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01-03-2011 | Clinical Research

NAFLD and Insulin Resistance Do Not Increase the Risk of Postoperative Complications Among Patients Undergoing Bariatric Surgery—A Prospective Analysis

Authors: Tarsila Ribeireiro, James Swain, Michael Sarr, Michael Kendrick, Florencia Que, Schuyler Sanderson, Anuradha Krishnan, Kimberly Viker, Kymberly Watt, Michael Charlton

Published in: Obesity Surgery | Issue 3/2011

Abstract

Background

Nonalcoholic fatty liver disease (NAFLD) and insulin resistance are common consequences of obesity and are highly prevalent among patients undergoing bariatric surgery. Insulin resistance and NAFLD have been reported to be associated with postoperative complications following major surgery.

Methods

We prospectively evaluated complications in a cohort of 437 consecutive patients undergoing bariatric surgery. Detailed metabolic profile was obtained prior to surgery, and liver biopsies were taken routinely during surgery.

Results

Mean age was 47.8 years (20–77), and mean body mass index (BMI) was 48.5 kg/m² (32–94). Common co-morbid conditions were metabolic syndrome (79%), obstructive sleep apnea (73%), and hypertension (60%). Seventy-seven percent underwent Roux-en-Y gastric bypass, 15% biliopancreatic diversion with duodenal switch, and 8% adjustable gastric banding. The operative approach was laparoscopic in 81% of patients. Liver histology was normal in 22% of patients. Seventy-eight percent of patients had NAFLD. Nonalcoholic steatohepatitis (NASH) was present in 18%. Advanced fibrosis (stage 3–4) was present in 5%. Complications were observed in 25% of the cohort, the most frequent being infection, occurring in 14%. The wound was the most frequent site of infection (9%). There were no cases of postoperative hepatic decompensation. Reoperation was necessary in 7%. In univariate analysis, the factors associated with complications were male gender (p = 0.009), type and approach of surgery (p = 0.023 and p = 0.0001, respectively), BMI (p = 0.000), serum creatinine (p = 0.023), and serum albumin (p = 0.0001). In multivariate analysis, the independent factors associated with complications in bariatric surgery were BMI (OR 1.039, 95% CI 1.010–1.068; p = 0.008), surgical approach (OR 2.696, 95% CI 1.547–4.698; p = 0.000), and serum albumin (OR 0.416, 95% CI 0.176–0.978; p = 0.044). NASH was not predictive of complications.

Conclusions

Bariatric surgery is a safe and efficient treatment for obesity. The occurrence of NAFLD or NASH without portal hypertension should not preclude the procedure.

Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988–1994 [see comments]. Diab Care. 1998;21:518–24.CrossRef

Sturm R. Increases in clinically severe obesity in the United States, 1986–2000. Arch Intern Med. 2003;163:2146–8.CrossRefPubMed

Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–93.CrossRefPubMed

Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.CrossRefPubMed

Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547–59.PubMed

Clark JM. The epidemiology of nonalcoholic fatty liver disease in adults. J Clin Gastroenterol. 2006;40:S5–10.PubMed

Angulo P. Nonalcoholic fatty liver disease [comment]. N Engl J Med. 2002;346:1221–31 [Review] [95 refs].CrossRefPubMed

Charlton M. Nonalcoholic fatty liver disease: a review of current understanding and future impact. Clin Gastroenterol Hepatol. 2004;2:1048–58 [Review] [117 refs].CrossRefPubMed

Noel M, Hickner J, Ettenhofer T, et al. The high prevalence of obesity in Michigan primary care practices. An UPRNet study. Upper Peninsula Research Network. J Fam Pract. 1998;47:39–43.PubMed

10.

Flegal KM. The obesity epidemic in children and adults: current evidence and research issues. Med Sci Sports Exerc. 1999;31(11 Suppl):S509–14 [Review] [47 refs].PubMed

11.

Popkin BM, Udry JR. Adolescent obesity increases significantly in second and third generation U.S. immigrants: the National Longitudinal Study of Adolescent Health. J Nutr. 1998;128:701–6.PubMed

12.

Fraser A, Longnecker MP, Lawlor DA. Prevalence of elevated alanine aminotransferase among US adolescents and associated factors: NHANES 1999–2004. Gastroenterology. 2007;133:1814–20.CrossRefPubMed

13.

Wolf AM, Busch B, Kuhlmann HW, et al. Histological changes in the liver of morbidly obese patients: correlation with metabolic parameters. Obes Surg. 2005;15:228–37.CrossRefPubMed

14.

Lima ML, Mourao SC, Diniz MT, et al. Hepatic histopathology of patients with morbid obesity submitted to gastric bypass. Obes Surg. 2005;15:661–9.CrossRefPubMed

15.

Harnois F, Msika S, Sabate JM, et al. Prevalence and predictive factors of non-alcoholic steatohepatitis (NASH) in morbidly obese patients undergoing bariatric surgery. Obes Surg. 2006;16:183–8.CrossRefPubMed

16.

Papadia FS, Marinari GM, Camerini G, et al. Liver damage in severely obese patients: a clinical-biochemical-morphologic study on 1, 000 liver biopsies. Obes Surg. 2004;14:952–8.CrossRefPubMed

17.

Sorrentino P, Tarantino G, Conca P, et al. Silent non-alcoholic fatty liver disease—a clinical–histological study. J Hepatol. 2004;41:751–7.CrossRefPubMed

18.

Adams LA, Lymp JF, St S, et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology. 2005;129:113–21 [see comment].CrossRefPubMed

19.

Kooby DA, Fong Y, Suriawinata A, et al. Impact of steatosis on perioperative outcome following hepatic resection. J Gastrointest Surg. 2003;7:1034–44.CrossRefPubMed

20.

Castillo J, Fabrega E, Escalante CF, et al. Liver transplantation in a case of steatohepatitis and subacute hepatic failure after biliopancreatic diversion for morbid obesity. Obes Surg. 2001;11:640–2.CrossRefPubMed

21.

Mason EE, Renquist KE, Huang YH, et al. Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction. Obes Surg. 2007;17:9–14.CrossRefPubMed

22.

Grimm IS, Schindler W, Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol. 1992;87:775–9.PubMed

23.

Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care. 1999;2:69–78.CrossRefPubMed

24.

Zerr KJ, Furnary AP, Grunkemeier GL, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63:356–61.CrossRefPubMed

25.

Gravante G, Araco A, Araco F, et al. Postobese patients and inherent surgical complications. Ann Plast Surg. 2006;56:585–6.CrossRefPubMed

26.

Van den Berghe G, Wouters PJ, Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med. 2003;31:359–66.CrossRefPubMed

27.

NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med. 1991;115:956–61.

28.

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Jama. 2003;289:2560–72.CrossRefPubMed

29.

Rodbard HW, Blonde L, Braithwaite SS, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13 Suppl 1:1–68.PubMed

30.

Grundy SM, Brewer HB Jr, Cleeman JI, et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109:433–8.CrossRefPubMed

31.

Brunt EM, Janney CG, Di Bisceglie AM, et al. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. Am J Gastroenterol. 1999;94:2467–74.CrossRefPubMed

32.

Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3–60 month follow-up. Obes Surg. 2000;10:233–9.CrossRefPubMed

33.

Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234:279–89. discussion 289–91.CrossRefPubMed

34.

Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial. Obes Surg. 2001;11:284–92.CrossRefPubMed

35.

Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543–51.CrossRefPubMed

36.

Weller WE, Rosati C, Hannan EL. Relationship between surgeon and hospital volume and readmission after bariatric operation. J Am Coll Surg. 2007;204:383–91.CrossRefPubMed

37.

Dimick JB, Welch HG, Birkmeyer JD. Surgical mortality as an indicator of hospital quality: the problem with small sample size. Jama. 2004;292:847–51.CrossRefPubMed

38.

Livingston EH, Huerta S, Arthur D, et al. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg. 2002;236:576–82.CrossRefPubMed

39.

Jamal MK, DeMaria EJ, Johnson JM, et al. Impact of major co-morbidities on mortality and complications after gastric bypass. Surg Obes Relat Dis. 2005;1:511–6.CrossRefPubMed

40.

Fernandez AZ Jr, Demaria EJ, Tichansky DS, et al. Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity. Ann Surg. 2004;239:698–702. discussion 702-693.CrossRefPubMed

41.

Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909–17.CrossRefPubMed

42.

Lancaster RT, Hutter MM. Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Surg Endosc. 2008;22:2554–63.CrossRefPubMed

43.

Kleiner DE, Brunt EM, Van Natta M, et al. Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Hepatology. 2005;41:1313–21.CrossRefPubMed

44.

Matteoni CA, Younossi ZM, Gramlich T, et al. Nonalcoholic fatty liver disease: a spectrum of clinical and pathological severity. Gastroenterology. 1999;116:1413–9.CrossRefPubMed

Title: NAFLD and Insulin Resistance Do Not Increase the Risk of Postoperative Complications Among Patients Undergoing Bariatric Surgery—A Prospective Analysis
Authors: Tarsila Ribeireiro
James Swain
Michael Sarr
Michael Kendrick
Florencia Que
Schuyler Sanderson
Anuradha Krishnan
Kimberly Viker
Kymberly Watt
Michael Charlton
Publication date: 01-03-2011
Publisher: Springer-Verlag
Published in: Obesity Surgery / Issue 3/2011
Print ISSN: 0960-8923
Electronic ISSN: 1708-0428
DOI: https://doi.org/10.1007/s11695-010-0228-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

NAFLD and Insulin Resistance Do Not Increase the Risk of Postoperative Complications Among Patients Undergoing Bariatric Surgery—A Prospective Analysis

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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