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

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

  1. 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 James’s University Hospital, Leeds
  2. 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. 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. 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;360:859–873.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. 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. 6. Bariatric & Metabolic Operations Laparoscopic SleeveLaparoscopic Gastrectomy AdjustableGastric Band Laparoscopic Roux-en-Y Gastric Bypass www.foregutsurgeon.com
  7. 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. 8. Insulin ResistanceMetabolic Surgery for the Metabolic Syndrome www.foregutsurgeon.com
  9. 9. Gut Hormones, Metabolic Surgery & Insulin ResistanceMurphy & BloomNature2006;444:854 www.foregutsurgeon.com
  10. 10. “The whole is greater than the sum of its parts” Aristotle www.foregutsurgeon.com
  11. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. Cost-Effectiveness of Bariatric Surgery Office ofHealth Economics 2010 www.foregutsurgeon.com
  22. 22. Treatment of NAFLDSurgery vs. Medicine Disputes 3 Safety Metabolic Risks Technical Risks www.foregutsurgeon.com
  23. 23. Recipe for Trouble Jejuno-Ileal Bypass www.foregutsurgeon.com
  24. 24. 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% www.foregutsurgeon.com
  25. 25. Mortality from Bariatric Surgery• Risk Stratification – OS-MRS – LABS Consortium – Blackstone Score• Patient Selection• Procedure Selection• Experience• Expertise www.foregutsurgeon.com
  26. 26. For Obese Patients with NAFLD:1. Bariatric surgery provides significant general health benefits2. Bariatric surgery most likely controls NAFLD better than medical management3. Bariatric surgery is cost-effective4. Bariatric surgery is safe www.foregutsurgeon.com

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