Hepatic pathology among patients without known liver disease undergoing bariatric surgery: observations and a perspective from the longitudinal assessment of bariatric surgery (LABS) study.
Liver biopsy is not routine during bariatric surgery. Alanine aminotransferase (ALT) is widely used to screen for liver disease. We assessed the relationship between ALT and pathology in biopsies from Longitudinal Assessment of Bariatric Surgery (LABS) patients with normal preoperative ALTs. Biopsies from the LABS-1 and LABS-2 studies were scored using the NASH CRN and Ishak systems. Diagnosis and histology were examined in relation to alanine aminotransferase (ALT) values. Six-hundred ninety-three suitable biopsies were evaluated. Biopsied patients had a median age of 45 years; 78.6% were female and 35.1% diabetic; median body mass index was 46 kg/m(2). Six-hundred thirty-five biopsied patients had preoperative ALTs. Median ALT was 25 IU/L (interquartile range [IQR] 19-36 IU/L); 26.6% had an ALT > 35 IU/L and 29.9% exceeded the more restrictive Prati criteria for normal. Using the Prati criteria, 7.9% of participants with normal ALT had steatohepatitis and 5.3% had ≥ stage 2 fibrosis. Logistic regression models were used to predict the probabilities of having bridging fibrosis/cirrhosis or a diagnosis of borderline/definite steatohepatitis in the unbiopsied LABS-2 sample. The proportion of biopsied participants with these findings was very similar to the modeled results from the unbiopsied cohorts. We estimated that 86.0% of participants with advanced fibrosis and 88.1% of participants with borderline/definite steatohepatitis were not biopsied and went undiagnosed. As ALT did not reliably exclude significant obesity-related liver disease in bariatric surgery patients, consideration should be given to routine liver biopsy during bariatric surgery and medical follow-up of significant hepatic pathology.
Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland.
David E
DE
Kleiner
Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York.
Paul D
PD
Berk
University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
Jesse Y
JY
Hsu
Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Anita P
AP
Courcoulas
Department of Surgery, University of Washington, Seattle, Washington.
David
D
Flum
Department of Surgery, University of Washington, Seattle, Washington.
Saurabh
S
Khandelwal
Department of Surgery, East Carolina University, Greenville, North Carolina.
John
J
Pender
Department of Surgery, Weill Cornell Medical College, New York, New York.
Alfons
A
Pomp
Neuropsychiatric Research Institute, University of North Dakota, Fargo, North Dakota.
James
J
Roerig
Sacramento Bariatric Medical Associates, Sacramento, California.
Laura L
LL
Machado
Division of General Surgery, Oregon Health and Science University, Oregon Weight Loss Surgery, Portland, Oregon.
Bruce M
BM
Wolfe
University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
Steven H
SH
Belle
D000410:Alanine Transaminase / Q000097:blood; D050110:Bariatric Surgery; D015415:Biomarkers / Q000097:blood; D001706:Biopsy; D016009:Chi-Square Distribution; D004796:Clinical Enzyme Tests; D005260:Female; D006801:Humans; D008099:Liver / Q000473:pathology*; D008103:Liver Cirrhosis / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D016015:Logistic Models; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D009765:Obesity / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D011237:Predictive Value of Tests; D012307:Risk Factors; D016896:Treatment Outcome
D015415:Biomarkers; D000410:Alanine Transaminase