Original article
Nonalcoholic fatty liver disease in patients with different baseline glucose status undergoing bariatric surgery: analysis of intraoperative liver biopsies and literature review

https://doi.org/10.1016/j.soard.2017.09.527Get rights and content

Abstract

Background

Bariatric surgery has been investigated as a treatment option for obese patients with nonalcoholic fatty liver disease (NAFLD). Because patients with NAFLD and type 2 diabetes show accelerated progression from liver disease to cirrhosis, it has been suggested that surgery could be indicated for patients with lower degrees of obesity and type 2 diabetes.

Objective

To analyze the degree of tissue damage in liver biopsies obtained from patients undergoing bariatric surgery, correlating histopathologic findings with their baseline glucose status.

Setting

General hospital in the public health system.

Methods

Intraoperative liver biopsies were obtained from 521 obese patients undergoing bariatric surgery. Patients were divided into 3 study groups according to their preoperative glucose levels: 167 (32.05%) type 2 diabetic, 132 (25.33%) prediabetic, and 222 (42.61%) normoglycemic patients. Tissue samples were classified in accordance with Brunt and Clinical Research Network Nonalcoholic Steatohepatis criteria.

Results

Prevalence of NAFLD was 95%. Higher rates of hepatic fibrosis were observed in diabetic patients (56.4%) compared with prediabetic (29.2%), and normoglycemic patients (28.6%) (P<.001). Nonalcoholic steatohepatitis was diagnosed in 59.4% of the diabetics, in 49.2% of the prediabetics, and in 36% of the normoglycemic obese (P<.001). Only 1.5% of the diabetics had no histologic hepatic alterations.

Conclusion

NAFLD is markedly more severe in diabetic patients. Our data suggest that intraoperative liver biopsy should be considered for diabetic patients undergoing bariatric surgery. Early bariatric surgery should be investigated as a means to prevent progression of NAFLD.

Section snippets

Methods

We analyzed a large series of patients undergoing bariatric surgery at the Class III Obesity Center within a General Hospital (Public Health System) from 2001 to 2016. Data were obtained through a retrospective review of their medical records.

Patients were selected for bariatric surgery according to the criteria of the National Institutes of Health Consensus Statement [17]: body mass index (BMI) ≥40 kg/m² or ≥35 kg/m² associated with one or more co-morbidities, age between 18 and 65 years, and

Demographic and clinical characteristics

Of the 521 patients, 439 (84.3%) were women with a mean age of 41.8 ± 10 years. Patients were classified into 3 groups according to their baseline glucose status, as follows: group 1 (G1) composed of 167 (32.05%) type 2 diabetics, group 2 (G2) with 132 (25.33%) prediabetics, and group 3 (G3) containing 222 (42.61%) normoglycemic obese patients. The mean BMI of our patients was 51.87 kg/m². None of the patients had a BMI<40 kg/m². Clinical and demographic characteristics of patients are shown in

Discussion

This is one of the largest series of patients to correlate the glucose status of patients undergoing bariatric surgery with the degree of histologic liver damage. Additionally, to the best of our knowledge, we are the first to include a group of prediabetic patients in the analysis.

Using liver biopsies, we were able to establish the diagnosis of NASH, which is not accurately identified in most studies based on clinical criteria. NASH is a severe and progressive liver disease that can result in

Conclusion

We demonstrated that the degree of histologic liver damage is related to the presence of T2D in morbidly obese patients. Our data suggest that intraoperative liver biopsy should be considered for diabetic patients undergoing bariatric surgery. Early bariatric surgery should be investigated as a means to prevent the progression of NAFLD and to promote remission of T2D in these patients. Further studies are warranted to substantiate our findings.

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

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