Elsevier

Surgery

Volume 135, Issue 1, January 2004, Pages 48-58
Surgery

Original communication
Effects of surgical treatment of the metabolic syndrome on liver fibrosis and cirrhosis

https://doi.org/10.1016/j.surg.2003.10.003Get rights and content

Abstract

Background

Both weight loss and gastrointestinal surgery for obesity can cause liver disease, making their role in the treatment of obesity-related liver disease controversial.

Methods

Six hundred eighty-nine severely obese women (n = 551) and men (n = 138), BMI = 47±9 kg·m−2 (mean±SD), without known liver disease, underwent biliopancreatic diversion (BPD) with liver biopsy. Fourteen patients (2%) had cryptogenic cirrhosis, 11 of whom underwent multiple repeat biopsies. After 38±18 kg weight loss, 104 of the 689 patients underwent routine second biopsies during reoperations 41±25 months after BPD. All biopsy specimens were graded for steatosis, fibrosis, and inflammation by a blinded hepatopathologist.

Results

All 689 patients lost weight accompanied by improvements in the metabolic syndrome. Among the 104 patients who underwent reoperation, severe fibrosis (grade 3-5) decreased in 28 whereas mild fibrosis (grade 1-2) appeared in 42. Increased fibrosis was related to low-normal serum albumin, uncontrolled diarrhea, low intake of alcohol, and menopausal status. Fibrosis and inflammation decreased over time (P<.01). The 11 patients with cirrhosis exhibited decreased fibrosis from a mean grade 5 to grade 3, as well as reduced inflammation, Mallory bodies, and glycogenated nuclei. Seven patients had disappearance and 2 regression of nodules and fibrous bridging.

Conclusions

The metabolic syndrome of obesity is a determinant of liver fibrosis and cirrhosis, treatable by substantial weight loss after malabsorptive surgery.

Section snippets

Patients

A total of 689 (651 women, 138 men) consecutive patients underwent biliopancreatic diversion (BPD) for severe obesity from 1984 to 1994 at Laval Hospital, Quebec, Canada.37 Wedge liver biopsies were performed in 95% of the patients. Baseline characterization of the population,18 operative morbidity, pattern of weight loss, and effects on comorbidity during a mean follow-up period of 112±32 (±SD) months (range 74 to 204) have been published.37., 38. No patients with hepatotoxic medication or

Patient characteristics

Before reoperation in the 104 patients (BMI = 31±8 kg·m−2), mean weight loss was 38±18 kg. Changes in blood chemistry are shown in Table III, demonstrating improvements in some serum liver function test results, in serum lipids, and through lowering of fasting blood glucose from 117±356 to 90±13 mg/dL (P<.0001). Blood pressure decreased from 137±17/83±12 mm Hg to 123±17/74±11 mm Hg (P<.0001). In aggregate these results entail significant improvement of the metabolic syndrome. There were no

Discussion

This study of 104 patients with repeat wedge liver biopsies after substantial sustained weight loss and correction of the metabolic syndrome by biliopancreatic diversion, demonstrates the role of obesity and the metabolic syndrome in the pathogenesis and prediction of liver fibrosis and cirrhosis. This association had been suggested by us18., 42. and others,21., 43., 44. but this is the first demonstration of proof-of-concept by reversing severe fibrosis and cirrhosis through elimination of the

Acknowledgements

The exceptional secretarial services of Diane E. Zarb are greatly appreciated.

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