Research Article

The Effects of Sleeve Gastrectomy on Nonalcoholic Fatty Liver Disease. A Review of the Literature

Angelou Anastasios* , Margonis Georgios Antonios, Skarmoutsos Athanasios, Athanasiou Antonios, Dimitrokallis Nikolaos and Alexandrou Andreas

Angelou Anastasios^1*, Margonis Georgios Antonios², Skarmoutsos Athanasios³, Athanasiou Antonios⁴, Dimitrokallis Nikolaos⁴ and Alexandrou Andreas⁴

¹Health center Alexandras, Athens, Greece
²Division of Surgical Oncology, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
³Halkida General Hospital, Halkida, Greece
⁴1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece

*Address for Correspondence: Angelou Anastasios, Health center Alexandras, Mikras Asias 39, Athens, Greece, Tel: +302130336157; Fax: +30210291604; E-mail: aangelou@med.uoa.gr

Dates: Submitted: 26 September 2017; Approved: 20 October 2017; Published: 21 October 2017

Citation this article: Anastasios A, Margonis GA, Athanasios S, Antonios A, Nikolaos D, et al. The Effects of Sleeve Gastrectomy on Nonalcoholic Fatty Liver Disease. A Review of the Literature. Int J Hepatol Gastroenterol. 2017;3(3): 060-063.

Copyright: © 2017 Anastasios A, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Keywords: Nonalcoholic Fatty Liver Disease (NAFLD); Nonalcoholic Steatohepatitis (NASH); Sleeve gastrectomy; Metabolic syndrome

Abstract

Background: Nonalcoholic Fatty Liver Disease (NAFLD) is the most common liver disease in the developed countries. Patients with Nonalcoholic Steatohepatitis (NASH), a subset of NAFLD, are at risk for progressive liver disease and in need of effective treatment options. There is a lack of data assessing sleeve gastrectomy and their effect on NAFLD.

Objective: To assess the effects of Sleeve Gastrectomy (SG) on NAFLD.

Methods: An online search of PubMed, Medline, and Google Scholar was independently carried out by two researchers using key words like Non-Alcoholic Fatty Liver Disease, Non-Alcoholic Steato-Hepatitis, Bariatric Surgery, Obesity Surgery, Sleeve Gastrectomy and Liver Biopsy, percutaneous liver biopsy, to identify all articles. Articles were also identified from references of relevant articles. All sleeve gastrectomies that had intraoperative and postoperative liver biopsies were included..

Results: The review included 10 studies that provided data regarding nonalcoholic fatty liver disease in men and women that had undergone sleeve gastrectomy for morbid obesity. Participants in these studies had undergone liver biopsy at the time of the operation and as a follow up. We decided to not perform a meta-analysis due to the high risk of bias and the high degree of heterogeneity of the included studies.

Conclusions: In addition to a correlation between NAFLD and metabolic syndrome, NAFLD may lead to a worse outcome in steatohepatitis (NASH). Surgery may provide a possible solution to this problem but we need further research to examine the associations, pathophysiology, and the impact of SG on this particular disease.

Introduction

NAFLD is a clinico-pathological condition [1] characterized by the histologic finding of 5% or greater macrovesicular steatosis of hepatocytes in an individual without significant alcohol use or other known causes of chronic liver disease [2]. The histologic spectrum of NAFLD are divided to isolated steatosis or nonalcoholic fatty liver to Nonalcoholic Steatohepatitis (NASH)-related cirrhosis and NASH-Hepatocellular Carcinoma (HCC) [3]. Although not entirely a diagnosis of exclusion, the diagnosis of NAFLD does require a careful query of alcohol consumption, because alcoholic liver disease itself can often demonstrate similar histologic features to NAFLD. As such, current guidelines recommend using criteria requiring alcohol exposure of less than 30 g/ day for men and less than 20 g/day for women as a component of NAFLD diagnosis. The diagnosis of NAFLD incorporates the clinical history, laboratory data, radiographic data, as well as histologic information. NAFLD can be diagnosed noninvasively by the finding of hepatic steatosis on abdominal imaging study; liver biopsy is not always needed to confirm the diagnosis. However, a liver biopsy is required to distinguish isolated steatosis from NASH and to stage fibrosis severity, which may subsequently affect risk of disease progression and disease management. Three key histologic features are needed to confirm the diagnosis of NASH and include steatosis, inflammation, and cellular ballooning. [4]. Bariatric surgical procedures are increasingly and successfully applied in the treatment of morbid obesity. Bariatric operations traditionally are divided to restrictive, malabsorptive or combined according to the mechanism they induce weight-loss. Malabsorptive procedures have been reported as having more sustainable long-term results in terms of weight loss and amelioration of related comorbidities compared to restrictive procedures, in exchange for more common post-operative nutritional deficiencies [5]. Restrictive procedures on the other hand are linked with a progressively attenuated weight-loss and metabolic result but have a more favorable long-term nutritional profile [6-8]. The aim of this study is to focus on NAFLD and the ensuing regression after sleeve gastrectomy which is one of the most popular procedure for the morbid obesity.

Material and Methods

A comprehensive search of PubMed Database was conducted and the review covered a period from 2000 to 2017. The keywords which were used individually or in combination were: sleeve gastrectomy, NAFLD, NASH, obesity, steatosis. This study was based on a retrospective review of a database comprising all patients with proven NAFLD undergoing SG.

Inclusion and Exclusion criteria

Studies with data for sleeve gastrectomy were only included. These studies included technical notes, review articles, original articles, case reports studies and case matched comparison studies. Duplicate publications and those not written in English were excluded. For duplicate publications, the latest and most complete study was included. Number of patients was not an exclusion criterion.

Results

Many studies have shown NAFLD regression after sleeve gastrectomy in bariatric surgery patients. (Table 1) Most studies included few cases. Manco, et al. [9,10] included 20 patients that underwent SG and they reported reversion of steatohepatitis and reduction of hepatic fibrosis in morbidly obese adolescents with NAFLD 1 year after surgery. Another study from Billeter, et al. [11] included thirty-four obese patients with a BMI >35 kg/m². The effects on LFT and glycemic control were evaluated over 12 months. An additional prospective study from Aldoheyan, et al. [12] evaluated the histological and biochemical effects of sleeve gastrectomy on nonalcoholic fatty liver disease in 27 patients with 3 months follow-up. Similarly Algooneh, et al. [13] examined 84 patients diagnosed with NAFLD prior to undergoing LSG and Froylich, et al. [14] studied nine patients that underwent SG with liver biopsies prior to surgery and in the follow up. In general follow-up is quite limited spanning from 3 months (10) to 1year [9,11-14].

Table 1: Patients characteristics.
Study	Patients	Regression of NAFLD	Comments	Additional benefits after SG
Manco, et al. [9]	93 Obese (BMI ≥ 35 kg/m2) adolescents	20/20 patients	20 Pts underwent LSG. Follow up: 1 year later	Decreased hypertension and ameliorated dyslipidemia, weight loss
Tariciotti, et al. [18]	1 patient (53years old- BMI 40 kg/m2)	NA	The patient underwent LT	Advantages in terms of allograft and patient survival, diabetes resolution
Billeter, et al. [13]	34 patients	17/17 patients	17 patients underwent LSG –Follow up: 1 year later	Improved insulin resistance, glycemic control, and reduced the need of insulin
Aldoheyan, et al. [10]	27 patients (35 ± 8 years old-BMI: 44.6 ± 7.8)	12/18 patients	27 patients underwent LSG plus Liver biopsy –Follow up: 3 months later	Weight reduction
Wolter, et al. [16]	302 patients (Age: 43.3 ± 11.9, BMI:43.3 ± 11.9)	80% with NAFLD	150 patients underwent LSG plus Liver biopsy- No follow-up	Decreased postoperative complications
Algooneh, et al.[15]	84 patients (Age: 17–62, BMI : 46.6 ± 7.8)	47/84 patients	84 patients underwent LSG- Follow up : Ultrasound	Weight reduction
Froylich, et al. [14]	9 patients (Age: 46.3 11.7, BMI : 72.7 21.0)	9/9 patients	9 patients underwent LSG plus Liver biopsy –Follow up: ½-1 year later	Weight reduction
Calvo, et al. [12]	19 patients (Age:34-55,BMI:42.1-51.2)	19/19 patients	19 patients underwent LSG –Follow up: 1 year later with MRI	Weight reduction
Praveen Raj, et al. [11]	20 patients(Age: 21–70, BMI: 45.99 +/- 11.71)	10/10 patients (with pre-op NAFLD)	20 patients underwent LSG plus liver biopsy Follow up: ½-1 year later	Weight reduction
Berry, et al. [17]	252 patients(Age: 15-70, BMI: 30-34.3)	213/252 patients (with pre-op NAFLD)	111 patients in the Follow up with Ultrasound	Insulin resistance was remitted dyslipidemia hypertension and GERD. T2DM had 60% of complete remission and 40% improvement.
NA: Not Addressed.

Most studies agree that following surgery NAFLD is either improved [10,15] or fully regressed. [9, 11-13] Techniques followed to evaluate NAFLD, however varied: some authors used liver biopsy (10, 11, 14, 16) and others used ultrasound sonography [15-17] or MRI [12].

Tariciotti, et al. [18] in their case report from Italy referred to a 53 years old woman with Hepatocellular carcinoma and Hepatitis C virus related cirrhosis. She also presented with severe morbid obesity (BMI 40 kg/m²) and insulin-dependent diabetes. Once listed for Liver Transplantation (LT), she was assessed by the bariatric surgery team to undergo a combined LT/SG. An experienced bariatric surgeon, following completion of the LT, performed the SG. The patient had an uneventful recovery and is currently alive, 5 months after the combined procedure, with normal allograft function, significant weight loss (BMI = 29 kg/m²), and diabetes resolution.

Discussion

LSG is a new and effective restrictive surgical procedure used with increasing frequency [19]. This surgical procedure was originally performed as the first step in a staged weight loss procedure for severely obese adults [20]. Sleeve gastrectomy was first performed laparoscopically by Ren, et al. [21]. In this restrictive procedure, the stomach is reduced to approximately 20% of its original size by the surgical removal of a large portion. The open edges are then stapled together to form a sleeve or narrow banana-shaped tube. As a result, the size of the stomach is permanently reduced [22].

Bariatric surgery in obese patients with NAFLD results in sustained and significant weight loss and improves NASH, according to the current literature. SG is considered a safe and effective option for these patients, as long as appropriate long-term follow-up is provided. Existing data are not sufficient to recommend general use of this surgical procedure in patients that exhibit NAFLD. The burden of obesity associated comorbidity such as NAFLD in selected patients may prove risky and future studies and a long-term risk analysis of patients with obesity associated liver disease are much needed to clarify the exact indications for bariatric surgery.

We propose the collection of data of all weight loss procedures until prospective and controlled trials are performed. This study tries to address the problem of a pathologic entity as NAFLD and the resolution after a rather commonly used operation like SG and as such, it can be helpful for the clinician.

Conclusions

In summary, this study reaffirms that many patients have been reported as having suffered from NAFLD [23] and SG for morbid obesity seems to play a significant role for the resolution of the disease. Physicians should be highly suspicious for the diagnosis of NAFLD in obese patients. Since liver biopsy should routinely be performed intraoperatively in those morbid obese patients undergoing bariatric surgery, the definite diagnosis in all suspicious cases by a hepatologist is imperative and usually results in the regression of the disease.

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