including osteoporosis, iron deficiency/anemia, and diarrhea, as well as their potential mechanisms, are described.

Bariatric Surgery and Liver Disease: General Considerations and Role of the Gut-Liver Axis

Weight loss is a therapeutic solution for many metabolic disorders, such as obesity and its complications. Bariatric surgery aims to achieve lasting weight loss in all patients who have failed after multiple dietary attempts. Among its many benefits, it has been associated with the regression of non-alcoholic fatty liver disease (NAFLD), which is often associated with obesity, with evidence of substantial improvement in tissue inflammation and fibrosis. These benefits are mediated not only by weight loss, but also by favorable changes in systemic inflammation and in the composition of the gut microbiota. Changes in microbial metabolites such as short-chain fatty acids (SCFAs), capable of acting as endocrine mediators, and bile acids (BAs) as well as modifications of the gut-brain axis, are among the involved mechanisms. However, not all bariatric surgeries show beneficial effects on the liver; those leading to malabsorption can cause liver failure or a marked worsening of fibrosis and the development of cirrhosis. Nevertheless, there are still many unclear aspects, including the extent of the benefits and the magnitude of the risks of bariatric surgery in cirrhotic patients. In addition, the usefulness and the safety of these procedures in patients who are candidates to or who have undergone liver transplant need solid supporting evidence. This paper aims to review literature data on the use of bariatric surgery in the setting of chronic liver disease.

BYPASS VS. SLEEVE AND ITS EFFECTS IN NON-ALCOHOLIC FATTY LIVER DISEASE: WHAT IS THE BEST TECHNIQUE?

Background:

Strongly associated with obesity, non-alcoholic fatty liver disease is considered the hepatic manifestation of the metabolic syndrome. It presents as simple steatosis and steatohepatitis, which can progress to cirrhosis and its complications. Among the therapeutic alternatives is bariatric surgery.

Aim:

To compare the effect of the two most frequent bariatric procedures (sleeve and bypass) on liver disease regarding to epidemiological, demographic, clinical and laboratory parameters.

Methods:

The results of intraoperative and 12 months after surgery liver biopsies were used. The NAFLD activity score (NAS) was used to assess and compare the stages of liver disease.

Results:

Sixteen (66.7%) patients underwent Bypass procedure and eight (33.3%) Sleeve. It was observed that the variation in the NAFLD activity score was significantly greater in the Bypass group than in Sleeve (p=0.028) and there was a trend regarding the variation in fibrosis (p=0.054).

Conclusion:

Both surgical techniques were effective in improving the hepatic histology of most operated patients. When comparing sleeve and bypass groups, bypass showed better results, according to the NAS score.

Metabolic networks of the human gut microbiota

The human gut microbiota controls factors that relate to human metabolism with a reach far greater than originally expected. Microbial communities and human (or animal) hosts entertain reciprocal exchanges between various inputs that are largely controlled by the host via its genetic make-up, nutrition and lifestyle. The composition of these microbial communities is fundamental to supply metabolic capabilities beyond those encoded in the host genome, and contributes to hormone and cellular signalling that support the dynamic adaptation to changes in food availability, environment and organismal development. Poor functional exchange between the microbial communities and their human host is associated with dysbiosis, metabolic dysfunction and disease. This review examines the biology of the dynamic relationship between the reciprocal metabolic state of the microbiota-host entity in balance with its environment (i.e. in healthy states), the enzymatic and metabolic changes associated with its imbalance in three well-studied diseases states such as obesity, diabetes and atherosclerosis, and the effects of bariatric surgery and exercise.

Clinical utility of transient elastography as an imaging tool to assess the short-term impact of laparoscopic sleeve gastrectomy, together with clinical and biochemical parameters and clinico-biochemical indices, on obese patients with nonalcoholic fatty liver disease: An Egyptian pilot study

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is a metabolic liver disorder commonly attributed to fatty acid deposition that can induce hepatic necroinflammation, defined as nonalcoholic steatohepatitis (NASH). It is strongly associated with obesity. Laparoscopic sleeve gastrectomy (LSG) is a favorable surgical modality for the treatment of morbid obesity.

AIM

Our study evaluated the impact of LSG on patients with NAFLD and morbid obesity, 3 months after the operation, through clinical and biochemical characteristics, clinico-biochemical indices, and imaging parameters.

PATIENTS AND METHODS

Morbidly obese patients with NAFLD±NASH underwent LSG. They were thoroughly evaluated clinically (body weight, body mass index, waist circumference) and biochemically (transaminases and triglycerides), as well as through the fatty liver index (FLI), the hepatic steatosis index (HSI), and ultrasound elastography imaging studies (liver stiffness measurement [LSM] and the controlled attenuation parameter [CAP]), before and 3 months after the LSG.

RESULTS

Twenty-six obese patients with NAFLD underwent LSG that resulted in a significantly high reduction in all the parameters analyzed, except for liver transaminases.

CONCLUSION

LSG is considered an efficient surgical modality for the treatment of morbidly obese patients with NAFLD.

Improvement in Non-alcoholic Fatty Liver Disease Score Correlates with Weight Loss in Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: a Two-Centre Study from an Asian Cohort

PURPOSE

Incidence of non-alcoholic fatty liver disease (NAFLD) is on the rise and is one of the most common causes of chronic liver disease worldwide. Obesity and metabolic syndrome are considered the most significant risk factors. Bariatric surgery is the only treatment modality in morbid obesity which allows long-term weight loss with improvement in associated co-morbid conditions. However, the effects of bariatric surgery on NAFLD are not well established. NAFLD fibrosis score (NFS) is a validated non-invasive scoring system used to assess advanced fibrosis. We used the NFS to analyse the impact of weight loss on NAFLD following sleeve gastrectomy.

MATERIALS AND METHODS

174 patients who underwent bariatric surgery between 2010 and 2016 were retrospectively reviewed. Multivariate analysis was performed using pre-operative patient characteristics, biochemical markers and TANITA body analysis measurements to determine significant risk factors for NFS > 0.675. Additionally, the NFS was calculated at 6 months, 1 year and 2 years post-operatively to determine correlation with weight loss.

RESULTS

Pre-operatively, 13.8% of our patients had significant fibrosis by NFS. Mean change in NFS was - 0.46 ± 1.02, - 0.55 ± 0.98 and - 0.55 ± 1.12 at 6 months, 1 year and 2 years respectively. This was significantly correlated with percent of total weight loss with R coefficients of 0.253, 0.292 and 0.274 respectively (P < 0.05). 79.2% of patients with NFS > 0.675 achieved resolution by 2 years post-operatively.

CONCLUSION

Based on our study, we conclude that sleeve gastrectomy may be a viable treatment option for management of NAFLD in the obese.

The advantages and disadvantages of sleeve gastrectomy; clinical laboratory to bedside review

Sleeve gastrectomy is a surgical technique and a leading method in metabolic surgery. Sleeve gastrectomy gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery and has proved to be a successful method in achieving considerable weight loss in a short time. There are some disparate effects that patients may experience after sleeve gastrectomy including a reduction in BMI, weight, blood pressure, stroke, and cancer and also a significant remission in obesity-related diseases including type 2 diabetes (T2D), Non-alcoholic fatty liver (NAFLD), cardiovascular disease, obstructive sleep apnea, and craniopharyngioma-related hypothalamic obesity as well as non-obesity-related diseases such as gout, musculoskeletal problems, ovarian disorders and urinary incontinence. The most common complications of sleeve gastrectomy are bleeding, nutrient deficiencies, and leakage. There are several studies on the impact of gender and ethnic disparities on post-operative complications. This study collects state of the art of reports on sleeve gastrectomy. The aim of this study was to analyze recent studies and review the advantages and disadvantages of sleeve gastrectomy.

The Impact of Comorbidities on the Pharmacological Management of Type 2 Diabetes Mellitus

Diabetes mellitus affects over 20% of people aged > 65 years. With the population of older people living with diabetes growing, the condition may be only one of a number of significant comorbidities that increases the complexity of their care, reduces functional status and inhibits their ability to self-care. Coexisting comorbidities may compete for the attention of the patient and their healthcare team, and therapies to manage comorbidities may adversely affect a person's diabetes. The presence of renal or liver disease reduces the types of antihyperglycemic therapies available for use. As a result, insulin and sulfonylurea-based therapies may have to be used, but with caution. There may be a growing role for sodium-glucose co-transporter 2 (SGLT-2) inhibitors in diabetic renal disease and for glucagon-like peptide (GLP)-1 therapy in renal and liver disease (nonalcoholic steatohepatitis). Cancer treatments pose considerable challenges in glucose therapy, especially the use of cyclical chemotherapy or glucocorticoids, and cyclical antihyperglycemic regimens may be required. Clinical trials of glucose lowering show reductions in microvascular and, to a lesser extent, cardiovascular complications of diabetes, but these benefits take many years to accrue, and evidence specifically in older people is lacking. Guidelines recognize that clinicians managing patients with type 2 diabetes mellitus need to be mindful of comorbidity, particularly the risks of hypoglycemia, and ensure that patient-centered therapeutic management of diabetes is offered. Targets for glucose control need to be carefully considered in the context of comorbidity, life expectancy, quality of life, and patient wishes and expectations. This review discusses the role of chronic kidney disease, chronic liver disease, cancer, severe mental illness, ischemic heart disease, and frailty as comorbidities in the therapeutic management of hyperglycemia in patients with type 2 diabetes mellitus.

Bariatric surgery improves nonalcoholic fatty liver disease: a contemporary systematic review and meta-analysis

High-level evidence of the impact of bariatric surgery on nonalcoholic fatty liver disease (NAFLD) is lacking. We conducted a systematic review and meta-analysis according to the Cochrane guidelines to assess the resolution of NAFLD after bariatric surgery. We searched PubMed, EMBASE, Web of Science, and CENTRAL for English language publications on bariatric surgery and NAFLD. We included randomized controlled trials and observational studies of patients with NAFLD who underwent bariatric surgery and were assessed by liver biopsy or liver function tests. Duodenal switch and biliopancreatic diversion were excluded. Our primary outcome was histologic or biochemical improvement of NAFLD. Twenty-one studies (12 Roux-en-Y gastric bypass [RYGB], 3 adjustable gastric banding, 2 sleeve gastrectomy, 1 vertical banded gastroplasty, 3 multiple procedures) enrolling 2374 patients were included. The pooled proportion of patients who had improvement of steatosis was 88% (95% confidence interval [CI]: .80, .94). Steatohepatitis improved in 59% (95% CI: .38, .78) and fibrosis improved or resolved in 30% of patients (95% CI: .21, .41). Similarly, aspartate aminotransferase (AST) improved in 32% of patients (95% CI: .22, .42) and alanine aminotransferase improved in 62% of patients (95% CI: .42, .82). After RYGB, the number of patients who had improvement in NAFLD was higher than the average of all the pooled studies. Bariatric surgery improves steatosis and steatohepatitis in the majority of patients and improves or resolves liver fibrosis in 30% of patients. RYGB has a greater impact on NAFLD histology compared with other procedures. This contemporary meta-analysis strongly suggests that bariatric surgery should be considered as a treatment of NAFLD.

Vertical sleeve gastrectomy reverses diet-induced gene-regulatory changes impacting lipid metabolism

Vertical sleeve gastrectomy (VSG) produces sustainable weight loss, remission of type 2 diabetes (T2D), and improvement of nonalcoholic fatty liver disease (NAFLD). However, the molecular mechanisms underlying the metabolic benefits of VSG have remained elusive. According to our previous results, diet-induced obesity induces epigenetic modifications to chromatin in mouse liver. We demonstrate here that VSG in C57BL/6J wild-type male mice can reverse these chromatin modifications and thereby impact the expression of key metabolic genes. Genes involved in lipid metabolism, especially omega-6 fatty acid metabolism, are up-regulated in livers of mice after VSG while genes in inflammatory pathways are down-regulated after VSG. Consistent with gene expression changes, regulatory regions near genes involved in inflammatory response displayed decreased chromatin accessibility after VSG. Our results indicate that VSG induces global regulatory changes that impact hepatic inflammatory and lipid metabolic pathways, providing new insight into the mechanisms underlying the beneficial metabolic effects induced by VSG.

Nonalcoholic fatty liver disease and bariatric surgery: a comprehensive review

CONTEXT AND OBJECTIVE:

Nonalcoholic fatty liver disease (NAFLD) has been increasingly diagnosed worldwide and is now recognized as a source of public health concern. It comprises a wide spectrum of histological features that range from simple steatosis to severe forms of fibrosis, steatohepatitis and even cirrhosis. The impact of bariatric surgery on the course of NAFLD in individuals with obesity has been extensively studied.

DESIGN AND SETTING:

Narrative review; public university hospital.

METHODS:

A comprehensive review was conducted based on an online search on the electronic databases MEDLINE and LILACS using the MeSH terms "fatty liver" and "bariatric surgery".

RESULTS:

The exact mechanisms that lead to improvement in NAFLD following bariatric surgery are not completely understood. Since Roux-en-Y gastric bypass (RYGB) is the bariatric surgical procedure most performed worldwide, it is also the one from which the effects on NAFLD have been most studied, although there is also consistent evidence regarding the effects from gastric banding, sleeve gastrectomy and biliopancreatic diversions.

CONCLUSION:

According to the currently available evidence, bariatric surgery leads to significant improvement in NAFLD. Further research, especially by means of randomized controlled trials enrolling larger cohorts of individuals, is needed to determine the optimal procedure for this group of subjects.

Laparoscopic Adjustable Gastric Banding In Patients with Unexpected Cirrhosis: Safety and Outcomes

BACKGROUND

The safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in the context of cirrhosis have not been established. We hypothesized that LAGB in cirrhotic patients is a safe procedure that may offer positive long-term benefits, both in terms of obesity and avoiding progression of liver disease.

METHODS

Data were gathered from a prospectively maintained database of 8402 patients who had undergone LAGB from November 1993 and April 2014.

RESULTS

Fourteen patients with biopsy-proven cirrhosis were identified in the database. In all cases, cirrhosis was an unexpected macroscopic finding at the time of surgery, confirmed with intraoperative biopsy. All patients were either Child-Pugh A or B. No patients had preoperative clinical evidence of decompensated liver disease. The mean initial weight was 116.6 kg and BMI 38.9. There was no operative mortality. Two patients experienced a surgical complication (Clavien-Dindo grade II and grade IIIa). At 12 months, the mean excess weight loss was 61.3% giving a mean BMI 31.7. Repeat biopsies were available in three patients. All demonstrated improvement in inflammation and two had fibrosis regression. Baseline liver biochemistry was compared in nine patients who had repeat biochemistry studies after 12 months. There was a significant improvement in alanine transaminase (ALT) (p = 0.04) and aspartate transaminase (AST) (p = 0.02). Two patients developed hepatocellular carcinoma (HCC). One has died as a result of this disease 11 years after LAGB surgery.

CONCLUSION

LAGB may be a safe and effective bariatric intervention in patients with compensated cirrhosis. Our findings support the need for a prospective study with paired liver biopsies.

Non-Alcoholic Fatty Liver Disease (NAFLD): The Search for a Cure

An alarming rise of obesity and, along with it, non-alcoholic fatty liver disease (NAFLD), has been observed in the USA and the rest of the world. NAFLD, the most common cause of chronic liver disease in many developed countries, is not always a benign disorder and considering its growing nature, will have a serious impact on healthcare systems worldwide. The search continues for a suitable therapy for this disorder; the therapy ideally needs to be safe, effective, and affordable. The biggest hurdle in the process of developing such a therapy is our lack of a complete understanding of the pathogenesis of the disease.

Treatment of Nonalcoholic Fatty Liver Disease: The Role of Medical, Surgical, and Endoscopic Weight Loss

Nonalcoholic fatty liver disease (NAFLD) represents a rapidly growing cause of chronic liver disease in the United States and is associated with significant morbidity and mortality, including progression to liver cirrhosis and hepatocellular carcinoma. NAFLD comprises a spectrum of liver conditions, ranging from simple steatosis to steatosis with inflammation (steatohepatitis) and progressive fibrosis. Weight loss represents a first line therapeutic modality for the management of NAFLD. Herein, we review the evidence base for medical, surgical, and endoscopic approaches to weight loss and their potential impact on the natural history of NAFLD.

Non-alcoholic fatty liver disease resolution following sleeve gastrectomy

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), a disease highly prevalent among the morbidly obese population, is one of the most common causes of chronic liver disease today. The purpose of this study was to observe the effect of laparoscopic sleeve gastrectomy (LSG) on the resolution of NAFLD.

METHODS

A retrospective study was conducted of 84 patients diagnosed with NAFLD prior to undergoing LSG. The diagnosis of NAFLD was achieved based on transabdominal ultrasonographic imaging as per the 2012 joint guidelines for the diagnosis of NAFLD (American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology). The patients had follow-up anthropometric measurements and were re-evaluated with postoperative ultrasounds at different time frames to assess the resolution of the disease.

RESULTS

The median age of the patients was 44 (17-62), and 66.7 % were female. Average time since surgery was 3.3 years (range 1-5 years). The mean pre- and postoperative BMIs were 46.6 ± 7.8 and 33.0 ± 7.1, respectively, with a mean percent excess weight loss (%EWL) of 55.7 % ± 23.0. A total of 47 (56 %) patients showed complete resolution of NAFLD postoperatively. Multivariate analysis showed a significant resolution of NAFLD in patients achieving >50 % EWL (OR 10.1; p < 0.001) after controlling for age and sex.

CONCLUSIONS

Weight loss after LSG effectively resolved NAFLD in more than half of the obese patients in this study and can prove to be a useful tool in tackling the disease in the future.

To band or not to band--early results of banded sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is the procedure with the fastest growing numbers worldwide. Although excellent weight loss can be achieved, one major obstacle of LSG is weight regain due to sleeve dilatation. Banded sleeve gastrectomy (BLSG) has been described as an option to counteract sleeve dilatation and ameliorate weight loss over time. In a retrospective study, we analysed 25 patients who underwent BLSG using a MiniMizer® ring. Twenty five patients who had previously undergone a conventional LSG were selected for matched-pair analysis. Patient follow-up was 12 months in both groups. Mean preoperative BMI was 56.1 ± 7.2 kg/m(2) for BLSG and 57.0 ± 6.3 kg/m(2) for LSG, P = 0.522. Operative time was significantly shorter for BLSG (53 ± 27 min vs. 68 ± 20 min, P = 0.0025). Excess weight loss (%EWL) was equal in both groups with %EWL at 12 months of 58.0 ± 14.6 % for BSLG patients vs. 58.4 ± 19.2 % for LSG patients. There was no procedure-related mortality in either group. At 12 months postoperative, vomiting was significantly increased in BSLG patients (OR 6.75, P = 0.035). New onset reflux was equal in both groups (OR 0.67, P = 0.469). Ring implantation does not increase the duration of surgery or early surgical complications. Weight loss in the first follow-up year is not influenced, but the incidence of vomiting is raised after 12 months when patients start to increase eating volume.

Helicobacter pylori infection is not associated with fatty liver disease including non-alcoholic fatty liver disease: a large-scale cross-sectional study in Japan

BACKGROUND

Fatty liver disease (FLD) including non-alcoholic fatty liver disease (NAFLD), a rapidly emerging and widely recognized liver disease today, is regarded as a hepatic manifestation of metabolic syndrome. Helicobacter pylori, one of the most common pathogens worldwide, has been reported to be associated with metabolic syndrome, but whether there is a direct association with FLD is as of yet unclear. The aim of this study was to clarify the association of FLD and NAFLD with causative background factors including Helicobacter pylori infection.

METHODS

This was a cross-sectional study of Japanese adults who received medical checkups at a single medical center in 2010.Univariate and multivariate statistical analysis was performed to evaluate background factors for ultrasonography diagnosed FLD. Subjects free from alcohol influence were similarly analyzed for NAFLD.

RESULTS

Of a total of 13,737 subjects, FLD was detected in 1,456 of 6,318 females (23.0 %) and 3,498 of 7,419 males (47.1%). Multivariable analyses revealed that body mass index (standardized coefficients of females and males (β-F/M) =143.5/102.5), serum ALT (β-F/M = 25.8/75.7), age (β-F/M = 34.3/17.2), and platelet count (β-F/M = 17.8/15.2) were positively associated with FLD in both genders. Of the 5,289 subjects free from alcohol influence, NAFLD was detected in 881 of 3,473 females (25.4%) and 921 of 1,816 males (50.7%). Body mass index (β-F/M = 113.3/55.3), serum ALT (β-F/M = 21.6/53.8), and platelet count (β-F/M = 13.8/11.8) were positively associated with NAFLD in both genders. Metabolic syndrome was positively associated with FLD and NAFLD only in males. In contrast, Helicobacter pylori infection status was neither associated with FLD nor NAFLD regardless of gender.

CONCLUSIONS

Body mass index, serum ALT and platelet count were significantly associated with FLD and NAFLD, whereas infection of Helicobacter pylori was not.

Bile Acid Signaling: Mechanism for Bariatric Surgery, Cure for NASH?

Bariatric surgery is the most effective and durable treatment option for obesity today. More importantly, beyond weight loss, bariatric procedures have many advantageous metabolic effects including reversal of obesity-related liver disease--nonalcoholic steatohepatitis (NASH). NASH is an important comorbidity of obesity given that it is a precursor to the development of liver cirrhosis that may necessitate liver transplantation in the long run. Simultaneously, we and others have observed increased serum bile acids in humans and animals that undergo bariatric surgery. Specifically, our preclinical studies have included experimental procedures such as 'ileal transposition' or bile diversion and established procedures such as Roux-en-Y gastric bypass and the adjustable gastric band. Importantly, these effects are not simply the result of weight loss since our data show that the resolution of NASH and increase in serum bile acids are not seen in rodents that lose an equivalent amount of weight via food restriction. In particular, we have studied the role of altered bile acid signaling, in the potent impact of a bariatric procedure termed 'vertical sleeve gastrectomy' (VSG). In this review we focus on the mechanisms of NASH resolution and weight loss after VSG surgery. We highlight the fact that bariatric surgeries can be used as 'laboratories' to dissect the mechanisms by which these procedures work to improve obesity and fatty liver disease. We describe key bile acid signaling elements that may provide potential therapeutic targets for 'bariatric-mimetic technologies' that could produce benefits similar to bariatric surgery--but without the surgery!

Vertical sleeve gastrectomy reduces hepatic steatosis while increasing serum bile acids in a weight-loss-independent manner

OBJECTIVE

Our objective was to investigate the role of bile acids in hepatic steatosis reduction after vertical sleeve gastrectomy (VSG).

DESIGN AND METHODS

High fat diet (HFD)-induced obese C57Bl/6 mice were randomized to VSG, Sham operation (Sham), Sham operation with pair feeding to VSG (Sham-PF), or nonsurgical controls (Naïve). All mice were on HFD until sacrifice. Mice were observed postsurgery and data for body weight, body composition, metabolic parameters, serum bile acid level and composition were collected. Further hepatic gene expression by mRNA-seq and RT-PCR analysis was assessed.

RESULTS

VSG and Sham-PF mice lost equal weight postsurgery while VSG mice had the lowest hepatic triglyceride content at sacrifice. The VSG mice had elevated serum bile acid levels that positively correlated with maximal weight loss. Serum bile composition in the VSG group had increased cholic and tauroursodeoxycholic acid. These bile acid composition changes in VSG mice explained observed downregulation of hepatic lipogenic and bile acid synthetic genes.

CONCLUSION

VSG in obese mice results in greater hepatic steatosis reduction than seen with caloric restriction alone. VSG surgery increases serum bile acids that correlate with weight lost postsurgery and changes serum bile composition that could explain suppression of hepatic genes responsible for lipogenesis.

Comparison of the effectiveness of four bariatric surgery procedures in obese patients with type 2 diabetes: a retrospective study

AIM

The aim of the present retrospective study was to evaluate the efficacy of four bariatric surgical procedures to induce diabetes remission and lower cardiovascular risk factors in diabetic obese patients. Moreover, the influence of surgery on weight evolution in the diabetic population was compared with that observed in a nondiabetic matched population.

METHODS

Among 970 patients who were operated on in our center since 2001, 81 patients were identified as type 2 diabetes. Laparoscopic adjustable gastric banding (GB), intervention type Mason (MA), gastric bypass (RYGB), and sleeve gastrectomy (SG) were performed, respectively, in 25%, 17%, 28%, and 30% of this diabetic population.

RESULTS

The resolution rate of diabetes one year after surgery was significantly higher after SG than GB (62.5% versus 20%, P < 0.01), but not significantly different between SG and RYGB. In terms of LDL-cholesterol reduction, RYGB was equivalent to SG and superior to CGMA or GB. Considering the other cardiovascular risk factors, there was no significant difference according to surgical procedures. The weight loss was not statistically different between diabetic and nondiabetic matched patients regardless of the surgical procedures used.

CONCLUSION

Our data confirm that the efficacy of surgery to treat diabetes is variable among the diverse procedures and SG might be an interesting option in this context.

Bariatric surgery and non-alcoholic Fatty liver disease: current and potential future treatments

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly common cause of chronic liver disease worldwide. The diagnosis of NASH is challenging as most affected patients are symptom-free and the role of routine screening is not clearly established. Most patients with severe obesity who undergo bariatric surgery have NAFLD, which is associated insulin resistance, type 2 diabetes mellitus (T2DM), hypertension, and obesity-related dyslipidemia. The effective treatment for NAFLD is weight reduction through lifestyle modifications, antiobesity medication, or bariatric surgery. Among these treatments, bariatric surgery is the most reliable method for achieving substantial, sustained weight loss. This procedure is safe when performed by a skilled surgeon, and the benefits include reduced weight, improved quality of life, decreased obesity-related comorbidities, and increased life expectancy. Further research is urgently needed to determine the best use of bariatric surgery with NAFLD patients at high risk of developing liver cirrhosis and its role in modulating complications of NAFLD, such as T2DM and cardiovascular disease. The current evidence suggests that bariatric surgery for patients with severe obesity decreases the grade of steatosis, hepatic inflammation, and fibrosis. However, further long-term studies are required to confirm the true effects before recommending bariatric surgery as a potential treatment for NASH.

The effect of bariatric surgeries on nonalcoholic fatty liver disease

A review of published data addressing hepatic histopathological, metabolical, and functional changes following gastric banding, sleeve gastrectomy, gastric bypass surgery, and biliopancreatic with duodenal switch surgeries on nonalcoholic fatty liver disease (NAFLD). NAFLD is currently the most common chronic liver disease. Owing to the strong relationship between obesity and NAFLD, the idea of weight reduction as a method to treat NAFLD has rapidly emerged. Bariatric surgery has proved to be the most efficient method for weight reduction; hence, their beneficial effects on NAFLD have been evaluated by several studies. A literature review of published data was performed during the years 2012-2014 using PubMed with the following key words: Bariatric, NAFLD, steatosis, sleeve gastrectomy, gastric bypass, gastric banding, biliopancreatic diversion with duodenal switch, obesity, and insulin resistance (IR). Exclusion criteria were non-English articles and inherited NAFLD, pregnancy-induced NAFLD, and children. The majority of published data are in favor of indicating that bariatric surgeries improve the histologic and metabolic changes associated with NAFLD. The suggested mechanisms are: The reversal of IR, reduction of inflammatory markers, and improved histological features of NAFLD. Accordingly, bariatric surgeries are potentially one of the future methods in treating patients with morbid obesity and NAFLD. However, some questions remain unanswered, such as whether timing of surgery, type of surgery most effective, and whether bariatric surgeries are capable of curing the disease. Long-term and well-designed prospective studies are needed to address these issues.

Advances in the surgical treatment of morbid obesity

Due to the rapidly expanding prevalence of obesity, bariatric surgery is becoming an increasingly popular treatment option. Bariatric surgeries including Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) produce long-term weight loss and metabolic improvement, reducing mortality. This review discusses the important benefits and risks of RYGB and VSG, highlighting hypothesized mechanisms for these effects. We present data suggesting that VSG, albeit a newer procedure, may be as effective as RYGB with fewer adverse effects including less surgical risk, reduced nutritional deficiency, and less incidence of dumping syndrome. This may position VSG as an increasingly important procedure, particularly for the treatment of pediatric obesity.

Excessive weight loss after sleeve gastrectomy: a systematic review

BACKGROUND

The clinical significance of sleeve gastrectomy (SG) as a primary bariatric intervention is still under debate. This article aims to systematically analyze excessive weight loss (EWL) in patients after SG.

METHODS

A systematic literature search on SG from the period January 2003 to December 2010 was performed. Data described from systematic reviews dealing with gastric bypass procedures was used as comparator.

RESULTS

The final study included 123 papers describing 12,129 patients. Most of the papers describe EWL at 12 months (43.9% of all papers). For SG, the maximum EWL occurred 24 and 36 months postoperatively with a mean EWL of 64.3% (minimum 46.1%, maximum 75.0%) and 66.0% (minimum 60.0%, maximum 77.5%), respectively. At 12 months, the mean EWL in patients receiving SG was significantly lower when compared to patients who underwent gastric bypass (SG 56.1%, gastric bypass 68.3%; p < 0.01, two-sided Wilcoxon test). Although patients with gastric bypass still had higher EWL rates at 24 months compared to patients after SG, these differences were not significant (SG 61.3%, gastric bypass 69.6%; p = 0.09, two-sided Wilcoxon rank-sum test). Reoperations after SG are necessary in 6.8% (range 0.7-25%) of cases with patients receiving SG as a stand alone procedure and in 9.6-28.5% of cases with patients undergoing SG as a planned first stage procedure.

CONCLUSIONS

SG is an effective bariatric procedure with a lasting effect on EWL. Compared with gastric bypasses, there is no difference in EWL at the time point of 24 months.

Nonalcoholic fatty liver disease: a review of the spectrum of disease, diagnosis, and therapy

Worldwide, there is an epidemic of obesity and overweight, with two-thirds of Americans affected. A strong association exists between excessive body weight and nonalcoholic fatty liver disease (NAFLD), the most common etiology of abnormal liver function tests. Nonalcoholic fatty liver disease is a spectrum of liver disease, from a "bland" fatty infiltration to chronic hepatitis (nonalcoholic steatohepatitis or NASH), that can result in cirrhosis and organ failure. With the increasing prevalence of obesity in the world, the proportion of people affected by NAFLD is only expected to be parallel. Although primarily noted in obese individuals, NAFLD has also been associated with a number of surgical procedures, metabolic conditions, and medications. NASH is commonly underdiagnosed as most affected patients are symptom free, and routine screening is not performed. Noninvasive diagnostic testing is not sensitive in diagnosis or staging the severity of disease. Fatty infiltration and oxidative injury to the hepatocytes are believed to be the major factors behind the progression of disease from simple fatty infiltration of the liver to chronic hepatitis. Understanding the inflammatory pathways involved in NASH is a subject of extensive research. Currently, few proven treatment options exist, and controlled weight reduction is the only safe modality recommended for treatment of NASH.

Third International Summit: Current status of sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been performed for morbid obesity in the past 10 years. LSG was originally intended as a first-stage procedure in high-risk patients but has become a stand-alone operation for many bariatric surgeons. Ongoing review is necessary regarding the durability of the weight loss, complications, and need for second-stage operations.

METHODS

The first International Summit for LSG was held in October 2007, the second in March 2009, and this third in December 2010. There were presentations by experts, and, to provide a consensus, a questionnaire was completed by 88 attendees who had >1 year (mean 3.6 ± 1.5, range 1-8) of experience with LSG.

RESULTS

The results of the questionnaire were based on 19,605 LSGs performed within 3.6 ± 1.5 years (228.8 ± 275.0 LSGs/surgeon). LSG had been intended as the sole operation in 86.4% of the cases; in these, a second-second stage became necessary in 2.2%. LSG was completed laparoscopically in 99.7% of the cases. The mean percentage of excess weight loss at 1, 2, 3, 4, and 5 years was 62.7%, 64.7%, 64.0%, 57.3%, and 60.0%, respectively. The bougie size was 28-60F (mean 36F, 70% blunt tip). Resection began 1.5-7.0 cm (mean 4.8) proximal to the pylorus. Of the surgeons, 67.1% reinforced the staple line, 57% with buttress material and 43% with oversewing. The respondents excised an estimated 92.9% ± 8.0% (median 95.0%) of fundus (i.e., a tiny portion is maintained lateral to the angle of His). A drain is left by 57.6%, usually closed suction. High leaks occurred in 1.3% of cases (range 0-10%); lower leaks occurred in .5%. Intraluminal bleeding occurred in 2.0% of cases. The mortality rate was .1% ± .3%.

CONCLUSION

According to the questionnaire, presentations, and debates, the weight loss and improvement in diabetes appear to be better than with laparoscopic adjustable gastric banding and on par with Roux-en-Y gastric bypass. High leaks are infrequent but problematic.