Surgery is Better than Medical Management for Non-Alcoholic Fatty Liver Disease

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  • 1. Surgical Management is Better Than Medical Management for Non-Alcoholic Fatty Liver Disease Abeezar I. Sarela MSc MS MD FRCS Consultant in Upper GI & Bariatric Surgery Hon. Senior Lecturer in Surgery St Jamess University Hospital, Leeds
  • 2. Treatment of NAFLD Surgery vs. Medicine What can we agree? 1.Weight-loss is the first line therapeutic measurein all overweight or obese patients with NAFLD A position statement on NAFLD/NASH based on the EASL 2009 special conference. Ratziu et al. Journal of Hepatology 2010;53:72-84 www.foregutsurgeon.com
  • 3. Treatment of NAFLD Surgery vs. Medicine What can we agree? 2.Lose Weight is easier said than done Maintaining weight loss is harder! www.foregutsurgeon.com
  • 4. Weight Loss by Diet and Life-Style Intervention Best OutcomesOnly 15% of participants lost 10% of their initialweight. For 80%, average weight loss was 4 kg.Sacks FM et al. Comparison of weight-loss diets with differentcompositions of fat, protein, and carbohydrates. N Engl J Med2009;360:859873.Even with an incentivized program, averageweight loss was only 7.4 kg (7.9%) at 2 years.Rock et al. Effect of a free prepared meal and incentivized weight loss program onweight loss and weight loss maintenance in obese and overweight women: arandomized controlled trial. JAMA 2010;304 (16):1803-1810 www.foregutsurgeon.com
  • 5. Treatment of NAFLD Surgery vs. Medicine What can we agree? 3.Bariatric surgery isnot for everyone. BMI>35 kg/m2 + co- morbidity BMI>40 kg/m2 BMI>50 kg/m2 www.foregutsurgeon.com
  • 6. Bariatric & Metabolic Operations Laparoscopic SleeveLaparoscopic Gastrectomy AdjustableGastric Band Laparoscopic Roux-en-Y Gastric Bypass www.foregutsurgeon.com
  • 7. Treatment of NAFLD Surgery vs. Medicine Disputes 1 How much weight loss is necessary?Modest overall weight loss produces results in significant decrease in liver fat Target for NAFLD treatment: 7% weight lossA position statement on NAFLD/NASH based on the EASL 2009 special conference. Ratziu et al. Journal of Hepatology 2010;53:72-84 www.foregutsurgeon.com
  • 8. Insulin ResistanceMetabolic Surgery for the Metabolic Syndrome www.foregutsurgeon.com
  • 9. Gut Hormones, Metabolic Surgery & Insulin ResistanceMurphy & BloomNature2006;444:854 www.foregutsurgeon.com
  • 10. The whole is greater than the sum of its parts Aristotle www.foregutsurgeon.com
  • 11. Treatment of NAFLD Surgery vs. Medicine Disputes 2 Efficacy of Bariatric Surgery Does it do what it is supposed to do?Effectiveness of Bariatric Surgery How does it compare with non-surgical treatment? www.foregutsurgeon.com
  • 12. Bariatric Surgery Weight LossSjostrom L et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007;357:741-52. www.foregutsurgeon.com
  • 13. Bariatric Surgery Resolution of Metabolic Syndrome 621 studies: 1990-2006 135, 246 patients Mean BMI 48 kg/m2 Resolution of Type 2 Diabetes Mellitus: 78% Effects of Bariatric Surgery on Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis. Buchwald et al. Am J Med 2009;122:248-256 www.foregutsurgeon.com
  • 14. Metabolic SurgeryEfficacy in Treatment of NAFLDEffect of Bariatric Surgery on Non-Alcoholic Fatty Liver Disease: Systematic Review & Meta-Analysis.Mummadi et al. Clin Gastroenterol Hepatol.2008;6:1396-1402. www.foregutsurgeon.com
  • 15. Effect of Bariatric Surgery on NAFLD 766 paired biopsies Improvement Complete or Resolution Resolution Steatosis 92% NR NASH 81% 70% Fibrosis 65% NREffect of Bariatric Surgery on Non-Alcoholic Fatty Liver Disease: SystematicReview &Meta-Analysis. Mummadi et al. Clin Gastroenterol Hepatol. 2008;6:1396-1402. www.foregutsurgeon.com
  • 16. Bariatric Surgery & NAFLD Prospective, Long-Term Study 1994-2005 381 patients Liver Biopsy at Liver Biopsy atLiver Biopsy during 1 year 5 years Bariatric Surgery follow-up follow-upProspective study of long-term effects of bariatric surgery on liver injury in patients without advanced liver disease. Mathurin et al. Gastroenterology. 2009;137:532-540 www.foregutsurgeon.com
  • 17. Bariatric Surgery & NAFLD 381 patients Steatosis 1 Year after Bariatric 5 Years after Bariatric Baseline Surgery Surgery 82% 36% 38% NASH 1 Year after Bariatric 5 Years after Bariatric Baseline Surgery Surgery 27% 12% 14%Prospective study of long-term effects of bariatric surgery on liver injury in patients without advanced liver disease. Mathurin et al. Gastroenterology. 2009;137:532-540 www.foregutsurgeon.com
  • 18. Bariatric Surgery & NAFLD Long-Term Follow-Up What about Fibrosis? Baseline: 77% F0 80%: Regressed or remained at same stage 20%: Progressed Higher baseline BMI & NAS > 90% progressed from F0 to F1 Bariatric surgery or intrinsic disease?Prospective study of long-term effects of bariatric surgery on liver injury in patientswithout advanced liver disease. Mathurin et al. Gastroenterology. 2009;137:532-540 www.foregutsurgeon.com
  • 19. Bariatric Surgery versus Medical Treatment Selection Criteria: All RCTs evaluating any bariatric procedure vs. no intervention, placebo or other intervention in patients with NASH Results: No RCTs or quasi-randomized studies that fulfilled selection criteria Bariatric surgery for non-alcoholic steatohepatitis in obese patients. Chavez-Tapia et al. Cochrane Database Syst Rev. 2010 www.foregutsurgeon.com
  • 20. Medical Treatment of NAFLD 49 RCTs: 30 in NASH1. Short duration: none exceeds 2 years2. 5% weight loss improves steatosis but not necrosis and inflammation3. Only 40% of patients achieved target weight loss even with multi-disciplinary life-style intervention and behavioral therapy A meta-analysis of randomized trials for the treatment of nonalcoholic fatty liver disease. Musso et al. Hepatology 2010;52:79-104. www.foregutsurgeon.com
  • 21. Cost-Effectiveness of Bariatric Surgery Office ofHealth Economics 2010 www.foregutsurgeon.com
  • 22. Treatment of NAFLDSurgery vs. Medicine Disputes 3 Safety Metabolic Risks Technica