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Decision Tree for the Performance of Intraoperative Liver Biopsy During Bariatric Surgery

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Abstract

Background and Aims

Bariatric surgery provides a useful opportunity to perform intraoperative liver biopsy to screen for non-alcoholic steatohepatitis (NASH). There is currently no consensus on whether intraoperative liver biopsy should be systematically performed. The aim of this study was to develop and validate a decision tree to guide that choice.

Approach and Results

This prospective study included 102 consecutive patients from the severe obesity outcome network (SOON) cohort in whom liver biopsy was systematically performed during bariatric surgery. A classification and regression tree (CART) was created to identify the nodes that best classified patients with and without NASH. External validation was performed. Seventy-one biopsies were of sufficient quality for analysis (median body mass index 43.3 [40.7; 48.0] kg/m2). NASH was diagnosed in 32.4% of cases. None of the patients with no steatosis on ultrasound had NASH. The only CART node that differentiated between a “high-risk” and a “low-risk” of NASH was alanine aminotransferase (ALT). ALT>53IU/L predicted NASH with a positive predictive value (PPV) of 68% and a negative predictive value (NPP) of 89%, a sensitivity of 77%, and a specificity of 84%. In the external cohort (n=258), PPV was 68%, NPV was 62%, sensitivity was 27%, and specificity was 90%.

Conclusions

The present work supports intraoperative liver biopsy to screen for NASH in patients with ALT>53IU/L; however, patients with no steatosis on ultrasound should not undergo biopsy. The CART failed to identify an algorithm with a good sensitivity to screen for NASH in patients with ultrasonography-proven steatosis and ALT≤53IU/L.

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Acknowledgements

We wish to thank Stephane Ruckly (ICUREsearch®, Paris, France), professional statistician who performed statistical analyses, and M’Barka Daoukhi, clinical research assistant for the SOON cohort. The authors also thank Valentine Lemoine (Institute of Cardiometabolism and Nutrition) for patient follow-up, Dr. Florence Marchelli (Centre de Recherche en Nutrition Humaine, Ile-de-France, France) for data management, and Rohia Alili (Centre de Recherche en Nutrition Humaine, Ile-de-France, France) for her contribution to biobanking.

Funding

The SOON cohort is supported by the foundation “Agir pour les maladies chronique,” the “Agence Régionale pour la Santé Auvergne-Rhône-Alpes,” France, and the “Direction de la recherche clinique et de l’innovation” of the “Centre Hospitalier Universitaire Grenoble Alpes,” France. BARICAN clinical study was supported by the Assistance Publique Hôpitaux de Paris and the Centre de Recherche Clinique (CRC) for clinical investigation (CRC P050318 to C.P., PHRC 02076 to K.C., and CRC-FIBROTA to K.C. and J.A.-W. and RC BDD 2017 to JAW). L’Agence Nationale de la Recherche supported the clinical study (ANR Adipofib, and the national program “Investissements d’Avenir” with the reference ANR-10-IAHU-05).

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Authors and Affiliations

  1. Department of Digestive Surgery, University Hospital Grenoble Alpes, 38043, Grenoble, France

    Sandrine Barbois, F. Reche & C. Arvieux

  2. Hypoxia Physiopathology (HP2) Laboratory, INSERM U1042, Grenoble Alpes University, 38043, Grenoble, France

    Sandrine Barbois & A. L. Borel

  3. Department of Anatomopathology, University Hospital Grenoble Alpes, 38043, Grenoble, France

    N. Stürm

  4. INSERM, NutriOmics Research Unit, Sorbonne Université, Paris, France

    J. Aron-Wisnewsky, K. Clément & Laurent Genser

  5. Assistance Publique Hôpitaux de Paris, Nutrition Department, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France

    J. Aron-Wisnewsky & K. Clément

  6. Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK

    P. Bedossa

  7. Assistance Publique Hôpitaux de Paris, Digestive Surgery Department, Pitié-Salpêtrière Hospital, Sorbonne Université, Paris, France

    Laurent Genser

  8. Department of Hepatology, University Hospital Grenoble Alpes, 38043, Grenoble, France

    M. N. Hilleret & C. Costentin

  9. Department of Nutrition, University Hospital Grenoble Alpes, 38043, Grenoble, France

    A. L. Borel

Authors
  1. Sandrine Barbois
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  2. N. Stürm
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  3. J. Aron-Wisnewsky
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  4. K. Clément
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  5. P. Bedossa
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  6. Laurent Genser
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  8. C. Costentin
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  9. F. Reche
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  10. C. Arvieux
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  11. A. L. Borel
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Corresponding author

Correspondence to Sandrine Barbois.

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Conflict of interest

S. Barbois has no conflict of interest to declare for the present study.

N. Stürm has no conflict of interest to declare for the present study.

J. Aron-Wisnewsky has no conflict of interest to declare for the present study.

K. Clément has no conflict of interest to declare for the present study.

P. Bedossa has no conflict of interest to declare for the present study.

L. Genser has no conflict of interest to declare for the present study

M. N. Hilleret has no conflict of interest to declare for the present study.

C. Costentin received fees for expert work by InterceptTM.

F. Reche has no conflict of interest to declare for the present study.

C. Arvieux has no conflict of interest to declare for the present study.

AL. Borel has no conflict of interest to declare for the present study.

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Barbois, S., Stürm, N., Aron-Wisnewsky, J. et al. Decision Tree for the Performance of Intraoperative Liver Biopsy During Bariatric Surgery. OBES SURG 31, 2641–2648 (2021). https://doi.org/10.1007/s11695-021-05309-w

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  • DOI: https://doi.org/10.1007/s11695-021-05309-w

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