Meeting Coverage

Bariatric Tx Best in Obese Patients With NASH

Published: Nov 12, 2014

By Ed Susman , Contributing Writer, MedPage Today

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BOSTON -- Bariatric surgery should be considered first-line therapy after the failure of lifestyle intervention in morbidly obese patients withnonalcoholic steatohepatitis (NASH), researchers reported here.

Among 109 bariatric surgery patients, 85% of the patients had no evidence of biopsy-proven NASH on subsequent biopsies at 1 year, reported Guillaume Lassailly, MD, of the University Hospital Center in Lille, and colleagues.

Patients also saw improvements in liver fibrosis, insulin resistance index, fasting glucose, HbA1c, triglycerides, and in HDL cholesterol levels, he said in a presentation at the American Association for the Study of Liver Diseases annual meeting.

Action Points

• Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

However, total cholesterol and LDL cholesterol levels were not significantly reduced in these patients, he added.

Lassailly noted that NASH represents the severe form of non-alcoholic fatty liver disease and leads to cirrhosis and hepatocellular carcinoma. He also cited research that suggests NASH is a growing public issue, as obesity and metabolic syndrome are increasing in Western countries.

Guidelines for management of NASH suggest lifestyle therapy, weight loss, and increased physical activity, as well as possible treatment with tocopherol (vitamin E). But "failure is common" with these approaches and "medications are disappointing. Therefore, bariatric surgery could be of interest to treat NASH in patient that failed lifestyle therapy as it reduces weight and liver injury as steatosis," the authors stated.

For this study, 109 patients in the Lille bariatric cohort with biopsy-proven NASH underwent bariatric surgery between 1994 and 2013. Data were prospectively collected before and 1 year after surgery.

About 63% of the patients were women and the mean age of the participants was 46.2. The mean body mass index (BMI) at baseline was 48.66 kg/m2. About 63% had diabetes while around 68% had high blood pressure.

The majority of the patients (63.4%) were diagnosed with a NASH Brunt score of 1 at baseline, while 25.6% were diagnosed as Brunt core 2, and 11% with Brunt score of 3.

Among these patients, 63% underwent bariatric bypass surgery, 30% had a gastric band procedure, and 6% had a gastric sleeve procedure.

Lassailly noted that two of the patients in the study died due to complications of surgery, including one man in his 30s who had a BMI of more than 50 kg/m2when he underwent surgery.

He reported that a year later, 9.8% of the patients were diagnosed by repeat biopsy with NASH Brunt score 1, 3.7% had Brunt score 2, and 1.2% had Brunt score 3. There was no NASH found in the other 85.4% of patients (P<0.00001).

Also, the average BMI dropped from baseline to 37 kg/m2 a year after bariatric surgery (P<0.00001). Liver function tests (ALT) also dropped from 52.1 IU/L at baseline to 25.1 IU/L after 1 year (P<0.00001).

The authors pointed out that the probability of NASH disappearing was higher in patients with mild NASH compared with severe NASH (94% versus 70%, P<0.05).

Commenting on the study at a press briefing, Adrian Di Bisceglie, MD,governing board president of AASLD said "we are seeing in this study that following bariatric surgery, the features of NASH actually resolve. Bariatric surgery is reserved for morbidly obese patients. For some years we have known that bariatric surgery probably is the technique that works best for severe fatty liver disease."

Di Bisceglie, chairman of internal medicine at Saint Louis University School of Medicine, acknowledged the concern that the diagnosis of NASH is "disease mongering," but he added that " fatty liver disease can become very severe" and the tools to combat it -- mainly lifestyle modification -- have limited success.

Lassailly said his group plans to perform biopsies on the patients at 5 years and at 10 years to determine if there is a waning of the effect of bariatric surgery and/or if NASH returns down the road.