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

Surgical Management is Better Than Medical Management for

Non-Alcoholic Fatty Liver Disease

Abeezar I. Sarela MSc MS MD FRCSConsultant in Upper GI & Bariatric Surgery

Hon. Senior Lecturer in SurgerySt James’s University Hospital, Leeds

www.foregutsurgeon.com

Treatment of NAFLDSurgery vs. MedicineWhat can we agree?

1.

Weight-loss is the first line therapeutic measure

in 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



2.

“Lose Weight” is easier said than done

Maintaining weight loss is harder!


Weight Loss by Diet and Life-Style Intervention

Best Outcomes

Only 15% of participants lost 10% of their initial weight. For 80%, average weight loss was 4 kg. Sacks FM et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009;360:859–873.

Even with an incentivized program, average weight 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 on weight loss and weight loss maintenance in obese and overweight women: a randomized controlled trial. JAMA 2010;304 (16):1803-1810



3.Bariatric surgery is not for everyone.

• BMI>35 kg/m2 + co-morbidity

• BMI>40 kg/m2

• BMI>50 kg/m2


Bariatric & Metabolic Operations

Laparoscopic Adjustable

Gastric Band

LaparoscopicRoux-en-Y

Gastric Bypass

LaparoscopicSleeve

Gastrectomy


Treatment of NAFLDSurgery 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


Insulin ResistanceMetabolic Surgery for the Metabolic Syndrome


Gut Hormones, Metabolic Surgery & Insulin Resistance

Murphy & BloomNature2006;444:854

“The whole is greater than the sum of its parts”

Aristotle




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?


Bariatric SurgeryWeight Loss

Sjostrom L et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007;357:741-52.


Bariatric SurgeryResolution 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


Metabolic SurgeryEfficacy in Treatment of NAFLD

Effect of Bariatric Surgery on Non-Alcoholic Fatty Liver Disease: Systematic Review & Meta-Analysis.

Mummadi et al. Clin Gastroenterol Hepatol.2008;6:1396-1402.


Effect of Bariatric Surgery on NAFLD766 paired biopsies

Improvement or Resolution

Complete Resolution

Steatosis 92% NR

NASH 81% 70%

Fibrosis 65% NR

Effect of Bariatric Surgery on Non-Alcoholic Fatty Liver Disease: SystematicReview & Meta-Analysis. Mummadi et al. Clin Gastroenterol Hepatol. 2008;6:1396-1402.


Bariatric Surgery & NAFLDProspective, Long-Term Study

Liver Biopsy during Bariatric Surgery

Liver Biopsy at 1 year

follow-up

Liver Biopsy at 5 years

follow-up

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

1994-2005381 patients


Bariatric Surgery & NAFLD381 patients

Baseline82%

1 Year after Bariatric Surgery

36%

5 Years after Bariatric Surgery

38%

Baseline27%

1 Year after Bariatric Surgery

12%

5 Years after Bariatric Surgery

14%

Steatosis

NASH

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


Bariatric Surgery & NAFLDLong-Term Follow-UpWhat 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


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


Medical Treatment of NAFLD49 RCTs: 30 in NASH

1. Short duration: none exceeds 2 years

2. 5% weight loss improves steatosis but not necrosis and inflammation

3. 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.


Cost-Effectiveness of Bariatric Surgery

Office of Health Economics

2010



Disputes

3

Safety

Metabolic Risks

Technical Risks


Recipe for Trouble

Jejuno-Ileal Bypass


UK National Bariatric Surgery RegistryFirst Registry Report to March, 2010

• 7045 operations in 2009 & 2010

• Complications: 2.6%

• 80% discharged by post-operative day 3

• Mortality: 0.1%


Mortality from Bariatric Surgery

• Risk Stratification– OS-MRS

– LABS Consortium

– Blackstone Score

• Patient Selection

• Procedure Selection

• Experience

• Expertise


For Obese Patients with NAFLD:

1. Bariatric surgery provides significant general health benefits

2. Bariatric surgery most likely controls NAFLD better than medical management

3. Bariatric surgery is cost-effective

4. Bariatric surgery is safe