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. Treatment of NAFLD
Surgery vs. Medicine
What 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
www.foregutsurgeon.com

3. Treatment of NAFLD
Surgery vs. Medicine
What can we agree?
2.
“Lose Weight” is easier said than done
Maintaining weight loss is harder!
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4. 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
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5. Treatment of NAFLD
Surgery vs. Medicine
What can we agree?
3.
Bariatric surgery is
not for everyone.
• BMI>35 kg/m2 + co-
morbidity
• BMI>40 kg/m2
• BMI>50 kg/m2
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6. Bariatric & Metabolic Operations
Laparoscopic
Sleeve
Laparoscopic Gastrectomy
Adjustable
Gastric Band
Laparoscopic
Roux-en-Y
Gastric Bypass
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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 loss
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

8. Insulin Resistance
Metabolic Surgery for the Metabolic Syndrome
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9. Gut Hormones, Metabolic Surgery &
Insulin Resistance
Murphy & Bloom
Nature
2006;444:854
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10. “The whole is greater than the sum of
its parts”
Aristotle
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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?
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12. Bariatric Surgery
Weight Loss
Sjostrom L et al. Effects of Bariatric Surgery on Mortality in Swedish Obese
Subjects. N Engl J Med 2007;357:741-52.
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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
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14. Metabolic Surgery
Efficacy 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.
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15. Effect of Bariatric Surgery on NAFLD
766 paired biopsies
Improvement Complete
or Resolution 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.
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16. Bariatric Surgery & NAFLD
Prospective, Long-Term Study
1994-2005
381 patients
Liver Biopsy at Liver Biopsy at
Liver Biopsy during
1 year 5 years
Bariatric Surgery
follow-up 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
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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. 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 patients
without advanced liver disease. Mathurin et al. Gastroenterology. 2009;137:532-540
www.foregutsurgeon.com

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
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20. Medical Treatment of NAFLD
49 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.
www.foregutsurgeon.com

21. Cost-Effectiveness of Bariatric Surgery
Office of
Health Economics
2010 www.foregutsurgeon.com

22. Treatment of NAFLD
Surgery vs. Medicine
Disputes
3
Safety
Metabolic Risks
Technical Risks
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23. Recipe for Trouble
Jejuno-Ileal Bypass
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24. UK National Bariatric Surgery Registry
First Registry Report to March, 2010
• 7045 operations in 2009 & 2010
• Complications: 2.6%
• 80% discharged by post-operative day 3
• Mortality: 0.1%
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25. Mortality from Bariatric Surgery
• Risk Stratification
– OS-MRS
– LABS Consortium
– Blackstone Score
• Patient Selection
• Procedure Selection
• Experience
• Expertise
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26. 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
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